As student, trainee, educator, scientist, practitioner, and occasionally as a patient I have observed medicine as an insider for close to two thirds of a century. While the power of medical technology has grown exponentially over this span, the general principles of medical practice remain the same. My subject is the interplay between these two (practice and technology) along with the complex (almost chaotic) economic system that has emerged like a tropical cyclone.
While political correctness has been spread over the medical curriculum as it has over all the academy the essential characteristics that are expected of a competent medical practitioner remain basically the same as they were in the time of William Osler and his predecessors.
The ancient precept of “first do no harm” was always ostensibly honored, though more in the breech than in practice. While modern medicine has vastly increased the ways to do harm, the principle remains taught, believed and often ignored.
Technology first – The difference in the education and practice of an ophthalmologist specializing in the diagnosis and treatment of diseases of the retina compared to that of a family practitioner is so vast that other than MD after their names they might as well be in different professions. They spend four years studying the same medial undergraduate curriculum because of little more than a habit going back a century or so.
The leaders of the American medical education establishment, in my view, have never been more distanced from the physician rank and file than they are today. Changing the medical curriculum to reflect the realities of today’s practice conditions is abhorrent to them. They frequently modify the medical curriculum to suit fashion rather than facts. They constantly proclaim the need for more primary care physicians, while the realities of medical practice result in ever increasing numbers of specialists and sub-specialists whose remuneration greatly exceeds that of their generalist colleagues.
A good case can be made for either abolishing medical school altogether or drastically shortening it and sending trainees directly into the program that will prepare them for the career path they have chosen. Ask any physician how much of the knowledge he, or increasingly she, uses daily was learned in medical school compared to that acquired in residency and fellowship training. They will confess that virtually all they know was gained after the MD degree was awarded.
Consider a renal fellow at the start of his training. His mentors will assume that he knows nothing of the biochemistry, physiology, and immunology germane to the discipline and teach it from the introductory level on up. This assumption is almost always correct. Four years of undergraduate medical education is a waste of time and money.
The current model of four years learning little of lasting value will not be abandoned by medical school administrators. It is based on a world that no longer exists. It does provide employment for teachers and administrators who would otherwise have to find gainful employment.
Compare the incomes of the specialist versus that of the generalist. An orthopedic surgeon who limits his practice to joint replacement surgery makes about four times the money earned by a family practitioner. Delve a little deeper and you will find that it takes years of training and experience to get really good at joint replacement surgery while most of what a family practitioner, general internist, or pediatrician does could just as well be done by a nurse practitioner or physician’s assistant.
A sensible approach to the perceived dearth of primary care physicians would be to train physicians to head large teams of physician extenders rather than grind out additional scores of thousands of physicians in the expensive hope that they will pursue a career in primary care. The remuneration of these team leaders could be raised to a level that might be competitive with those of their specialist coevals.
There’s more to medical practice than technology. Those physicians expert in its use typically care for specific parts of their patient’s anatomy or for isolated systems that have gone awry. The care of the whole patient over an indefinite span is the province of the generalist and is the reason that the leaders of medicine advocate for a greater number of them.
The reasoning just presented forces two conclusions. A generalist who heads a team of physician extenders necessarily will not have a close connection with any of the patients under his clinical umbrella. If he adheres to the old model of primary care he will find that the ground rules have changed.
Instead of working for himself or as part of as small partnership, the internist (whom I consider the best qualified generalist for adult care) will be part of a large multi-specialist group, often owned by a hospital. The demands of such an arrangement are such that this physician will be under enormous pressure to see a large number of patients every day – sometimes as many as 32. Why so many?
The rules and economics of medical practice are the product of health insurance and Medicare. They determine the payment for every medical service. Remuneration is tilted sharply towards procedures. A cardiac catheterization or a cataract removal pays much more than an hour spent evaluating a new patient and exponentially more than a followup visit. Thus, the internist must earn his salary by seeing large numbers of patients. The large volume of patients seen daily is the result of the relatively small payment for a visit that doesn’t involve a procedure.
Medical students and resident physicians are still taught the value of a well done history and physical exam. But the complete H&P suffers under current practice conditions. Because it takes more time than is available for a physician to take a thorough history, the task is delegated to a non physician staff member or limited to a questionnaire filled out by the patient. Depending on the educational level, literacy skill, or linguistic fluency of the patient such a form may be incomplete or inaccurate. Even if well done, the information provided to the doctor is not the same as that provided when the doctor takes the history himself.
A cursory physical exam is now the rule. Almost no physician takes his patients vital signs; a nurse does it. Rare is the doctor who observes his patient’s gait. Physicians listen to heart and lung sounds without removing the clothing that separates the stethoscope from the patient’s skin. Diabetics are routinely seen with shoes and socks on. Even rarer is the physician who examines the shoes of diabetic patients. A physical exam is typically over in less than a minute. All of this compression is the result the high rate of turnover needed to sustain a primary care practice. The economic gain is paid by the deterioration of patient care.
Almost no doctors see their patients when they are hospitalized. Their care is transferred to a hospitalist who knows nothing of the patient prior to his arrival in hospital. These hospitalists work shifts so that the inpatient care of a patient may be moved to different doctors during the course of a hospital stay. The reason most generalists have stopped providing inpatient care is that it’s not cost effective.
This depersonalization of primary care explains the growth of concierge medicine. In this system the patient pays a yearly fee for as much care as is needed. The concierge physician limits the number of patients he follows. He makes himself readily available because he has only 500 to 750 patients whom he knows very well. The cost of this service is out of pocket, thus no insurance company or federal bureaucracy is involved. The concept is similar to the way medicine was practiced and paid for prior to the advent of health insurance and Medicare. Conventional insurance and Medicare is used for consultations and hospital stays. Concierge medicine is only for the relatively affluent. It likely will always be on the outskirts of medical care.
The rise of administration as the dominant force in medical practice is inexorable. It corresponds, or even surpasses, the administrative control of the other pachyderm of the modern world – higher education. The current state of medicine is Manichean. If you have an identified problem that requires a defined treatment, you will likely find a physician who has the expertise to fix it. If your problem is complicated and crosses medical boundaries, you may find yourself in a maze. The patient who has multiple problems, the boundaries of which are blurred, likely will bounce from specialist to sub-specialist with uncertain outcomes. It is precisely this state of confusion that requires the knowledge and supervision of a confident primary care physician – one who can integrate all the information flowing in torrents from different consultants and who can steer the patient to a satisfactory outcome.
The conditions of medical practice outlined above are such that a primary care doctor who has the insight and authority to supervise the patient under complex circumstances is as rare as wisdom. But even more is required of a generalist who wishes to provide excellent service over long durations. He must somehow find a way around a system which purports to value general practice (an outdated, but useful term) while discouraging its successful employment. Such a practitioner must work for a lower salary than his specialist colleagues, while receiving less recognition, in a job that requires more intelligence and insight than that of a super-specialist. The odds of finding such a physician, while not zero, are lower than a sub-basement.
Unsurprisingly those “experts” who helped the government create the problem want it to intervene to fix it. This at the same time that the AMA is going full speed to “embed racial justice and advance health equity.” Some medical schools are downplaying board certification as a hiring criterion. If there is a profession where merit, skill, and knowledge are of life and death importance, it’s medicine. It’s a hard enough job under the best of circumstances without shrinking it to fit lunatic theories of social justice.
What every patient not bereft of his senses wants is a primary care physician who has the skill, energy, and time to deliver first rate care. Such a doctor is not easy to find for the reasons described above. The insanity that has engulfed the academy, and now our polity is metastasizing to our medical schools and their associated training programs. The litany of utterly conflicting demands on the medical profession emanating from the public, politicians, medical experts who haven’t seen a patient in decades, and for all I know Martians is such stuff as nightmares are made on.