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The five generations of American medical revolutions.

Current medical authors frequently use the term "revolution," yet American medicine is resisting change rather than embracing it. The last completed American medical revolutionary movement was the specialist-technologist movement of the late 19th and early 20th centuries. This paper describes a five-generational model of revolution. First-generation persons foment revolution; second-generation persons shape it into workable form and precipitate conflict; third-generation persons join the fight only when it appears to be all but won; fourth-generation persons enjoy the fruits of revolution; and fifth-generation persons, having risen to domination in the mature system, resist all attempts at reform by the next round of revolutionaries. In political revolutions, severe reactionary activity by the ruling party is often an indicator of an imminent overthrow by revolution. In scientific revolutions, the opposition of an established (specialist-technologist) paradigm to an emerging alternative (generalist) paradigm increases in intensity as the old order declines in strength; the opposition becomes most fierce just before the collapse of the old order. American specialist-technologist medicine, declining into its senescent fifth generation, will resist all but incremental change whenever possible, and accept major change only by force.