The State Of Medical Care, 1984

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A great push was made in the 1960s to expand medical training, and the schools were persuaded to enlarge the size of their classes. However, we overshot the mark. I think there is everything to suggest that we are well on the way to a surplus of doctors. This is likely to bring about many changes in medicine—some good, some bad. It may help to right the specialist-GP imbalance. It may get more doctors moving to places where they are urgently needed. We’ve greatly improved the reach of medical care in this country, but there are still pockets of people who, by virtue of culture, language, or location, are still having a tough time getting into the medical care system. Now it turns out that doctors are moving out into the hinterland and into smaller communities because there’s no more room at the inn in suburbia. That’s good. Another result—although it may only be a coincidence—is that doctors’ incomes have reached a plateau. That’s very good news.

Doctors are moving out into the hinterland and into smaller communities because there’s no more room at the inn in suburbia.

Will the house call come back?

I hope so. It was the new technologies, plus the doctor shortage we had for a while, that drove out the house call. Most doctors genuinely felt that while the house call was comforting, there was so much more they could do for you in the office or in the hospital that it made sense to get you there; and they could treat a lot more patients that way too. But a number of thoughtful physicians today are saying that for the crippled, lonely old lady with arthritis, there is only a modest amount that can be done for her in the hospital, but in terms of her ability to function as a human being and to feel good about herself, yes, it does pay off to see her at home.

What is the role of the physician’s assistant or nurse practitioner in all of this?

That was another outgrowth of the doctor shortage as well as the advance of technologies. It was a very important development and remains so: certainly there were many things that could very properly be delegated, freeing physicians for the work that they were most needed for. The convenient term for these people was physician extenders , which I always felt was a denigrating term. It sounded like putting bread into hamburger mix. But these new health professionals are extremely valuable, and many, I’m convinced, will continue in certain specialty areas. Intensive care nurses, for example: they are more proficient than most doctors in dealing with critically ill patients. In certain instances the same goes for pediatric nurse practitioners and surgical nurse clinicians, not to mention the nurse-midwife. But with more doctors around, the trend seems to have leveled off. With doctors’ incomes static or even declining, they are more likely to say, “I’ll do it myself.” Also, with fewer patients per doctor, doctors are going to spend more time with those they have. At least, it is my fond hope that this will happen. But it does mean that the physician will be less willing to delegate patient care to others.

What has happened to the typical doctor? Is he still the totally dedicated, almost driven person who seems to have to work around the clock?

I think the days of “iron men in wooden ships” are mostly over in medicine, as they are in many other areas. Maybe it’s an outgrowth of the feeling that became widespread in the 1960s, when young men and women were saying, “Work is important to me but I do want to raise a family and I’m going to put that in my priority of things.” So the total dedication to medicine that typified people of my generation is not so evident. Particularly in the case of the children of old-time doctors, there was the feeling that “I watched the old man killing himself, I never knew him, and toward the end he was embittered about it. He didn’t even like his patients because he was so overworked, and I don’t want to be like that—there are some other things to life as well.”

Is there also a feeling that they may be better physicians if they don’t overwork themselves?

Yes, I think that’s true. You get enormous arguments between the generations on this. The old guard says: “What is medicine coming to? When I started, I couldn’t get married till I was thirty-five, I never made over five thousand dollars a year, and I got up anytime in the middle of the night when I had to. What’s the matter with these kids who gripe about working every other night? I worked every night. To want to have every other weekend off is a disgrace—it’s ruining the profession.” I think the answer to that has to come from knowing how long you can stay up and still make sensible decisions. Young doctors make many more critical life-or-death decisions nowadays. Without a doubt, overwork can have its unfortunate effects. Of course, it is a basic part of the training of physicians to be capable of making decisions on the basis of considerable uncertainty about every fifteen minutes all day long, some of them with rather profound implications. When you are terribly tired, there is probably too big a chance that you might not make the right one.

And I suppose you could say that with all the new technologies around and so much recently discovered knowledge, the job of being a good doctor is tougher now and the clear-cut decisions even harder to come by.