The State Of Medical Care, 1984


Yes—and that’s an inflationary pressure too. Since your insurance pays for the tests, the tendency is to think they are free. So let’s do them even if they are not absolutely necessary. But one way or another you end up paying. You pay for your insurance—directly or via your employer. Worse yet, the insurance is so designed that it often pays for costs while you are in the hospital but not for outpatient care. So people are admitted to hospitals for work that could just as easily be done on an ambulatory basis where it would be cheaper. Insurance that pushes us toward hospitals is helping to drive costs through the roof. We’ve got to change the way medical care is reimbursed. The money often goes for the wrong things. That reminds me of the story of a friend of mine, a medical school dean who decided to take his sabbatical by practicing in a small town in Maine. After it was over, he said to me: “Dave, I learned a lot from it. I worked my butt off for ten hours every day, spending time with patients, talking with them, working with them, and I really enjoyed it. But one thing bothered me. Because I was the only really knowledgeable physician in the area, the other doctors began asking me to read all the electrocardiograms. So in the evening I would take twenty minutes and read them. No problem. But would you believe that that twenty minutes generated much more income for me than all the hours I had spent with patients?” That’s a shame, and we have got to do something about it.

Your friend the dean was really acting as a specialist when he read the EKGs, wasn’t he? And isn’t such specialization exactly what is responsible for a big hunk of the increase in costs?

Yes, it’s another expensive by-product of the technological revolution. As we’ve acquired new machines, new drugs, and new techniques over the past few decades, and as science-based medicine took over, we required new kinds of people to operate the system. There was much too much for any one person to know. So we trained the specialists, the subspecialists and superspecialists, and they all charge more than the family practitioner or generalist. Our dilemma as a country has been that we have no national monitoring system to specify what kinds of doctors will be trained. We have 127 medical schools, none of which has any responsibility for what the total system looks like, plus an American ethos that says that if you get into medical school, it is your right to choose what you are going to do. If you want to be an anesthesiologist or neurosurgeon, that’s what America is all about. And those are very attractive, fascinating callings.

I gather that many of the students enter medical school not expecting to specialize, but while they are in training they find that specialization is where the action is, where the romance is, and coincidentally where the money is.

Yes, but it’s a little more than that. Almost all the medical schools are based in the very high-technology hospitals, and virtually all the faculty are superspecialists. A young person cannot help being impressed by the hospital drama of a superspecialist coming into a situation that is one of utter chaos and dealing with it calmly and effectively. You see this guy come in and save the patient’s bacon, and you say to yourself, “I’d sort of like to be that doctor. ” Just being a kindly, thoughtful physician with only a smattering of the technological know-how may well help lots of people, but you know that when you become a doctor, you’re going to have this sacred responsibility for humans, and some people are going to come to you bad sick and you’re going to kill them if you do wrong. Doctors tend to be high achievers, and after thinking about it, many of them are going to head toward a specialty.


Where does this leave the family practitioner or general practitioner? Are they a vanishing breed?

No, but there aren’t enough of them, and we are trying to do something about that here at the foundation. One thing we’re working on is the reward or reimbursement system. What can we do about it? Specialists earn more than generalists. Part of that is because they have gotten more training: it costs a lot more to train a neurosurgeon than a family practitioner. But we’ve got to narrow the gap. Then there’s the prestige factor. The public regards the advanced hospital institutions as if they were space centers manned by astronauts. Meanwhile, community-oriented physicians are viewed as those who drive the buses and the subway trains. The paradox is that the generalists have, in many ways, the tougher job. They’re right out there on the front lines, dealing with uncertainty all the time and without this enormous professional support system all around them. They don’t have fifty well-trained people around to make them look smart and keep them up to date. I think if I went back into practice today I would do it as a general practitioner. Because I think that after a doctor gets the technologies very well in hand, the satisfactions come from real interaction with individuals. After treating a patient with pneumonia, the doctor wants to know more about that person—what’s he really like? The generalist is dealing with the whole person, not just a part.

If we don’t have enough GPs, what about the total supply of doctors?Are there enough of them?