The State Of Medical Care, 1984


Is this excess capacity true in the case of the great urban medical centers, the teaching hospitals?

Not so much, but they themselves face a severe crisis today for other reasons, and this has troubled me for some time. The teaching hospitals occupy an odd position. They are the major producers of doctors, but they are also the court of last appeal for very sick people, the providers of the most expert care and treatment. And they have a third responsibility: To care for the sick poor. This close tie with the public is something you don’t find in the law schools or engineering schools—all they do is train professionals. Now the three-part responsibility was perfectly all right in the old days. The fledgling doctors could learn their craft by taking care of the sick poor and they also could observe extremely complex medical cases at firsthand. But the teaching hospitals took on a greatly expanded role when the technological revolution came along: they were asked to be the centers of biomedical research. This made them quite expensive. On top of that, in recent decades they were asked to expand their community services tremendously. More than a quarter of these magnificent institutions sit squarely in the midst of our largest and most troubled inner cities. So they found themselves running all sorts of drug abuse centers, alcohol programs, outreach clinics, and the like, largely for the poorer segments of our society. Most of this was paid for by the public through government funding. I’m not sure that it was wise to ask all this of teaching medical centers: perhaps the private medical profession could have shared in the responsibility for taking care of the have-nots. But the government and organized medicine simply have never been able to settle that question. As a result, many of the problems came to rest on the academic centers. Now comes the crunch: The government is beginning to cut back on its funding, but meanwhile the teaching hospitals have lost not only many of their biggest sources of private money—middleclass patients—but also many of their most competent doctors to the suburbs. They are in a terrible bind. They are still being asked to do everything they did before, but the money is simply drying up.

What are they going to do about it?

I’m afraid they will have to cut back on many of those new services, and simply do less. The one thing they cannot give up is their traditional mission of providing care for poor people, who have the toughest time getting it. If they back away from that, I believe they will forfeit much of their legitimate call on public support.

All this adds up to a formidable lot of changes that have come over the U.S. medical community in the past half-century. Sometimes it almost looks as though doctors have to keep scrambling just to stay abreast of all the shifts and crosscurrents.

I would agree. Once society has acquired technology with such great potential, you ask yourself, What do we want of the medical profession? You want your doctors to fulfill their sacred vows to take care of you as an individual, on a one-on-one basis, without regard to any political beliefs, yours or theirs. You surely do not want your physician to make value judgments as to whether you do or do not deserve good care because of your age or social status. But you probably hope that he or she will be aware of the changes that are going on in society and in the profession and will be ready to adapt. I think they are. I’ve watched my colleagues and believe that an encouraging number of them are saying: “The practice of medicine has changed profoundly, but I’m changing too. I admit patients to the hospital much less often than I used to when appropriate, and I do virtually all my work-ups on the outside. Many of my dying patients die at home. The system is too expensive. We don’t have to fill all those hospital beds. The support system is there when I need it, but I don’t need it that often. I’ve got to do everything I can to cut down on those costs. I think my patients are better off—and happier—that way.”