Annual Oration 1995
By Grant V. Rodkey, M.D.
Physicians are currently enveloped in a revolutionary social
challenge that involves the science of medicine; medical education; the
financing, organization, and delivery of
medical care; the traditional tenets of
patient-doctor relationships; and even the ethics of medicine. In responding to
this challenge, we need to reexamine the core values of our profession and to
preserve those that are relevant to social need.
In considering these issues, I have been particularly influenced
by the insight and writings of some of my fellow Massachusetts physicians,
particularly J. Englebert Dunphy, M.D., "On Caring for the Patient with
Cancer," 1976, H. Thomas Ballantine, M.D., "The Crisis in Medical Ethics,
Anno Domini 1979," and the Shattuck Lecture by H. Brownell Wheeler, M.D.,
"Healing and Heroism," 1990.
Why are these three statements so outstanding? Because each of
them deals in a very significant way with aspects of the most fundamental
element in our profession — the relationship between patient and physician.
Medicine has its roots in prehistory, and a fascinating glimpse
into its origins has been provided by a Massachusetts physician, Guido Majno of
Worcester, in his book The Healing Hand: Man and Wound in the Ancient
World. Even in those ancient times, individuals possessing special
skills in the care of the ill or the wounded were identified, so that nearly 5,000 years ago
Imhotep was described as a physician as well as an architect in the Old Kingdom
of Egypt during the reign of Pharaoh Zoser.
More directly, the traditions of Western Medicine are traced to
Hippocrates, of the Island of Cos, who studied in the Temple of Aesculepius on
Cos and also in Egypt about 2,400 years ago. Hippocrates laid the foundation
for modern medicine by his emphasis on careful observation, methodical
recording of observations, and clinical correlation of his results. He lifted
medicine from superstition to a science, but he also gave it a soul. The
"Oath" that he taught his students has survived to this day as a living
code of conduct for physicians. In essence, he commanded good character,
proficiency in the art, putting the patient's interest before one's own,
confidentiality in the care of patients, generosity towards fellow physicians,
and the faithful teaching of the art to one's successors. Universal attributes
of medicine throughout the history of man have been the twin ingredients of a
person in pain, distress, or illness, and a compassionate and more skilled individual
providing comfort and assistance.
Remarkably, despite the immemorial suffering of man and the
earnest efforts of physicians to comfort and help, most of the effective tools
for treatment of disease and injury have become available within the past 150
years. With the discovery of ether anesthesia in 1846, a new epoch was born.
The swift development of surgery, pathology, bacteriology, antisepsis-asepsis, and
X ray closed out the nineteenth century. During our own century, the scientific
basis for medicine has exploded at a logarithmic rate through physiology,
biochemistry, endocrinology, immunology, antibiotics, transplantation, cell
biology, chemo- and radiotherapy, diagnostic imaging, genetics, and every other
related field. We are now forcing open the door of gene therapy, xenografting,
and defining the human genome. A major impetus to the scientific advances in medicine
has been the funding of research by private philanthropy through foundations and by the United
States government through the National Institutes of Health. The science of
medicine continues to expand, and we can be sure that before the younger
members of our cohort retire, there will be an even greater explosion of
knowledge than has occurred during the century just closing.
As our scientific skills have advanced, however, public
confidence and trust in physicians seem to have declined. The extent of public
reliance upon and expenditures for remedies outside the realm of scientific medicine
is astonishing. Political support for alternate systems of health care outside
of the profession of medicine is always strong. As the training and
certification of physicians becomes ever more thorough and scientifically
based, demand increases for physician report cards, for their treatment
outcomes analyses, for their malpractice claims data, and for more stringent
penalties for fraud and abuse — all certainly manifestations of public
distrust. What do these contradictions mean? What is their portent for the
future of the profession of medicine?
Almost in parallel, the revolution in scientific medicine has
been accompanied by great changes in the financing and administration of
medical care. Otto von Bismarck, in 1883, secured passage by the German
Reichstag of the Sickness Insurance Act. This act initiated the idea of
state-controlled health insurance, which has spread in various forms throughout much of the
world. In the United States the rise of health insurance dates from the
Depression days of the 1930s. It received tremendous impetus during World War II and thereafter,
when unions, business corporations, and government began to use the provision of
health insurance as a tax-free fringe benefit to employee compensation. The enactment of
Medicare and Medicaid in 1965 further increased the pool of individuals in this
country covered by health insurance, both public and private.
In anticipation of greater utilization of medical care by
insured individuals, the United States government, through enactment of the Hill-Burton
Act of 1946 and subsequent amendments, stimulated the building of hospitals
throughout the nation. The Health Professions Educational Assistance Act of
1963, with subsequent amendments, doubled the output of graduates of medical schools
from 8,000 to 16,000 per year. Thus, from 1960 to 1994 physicians in the United States
increased from 142 to 263 per 100,000 population with their numbers growing at
a rate almost four times that of the general population. That period also saw a rapid increase in specialization among medical graduates,
with progressively longer and costlier training programs. Certain specialties
appear to have reached a saturation point, with some 1995 graduates unable to find
employment in their specialty. Yet, the medical schools and the graduate training
programs grind on, and we have at least ten more years of current production
quotas in the pipeline.
Thus, during the past half century many factors have encouraged
increased utilization of medical care: better science, more accessibility, more
affordability (often with no out-of-pocket costs to the patient), increasing
population, increasing longevity, and the ability to prolong tenuous life at
both extremes (neonatal and senile). With the crescendo in services has come an
explosion in the costs of medical care that was not moderated by the restraint imposed
by the patient having to pay for the transaction — restraint that would have
affected not only the patient but also the physician and institutional providers.
This climate has encouraged emphasis on therapeutic medicine to the neglect of
preventive medicine and has encouraged a reckless disregard of good health
practices within a public whose members feel that whatever physiological damage
they do to their bodies can be repaired by the magic of medicine — at no cost
to the recipient! We live in an environment of epidemic violence, injury, and
death, the antithesis of preventive health practices.
Of course, not all the ills of society are the fault of health
care — or the lack of it. Many voices decry the decline in morality in our
society. As members of that society, physicians inevitably share in the climate
of the times. It should not be surprising
to find that some physicians operate from motives of selfishness and greed, and
that some engage in practices that are immoral or criminal. We know that only a
small fraction of our colleagues behave in these ways; however, their ill repute goes far beyond their
number.
Physicians' policing of their own ranks has been seriously
hindered by the application of the antitrust laws to the learned professions
since Supreme Court action in 1943, which classified the practice of medicine
as a trade within the meaning of the Sherman Antitrust
Act, and its ruling in 1975 that the Virginia
State Bar Association could not establish or enforce a minimum fee schedule for
lawyers. In the interest of protecting the public, the medical profession has tried
diligently to regain the right to perform rigorous peer review without risk of
antitrust prosecution. As yet, these attempts have not succeeded.
In the United States, the ferment of
all these ingredients, catalyzed by the efforts of government and business to
restrict the costs of medical care, has generated the rapidly evolving
"managed care" variant of health insurance. The essential arrangement
of all managed care is the interposition of a financial manager between patient
and doctor, constricting payment for services and imposing restrictions upon
the behavior of both parties, with necessary administrative fees (and often a
profit margin) for the manager. If the physician's own earnings are to be diminished by expenditure outlays
for the care of patients — a frequent arrangement — there is an incentive to undertreat,
which may become near imperative. If the physician is at risk of losing employment unless he or she meets
arbitrary goals of cost restriction, the twin pincers of physician glut and
antitrust threat leave him or her defenseless in the advocacy for his or her patient.
Two thoughtful analyses of the social dynamics of these changes are the Shattuck Lecture of 1983 by Alvin R.
Tarlov, and the book The New Medical Marketplace, with "Foreword" by Arnold S. Reiman, M.D.
So how did our great profession sink so low? Did physicians
bring these conditions upon themselves? In part, they did; but, in the main, I think
they did not. Before 1950, physicians generally were not highly paid. With the
rise of third party payors, however, fees could increase without an immediate
direct negative feedback. Many physicians exploited that opportunity — some
with unconscionable greed. This period was, of course, the one when organized
physicians were proscribed by the federal government from reviewing and
restraining fee gouging. Without doubt, the rapid increase in physicians'
earnings attracted many candidates to the profession who were not motivated mainly
by humanitarian impulses, further compounding the downhill spiral in idealism. These changes have
generated both public envy and cynicism. The extremely high cost of medical
education and postgraduate training, coupled with a decade's shorter span of
lifetime earnings, do not excite pity among our critics.
The post-Flexnerian pattern of medical schools as separated, scientific institutes combined with rigorous and competitive premedical courses has resulted in
the monastic segregation of medical students, residents, and physicians
from much of the normal social interaction with other groups in society.
Over time, this lack of close acquaintance breeds misunderstanding and
distrust, and it tends to discourage physicians from taking leadership roles
in their communities after their training has been
completed.
This separation is further compounded by the long
days of work and irregular hours imposed on physicians by
"demand scheduling;" that is, patient calls and needs.
Selfish impulses — perhaps combined with ignorance — may have hindered our making
specialty choices on the basis of demography, or settling in the
Wyoming hills or the Big Sky country of Montana, where physicians are scarce and
social amenities may seem scarcer. These and other failures to
respond to perceived public need have earned us no affection.
Yet, we know as a matter of daily routine the devotion, skill,
humane concern, and personal sacrifice that define the lives of the mass of our
fellow physicians. After twenty-two years of service in the House of Delegates
of the American Medical Association, I can attest to the near universality of
that behavior among physicians in the United States. And after fifty-seven
years of constant immersion in medical education, I think that most medical
students pursue their strenuous studies still with the idealistic hope of being
helpful to others.
So, how will we right the ship? First, we need a realistic
acceptance of our present problems. There is no doubt that, as a profession, we
have less public influence than formerly. It seems inevitable that physicians will be less secure in their employment and in their
income for the foreseeable future, and that they will have less independence.
They may be required to work even harder and for longer hours. Yet, each one of us has
the opportunity to make a successful adaptation to the current pressures on our
profession by controlling his or her own behavior. To take advantage of our
opportunities for success, we should:
- Take a realistic
inventory of our own assets.
- Recognize the power and
potential of social interaction — politics — and be participants.
- Resolve to put patients'
welfare ahead of our own — genuinely to love our neighbor and
reflect concern and goodwill in our words and actions.
- Walk humbly — listen and
respond to the questions and suggestions of others.
- Be open to change — in
opportunity and responsibility.
- Strive constantly to
increase our knowledge and skill as a lifetime commitment.
Our profession has suffered from the withdrawal of physicians
from the political life of their professional organizations, their home
communities, and the nation at large. A part of our challenge and opportunity
is to educate our patients to the value of personal, preventive, health care
and self-responsibility. We must assume leadership in health and behavior education
in our home communities and associate ourselves actively in the political processes
of government. To do this, surprisingly, is to conform with Principle VII of
the Code of Ethics of the American Medical Association and the Massachusetts
Medical Society: "A physician shall recognize a responsibility to
participate in activities contributing to an improved community."
And we shall magnify the effectiveness of our efforts if we work
together in our state medical societies and the American Medical Association — as
well as our specialty societies.
The long-term success of the profession of medicine is inextricably
bound to the survival of humanity. Inescapable human need will demand our
knowledge, skills, and compassion. Each of us — and even the most intransigent
political detractors of the profession — will require the assistance included
in the art and science of medicine. We are challenged through our present
stresses to find more effective and more relevant pathways of public service.
Challenge, struggle, disappointment, and pain are not new, but they
may become part of a renewal process. As a profession, we are forced to
reexamine and refine our effectiveness, our systems for delivery of care, and
even our own motivations. Medicine is a personalized bridge between science and humanity and
must always be changing to accommodate knowledge and need.
Together, we look to the future with confidence grounded in the bedrock
of human experience. Three and one-half centuries ago, in the era of Cromwellian
England, when all social beliefs and institutions were challenged and disrupted,
a church in Leicestershire was dedicated by this inscription:
In ye year 1653, when all
things sacred were throughout ye whole nation either demolished or profaned, Sir
Robert Shirley, baronet, builded this church; whose singular praise it was to have
one the best things in the worst times, and to have hoped them in the most calamitous.
Our great profession, sensitive and responsive to the vastness
of human need, will regenerate as a beacon of hope for humanity.
_______________
Rodkey, Grant V., “Quo
Vadis Medicina?” The Pharos, Spring
Issue (1997), 32-34.
Reprinted with
permission from Alpha Omega Alpha Honor Medical Society.
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