In the eighteenth and early nineteenth century, students in medical schools paid fees directly to their professors — a fee for each course of instruction. The great John Hunter’s fatal attack of angina pectoris was induced by a quarrel with the other members of the staff of St. George’s Hospital over a problem of fees paid by students to teachers. At Harvard also in the 1840s, students paid fees directly to their professors for courses. For the course in anatomy and operative surgery by Dr. J. C. Warren they paid $15, and for that on materia medica by Dr. Jacob Bigelow the fee was $10, and so forth. But all that is long past history except perhaps in the case of certain graduate courses. Therefore, we may ask, if a better way than fee-for-service has been found for paying for instruction, why should not a better way than this be found also for paying for medical

—James Howard Means, M.D., in the George W. Gay Lecture at Harvard Medical School, May 13, 1959