The Changing Face of Medicine

When I entered medical school a long time ago my classmates and I had a number of things in common:  We liked science and math, we enjoyed the challenges of hard work, and all but two were male.  When I completed five more years of training after medical school (plus two in the Army) I felt I was quite ready to enter practice.

To my surprise, the older physicians, for whom I had a great respect, were dismayed at their younger colleagues’ differing views of how we should practice. We rarely made house calls, not because we were lazy, as the older physicians suggested, but because it was an extraordinarily inefficient way to deliver care.  They considered us pampered because we had been paid $75 a month in our early training while they had received only room, board, uniforms, and were not allowed to marry.  Some things really needed to change!

In the mid-1960s sub-specialties and group practices were just starting.  A free-standing private practice was the way many of my colleagues chose to start their professional lives.  It served us and our patients well, but with the advent of third-party payers and the government institution of Medicare things changed rapidly.

Today, those entering medical school have many of the same aptitudes and interests as we had and half of them are women, a definite plus. Their training is as long, if not as arduous as ours, and I find myself, as a very senior physician, grousing about their exorbitant pay, their insistence that they not work 80 or more hours a week, and that they have a life beyond medicine.  I must admit that they have important points.  They have earned their pay; just because we worked for peanuts did not make it right.  Most young physicians have massive educational debts.  By wanting more control over their working schedule, they may well turn out to be better-rounded, particularly in family life, than we were.

The expectations of the younger physicians will be difficult to meet in the private practice model.  Like everything in this country, conglomerates and government have moved in to take the place of the stand-alone company, be it a family pharmacy, a mom and pop grocery, or a local banker who deals directly with you as an individual.  The personal touch has often been lost in favor of economies of scale.

The future of medical practice will be determined by those who do not actually deliver the care:  by the government, by the insurance companies, and the medical suppliers who have political clout.  A private practitioner will have little choice except to be swept along with the flow.

The new model, if medicine is to remain an art as well as a science, will be an integrated system such as is being implemented by the Carilion Clinic, Lewis-Gale, and other centers across the country.  Without question there is the possibility of much greater efficiency in such a model and the power they wield will allow physicians to do what they are trained to do:  Care for the patient.  Let the administrative side be attended to by those who enjoy that sort of thing.

The concern of the medical community is that we will become pawns in a medical/government complex, that no one will take seriously our concerns about patient welfare, that finances will rule, not quality of care.  Objections to the formation of the Carilion Clinic were, as least in my mind, not to the concept itself but the inference that those of us who built the infrastructure of our medical community had been practicing inferior medicine.  That was not Carilion’s intent, I am sure, but had they included the established medical community in their planning that misunderstanding might have been avoided.  As good business persons, Carilion and others like them, understand it is often easier to get forgiveness than permission.  It is possible that including the doctors in the planning stages might have ended in a pitched battle which would have served no one well.

Change is upon us, physician and patient alike.  We must all work together for the commonweal recognizing that our old way of doing things is as out-dated as the house call.  As these changes come, there is one thing we must not lose.  We should all remember that in any illness, in every emergency one of the most important treatments is delivered by ear:  words of comfort.  Only doctors, nurses, and ancillary personnel can speak those words.  If that voice is silenced, then we will have lost the greatest thing of all:  our ability to care for one another.