Sixty Plus Years of Reflections on the Medical Profession By An “Old-Timer”
When I graduated from medical school in February 1947, I looked forward to a profession where physicians were admired and respected in the community. I, like most of my classmates, expected to earn a good living, but few of us aspired to wealth. I entered medicine not as an idealist determined to save humanity, but because of a keen interest in pursuing a profession that dealt with people. I wanted to do something that required me to remain intellectually curious.
It was an exciting time. Medical school was completed in 3 years because we were in the middle of World War II; I then entered into 4 years more of rigorous training that often involved 20-hour shifts and working at least 6 days a week. The practice of medicine was vastly different in those days. In the 1940s and early 1950s, advertising by physicians was considered unethical. Doctors worked in hospital clinics for many hours a week without pay, as a condition of remaining on the staff. Hospitals were prohibited from advertising. Advertisements urging patients to “ask your doctor” about X or Y drug were not FDA approved. Medical education was pursued for the joy of teaching and passing on knowledge. Scientific papers were written by the researchers who actually did the research. Stockholders and executives of health care companies were not siphoning off 20% to 30% of health care dollars.
The tools we had to work with then would be viewed as primitive today, but we listened to patients and learned how to put two and two together. Technology was in its infancy; few people had even heard about CAT and PET scans or MRIs. We relied on our training and judgment, stethoscopes and a few other simple tools, and our hands, eyes, and ears to make a diagnosis and institute treatment. We were looked up to as role models and considered pillars of the community. We didn't watch the clock and, as noted, we didn't expect to become millionaires.
The Influence of Technology—Good and Bad
Fast forward to the 1990s and 2000s. Many doctors are now technocrats. We no longer have to listen to a heart murmur or to a patient describing a headache. We can order an echocardiogram to tell us all about the interior of the heart and the state of the heart valves. We can get an MRI to rule out a brain tumor, even though taking a few minutes to question the patient might reveal a tension headache.
Many more medical students now choose their specialties with an eye on anticipated income. While some physicians complain about the fee structure today, the fact is that a large number do earn substantial incomes. There are, of course, exceptions: family physicians and pediatricians, for example, are at the low end of the income scale, largely because they perform few high-cost procedures. In just a few decades, we have progressed or, more correctly in many cases, regressed—from a profession to a profit-oriented business. Yet, being a physician is still gratifying. Yes, I would tell a son or daughter to pursue a medical career if they were so inclined. I personally have had a wonderful, exciting career as the Senior Medical Consultant to the National High Blood Pressure Education Program of the National Heart, Lung & Blood Institute and have watched and participated in the evolution of treatment of hypertension. I have enjoyed experiences as a practitioner, researcher, and teacher at several medical colleges. It has been a remarkable journey.
Advances in technology have dramatically improved diagnostic and treatment capabilities, but in many cases procedures are overused and abused for economic not medical reasons. A great many people in the medical profession have been co-opted by industry, by pharmaceutical companies attempting to prove that their product is better than one that just became generic, by instrument companies trying to prove that patients need costly procedures, by hospitals that now advertise to lure patients for high-tech procedures while cutting back on basic, less-profitable care. But exorbitant charges for even simple procedures are almost the norm. Now there are $1000 hospital bills for metabolic panels, $500 plus bills for a blood count, and a $300 fee for a urinalysis. The first question in the emergency room years ago was, “What are your symptoms and how can we help?” Now it is, “What insurance do you have?”
We should not completely blame industry for the current state of affairs; their job is to sell a drug or a procedure. Nor can we overlook the enormous beneficial contributions of pharmaceutical companies, which have developed new therapies that have made such a great difference in the treatment of numerous diseases, including diabetes, hypertension, and cancer. These efforts must continue, but changes must be made in the way new drugs and procedures are marketed. We can certainly place some of the blame for current abuses on the greed of some physicians and their desire to become celebrities. Many have let their scientific judgment lapse by doing protocol research desired by industry and participating almost as sales persons at national meetings to advocate particular products. Negative studies are often not published and bias has clearly influenced scientific inquiry.
Thus, while American medicine is still at the forefront, we have allowed a complex system of for-profit care to emerge, both in hospitals and through health care companies and other plans such as Medicare Advantage that view medical care as profit centers.
Medical education has also been transformed. At one time, physicians took pride in educating others; they took the time to learn and transmit knowledge. Today, however, aside from some academic centers, much of the “hands-on” medical education and training are done by physicians who, in many cases, are directly or indirectly coached by industry. Grand Rounds, once an exciting place to learn about the latest medical treatment from unbiased speakers, have been co-opted in many institutions by pharmaceutical and procedure companies. They oftentimes pay for and provide the speakers with lecture materials. In recent years, restrictions on lecture content may, however, become too stringent. Significant attendance at conferences in many hospitals now only occurs when the topic relates to the business of medicine.
Articles in scientific journals often are not written by those designated as senior authors, but more and more frequently are written by science writers employed by an agency that, in turn, is paid by a company. As Editor-in-Chief of the Journal of Clinical Hypertension from 1999 to 2009, I frequently had to remind authors of their responsibilities.
Many of us who were practicing in the 1950s to 1970s have an increasing sense of frustration over what has happened to our profession and by the dehumanization of medical care in some doctors' offices and in “up-to-date” hospitals. Unanswered telephone calls and delays in reporting results of x-rays and blood tests are common examples of the lack of empathy and caring that should be part of the medical profession. It is true that some of the problems relate to the fact that physicians are hassled by multiple insurers and conflicts over their treatment options. Electronic billing has contributed to dehumanization, with doctors spending more time with computers than with patients. Billions of dollars have been spent implementing these systems, which, in many cases, do improve transmission of medical data, but also result in the ordering of more tests and procedures and add to the cost of care.
There is universal frustration over the spiraling cost of medical care, much of it driven by the overuse and abuse of technology as well as the increase in for-profit hospitals and publicly owned health care companies. As the nation's annual medical bill spirals well past the 2 trillion dollar mark, no one can deny that medicine is now big business. Few people fully realize how profitable the healthcare business has become. Nor are they fully aware of the exorbitant salaries paid to healthcare company executives or of the huge profits stockholders reap from the healthcare industry. Where is all of this money coming from? Simply put, from the dollars that should be going to pay for medical care. Instinctively, patients do not want to turn their health care over to a federal bureaucracy, but few realize that Medicare, despite some problems, is perhaps our most successful and satisfactory healthcare delivery system; it operates with an overhead of only about 3%, compared with 20% to 30% for-profit plans.
It is also an ongoing concern about the extent to which postgraduate and continuing medical education is being distorted by promotional activities. Many scientific reports so glowingly described by the media are, in reality, often based on studies designed to “prove” a specific premise favorable to a drug company or instrument manufacturer.
What can be done? Somehow we must gradually move toward a single-payer program and curb some of the major abuses in the profit-driven overuse of technology. We must also modify the tendency of hospitals to become profit centers, with their emphasis on cardiovascular or orthopedic surgery, and divert some of these efforts and dollars to preventive practices. We all know that, in the long run, preventive medicine pays high dividends both in real savings and quality of life; look at what the treatment of hypertension has accomplished. At the moment, many insurance companies do not pay for this approach to care.
No one wants to vilify industry or hospitals; we all have benefited greatly from their activities. But the advances have come at a cost we should attempt to moderate. I am convinced that many doctors and hospitals are resorting to unnecessary (and expensive) tests, not just to limit their liability to malpractice litigation, as is often claimed, but to increase their income. The fact is, doctors can still earn a good living without overusing tests. Similarly, they still should be providing simple services, such as answering telephone calls or refilling prescriptions, without charging an annual fee or becoming boutique or concierge doctors. Too often people with simple ailments like sore throats or a stomach ache are unable to reach their doctor or are referred to an emergency room by an answering service only to incur almost fictitiously high charges. Somehow, this sequence of events must be changed.