Norman Rockwell-like painted period images turned into the fashion of polyester pantsuits and disco dancing. Medical school admissions for women and nonwhite ethnic groups turned an upward slope from a straight line. AIDS was a feared epidemic. Cold draft beer from the Rockies competed with what made Milwaukee famous. The military draft and the cold war would soon be forgotten.

At the beginning of the first medical ecolo-nomic generation (1950-70), World War II had ended and military veterans had many job opportunities. However, at the beginning of the second medical ecolo-nomic generation (1970-90), the end of the Vietnam War offered no hero's welcome to soldiers coming home. Vietnam vets didn't have the same employment opportunities. Many women held wartime jobs that displaced men in the workforce, and they didn't want to give them up.

In spite of their drug abuse and anti-Vietnam War support, The Beatles went platinum and Americans liberally forgave war protesters. VA hospitals overflowed with disability claimants. New "war diseases" made newspaper headlines. Courts of justice became overwhelmed with lawsuits of every sort, and juries offered outlandish settlements from imaginary pools of money.

The national work ethic and the pride and honor of earning a living through elbow grease teetered, soon to give way to an entitlement-oriented society. In spite of the obvious need to take responsibility for their personal healthcare needs, patients had little desire and made little effort to become members of a steadily growing healthkeeper contingent.

The period of 1970-90 was a time of adjustment to the social changes of the 1960s. Protesters from the '60s lectured as college professors in the '70s. Patients redefined the concept of "rights." Historically viewed as freedoms from government encroachment, "rights" evolved, becoming entwined with government, making "entitlements" the new cultural paradigm.

The third medical ecolo-nomic watershed event was the passage of Medicare and Medicaid entitlements in 1965. Federal Medicare and Medicaid (Medi-Cal in California) programs soon blossomed, and the federal government immediately appointed itself as an organizer of healthcare delivery.

The Johnson Administration insisted that the "level" of care (rather than the quality of care) be the same for the rich and the poor. Federal financing was set for an average American life expectancy of 65 years. The poor suddenly had access to multiple admissions at "expensive" hospitals. Unintended consequences were not considered. Therefore, soon after the Medicare legislation was enacted, many unforeseen loopholes allowed financial abuses to occur. Virtue was surrendered to administrative mores.

A quartet of conspirators-hospitals, drug and product companies, doctors and patients--all took advantage of the ample available medical care and collected fees from a fat payment schedule. The conspirators abused what they supposed were endless financial resources from business and government payers. The conspirators ignored the consequences of their actions and created a future federal debt that would never be fully repaid.

As part of the Medicare era, a "something for nothing" entitlement mentality characterized the second medical ecolo-nomic generation. Unlimited expectations continued to exist in the face of limited Medicare reserves. So medical ecolo-nomics evolved a new type of healthcare delivery model and new cultural expectations. Organized healthcare delivery took the form of cradle-to-grave security--the health maintenance organization. HMOs then spawned many other new models, including the staff model, group model, IPA model and network model. Indemnity insurance persisted.

In the second medical ecolo-nomic generation, the average patient showed little patience. Patients stopped blindly trusting doctors and viewed health plans with disdain, but patient-healthkeeper autonomy, although essential, lacked support. Entitled patients played a role akin to rebellious teenagers when interacting with organized healthcare delivery systems. Patients objected to what was being offered, but could not and did not define their real needs or true desires. The doctor's office was perceived as just another business establishment on a commercially zoned street.

Concern for the total well-being of individual patients, on a one-to-one or case-by-case basis, was preached in medical schools. However, the Vulcan philosophy of Mr. Spock--the need of the many outweighs the need of the few--was coming into vogue. Public health messages, especially about sexually transmitted diseases, were starting to be taken seriously at the start of the second medical ecolo-nomic generation. Patients heard a message that was well understood a century earlier--disease processes arise because of environmental and social factors. Staying healthy became an affordable fad. The number of patient visits to doctors increased, especially when there was no co-pay. Still, the quality of healthcare did not increase with overutilization of health resources. The incentive for a patient to become a healthkeeper diminished when the healthcare dollar did not come directly out of the patient's pocket.

The newly formed Health Services Agency downgraded the title of "physician" to "provider." "Provider" physicians functioned as consumer advocates on behalf of patients along with other healthcare "providers," such as laundry workers in a hospital. Medical costs grew dramatically. Access to many medical services increased, but access to essential healthcare decreased. According to doctors, quality was improving, but payers (predominantly businesses and government) doubted the veracity of the claims. Patients lacked valid data to evaluate true quality.

Corporate forces were determined to control the new patient mindset. Patients had come to believe that cradle-to-grave HMO healthcare would cure all diseases and prolong youth indefinitely. A clever propaganda campaign compelled the patient to yearn for some sort of fantastic, imaginary healthcare delivery organization. Such an imaginary organization did not and would not ever exist.

Nonetheless, patients falsely believed that a true solution for human diseases had been found. The idealized healthcare delivery system--the HMO--offered "preventive care" to miraculously prevent all diseases in advance. No entity or physician ever offered what the HMO falsely promised. The HMO concept proved too good to be true--literally. HMOs had no ability to handle incipient increasing costs from a myriad of technological advances and patient longevity.

From a cold and heartless economic perspective, the national economy never benefited from curing accident victims or preventing deadly diseases. However, cures and preventions were championed to save medical costs immediately. Healthcare delivery was and always will be an expensive yet essential aspect of a nation's economy, although never directly profitable for the nation.

Patients no longer accepted unquestioned paternalism from the all-knowing doctor; only a faint flicker of fraternalism between doctor and patient gleamed in their mutual eyes. Legalese took the place of trust. Lengthy disclosures became commonplace for certain treatments, discussing the risks, discussing the indications, discussing possible alternative treatments, and discussing possible varying levels of benefit.

In addition to written documentation by the physician, many types of lengthy legal forms were developed to standardize patient consent. As the legal need for assurance increased, so did the number of words in a document. At one point, special informed consent forms for newly devised surgical procedures, such as joint replacements, were as many as 5 pages long. The forms did not help most patients achieve greater understanding and insight: They simply got their tongues twisted and eyes crossed.

With the advent of the Internet, federal legislation demanded that all information transmitted online would be subject to review. Medical privacy issues were revisited. The Health Care Financing Administration published mortality rates for hospitalized Medicare patients. Public knowledge concerning medical quality began to accumulate. The supposed MD conspiracy of secrecy and silence regarding medical misadventures was broken forever.

As the total number of HMOs increased, dollars spent on healthcare also increased. Yet, corrected for inflation, the average income of the individual physician decreased. The golden age for medical practice, the first medical ecolo-nomic generation, had ended. This was especially true for primary care physicians. Surgical sub-specialists remained an exception. Even with the influx of foreign-trained surgical sub-specialists, sub-specialty surgeons remained fewer in number and were more difficult to replace. Surgical specialty societies sought further control by freezing or reducing the size of residency training programs. The sub-specialists used HMO manpower studies as a statistical yardstick to mold the public mindset and justify the residency reductions.

At the same time, government officials truly believed that decreasing the number of sub-specialists would decrease healthcare spending in a nation that continued to spend a greater percentage of GDP on anecdotal remedies apart from traditional medicine. The political spin was that there were too many specialists and not enough primary care physicians, further justifying the downsizing of residency programs. Fewer sub-specialists trained for an increasing sub-specialist public demand. Then a sudden realization struck. Physician extenders could do most of the general practitioner's work, and sufficient sub-specialists were not available for a sophisticated public that demanded direct access to those sub-specialty services.

More importantly for preservation of sub-specialist income, the HMOs did not as easily transfer a specific task (i.e., surgery) to physician extenders. Extenders, such as physician assistants, were employed in surgery; however, they were utilized as subordinate team members, for example, harvesting a vein graft for cardiac bypass surgery, taking a bone graft for spinal surgery, and reducing simple fractures in the emergency room, without direct supervision.

Since sub-specialists represented a small, highly paid subset of the physician marketplace, when threatened with the loss of patients by the HMOs, they took an entrepreneurial path. Sub-specialty groups formed to deliver healthcare more efficiently, with lower costs and high quality. These groups successfully negotiated for higher-priced tertiary care contracts from the HMOs.

In both the second and third medical ecolo-nomic generations, the static competition concept for medical practice was generally believed best and taught as such in medical schools. Schools of business and economics disagreed with the static state and taught dynamic strategic competition concepts, but somehow kept that fact secret from medical school professors. Medicare costs continued to tug at the federal government's purse strings and the coffers were running dry. A fourth medical ecolo-nomic watershed became a totally predictable evolutionary adaptation.