Looking back--then forward--at American medicine.

Does graduating from medical school at Tulane University on V-J Day, August 14, 1945 qualify one to look back over more than 60 years of American medical practice? Having practiced as an intern and resident in hospitals, done solo and group practice, served at a university, civilian and military hospitals and done research in teaching facilities, I still maintain a current medical license and DEA number. Feeling qualified to at least express observations and opinions, here are a few thoughts and predictions.

The most obvious alteration in medical practice has been due to one thing--the technology revolution! As the industrial revolution changed the world in the 19th century, technology altered our world throughout the 20th century. Technological changes in the transportation, communication, legal and medical fields have led to a different type of medicine in the 21st century.

Transportation allowed for centralization of medical services, and a new focus on medical care emerged--the emergency room for civilians, and the Mobile Army Surgical Hospital for military personnel. Due to the ease of transportation in this country, patients can be treated in high-tech hospitals on an emergent basis, regardless of their location. Communication advances have also furthered the practice of medicine. Media advances have occurred in news print, radio, television, computers and iPods. Personal and hospital records are stored digitally, allowing access by the patient, physician or a third party with ease, rapidity and security. The days when the radiologist needed to come to the hospital where the roentgenogram was taken and developed are over. Now, the x-ray may be sent to him at home or to his office, to be reported by phone or other means to the attending physician.

Legal modifications, to a great extent culturally motivated, have also been a byproduct of the computer age. Research of any issue has been advanced and simplified by Internet outreach. Interestingly, the United States has more attorneys per capita than any nation in the world. This has encouraged more litigation which in turn has affected the cost and practice of medicine. Litigation against healthcare facilities, as well as practitioners, has been so affected that even death from natural causes is contested. The litigious aspect of healthcare has been discussed, debated and dealt with politically, aggravating rather than stabilizing healthcare costs. Entering medical practice in 1945, there was minimal expense for malpractice insurance. Now exorbitant premiums for coverage have even caused some physicians to discontinue practice.

Finally, the medical technological changes. Tremendous advances in materials such as plastics, metals, solutions and blood fractionalization have led to favorable changes in healthcare at all levels--in-and outpatient care, on the battlefield and in the transportation of patients. As a surgical resident, it felt as though I tied 100,000 knots to control bleeding vessels. Now the superb micro-optics, electrosurgical unit, laser and other magnetic and electrical equipment perform functions unimagined decades ago. Antibiotics have tremendously reduced many of the infections seen during the last century. As a medical student, I recall the banners floating over Canal Street in New Orleans advertising cures for the "great crippler," ie, gonorrheal arthritis which could be treated with the sulfonamides. The wealth of research and knowledge accumulated throughout the past century has necessitated narrowing the fields of medical care, leading to specialization. Fifty-eight years ago when I met and married my wife, there was only one medical clinic in the D.C. area with about 80 doctors. Today, physicians are bound together in clinic operations for group protection and monetary reasons. Medical, health and life insurance companies have been able to capitalize from their statistical study and application of health data to their profit. In addition, as a result of their influence, they have come to control large segments of medical practice and care. The pharmaceutical industry has likewise reaped benefits by virtue of some "miracle drugs," such as penicillin, that set the stage for those to follow. Any practicing physician can attest to the innumerable gadgets available in hospital care--some valuable, but others convenient and adding only to hospital bills. For example, monitoring machines, attendant call devices, TV monitors, Web connections, self-medication units, in-hospital advisors for living wills, terminal and prolonged care additions to the hospital complex, etc. Volunteers have been the bright light in healthcare and have contributed heavily to reduction of healthcare costs. Medical education expenses have increased and clinical material for medical students has often been a problem for teaching institutions. The feminist movement has seen one of its greatest rewards in the fact that more than half of present medical school classes are comprised of women. In 1942, when I entered Tulane School of Medicine, of the 155 in our class, only 4 were women and one dropped out the first week. Another tremendous shift in healthcare has been the reduction of religiously dominated facilities. Last, but by no means least, the computers that have become essential to the practice of medicine have been both a panacea and a problem in the sense that each item or service can be edited and billed--accurately or inaccurately--to the responsible party or agent. This resume could go on, but anyone reading this summary is probably saying, "True--so what?" What is going to happen to the system which, with all its benefits, seems to be out of hand, and is perhaps even unmanageable and too expensive?

What does the future hold? Where do we go from here? Although to prophesy is often considered the pastime of a fool, it is my belief that "past is prologue" and to ignore the lessons of the past is an assurance of future failures. Furthermore, it seems that human nature tends to consistently lead to abuse of power. Thus, the next step is to see that all major players; the healthcare providers, facilities and the health-paying agents stop abusing the system. As the cost of healthcare has reached a point that the average individual can no longer afford even basic services without insurance, recourse may have to be found in government restraints and controls. As the government enters more into the healthcare arena, there will be a tendency for abuse of power, and in another decade or so, the pendulum will shift to the "old" fee-for-service system that I was brought up in with state supported indigent care. Individual responsibility is even now showing its power where the government as well as independent sources are actively trying to shift responsibility for one's health to the individual. The most recent publication of The Physician Executive devotes its issue to "Consumer Driven Health Plans" and a recent editorial in U.S. News and World Report relates how evidence-based medicine "breaks the lock hold" the profession has over the consumer. Organizations and individuals recognize that self care pays dividends and in the long run is the finest form of preventive care and the most economically sound. The indigent population still needs quality health services and this was the case in Louisiana several decades after the 1930s. With time there came abuses and excesses in expenditures and utilization, and thus, the system failed. This forced the state to discontinue financing the monstrous expenditures demanded by redefined indigent health services. A century later, I've seen the cycle turn and so today come demands for a government-operated system for all--and just as assuredly, a century later history will likely repeat itself!

Bore, n.: A person who talks when you wish him to listen.
--Ambrose Bierce

Gerald N. Weiss, MD, FACS, DABS, FICS, DACPE