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The Crisis in Medical Care
The Crisis in Medical Care JOHN W. ABBUHL, M.D.
In October 1966, before the American Academy of Pediatrics at its annual meeting, the Surgeon General of the U.S. Public Health Service stated that by 1980, half of all medical college graduates would have to enter pediatrics in order to maintain the existing pediatrician-topatient ratio. It was not necessary for him to refer to the similar needs of many other specialties. There are two broad categories of activities that may occupy the time of a physician. Each requires special training, talents, and interests. Today, these talents and interests have so far diverged that the two kinds of activities have become to a large extent mutually exclusive. The first activity category includes super-specialization, research, teaching, and administration, and the second includes the 99 per cent of physician-patient contacts that make up what might be called first-call or continuing care. The difficulties, the required talents, and the rewards of each kind of activity need not be enumerated here. Statistically obvious is the fact that an increasing number of medical students gravitate to the first category as they advance through their training. The general practitioner, in the sense that he represents a man of lesser training for a lesser job, is vanishing. As his numbers have diminished, however, the need that he fulfilled has not changed. It has, in fact, become greater, along with the increasing medical sophistication of the public. In a brief la-year period, the dictates of science and necessity have changed much of the old pattern of medical care delivery. The pediatrician, especially, has had to spend a much greater amount of time in his office, and the house call has almost disappeared. Surgical emergencies have uniformly been referred to those specialty colleagues who work in emergepcy rooms or in the hospital setting. Where group practices have been feasible, they have helped to increase efficiency. But these are mere holding actions when viewed against the broader aspects of the problem. The relative numbers of internists and pediatricians - the "specialists" who have replaced general practitioners in the broadest medical areas-are also being diminished by the attractiveness of still other and more highly specialized fields. Pediatric Clinics of North America- Vol. 16. No.4, November, 1969
775
776
JOHN
W.
ABBUHL
The cnSlS in medical care today has resulted from three major failures, and from one bold attempt in a nonmedical field to correct the inequities. The first failure has been that of the physician himself. He has been unable to meet the demand of the public for total care of all of the people. He has not even assumed that he has had an individual responsibility for the total public. This is not to say that he has not individually worked to his capacity, but working to capacity has not been enough. The second failure has been that of organized medicine. Collectively, in our broad professional societies and in our narrow specialty groupings, we have not been able to promulgate plans and actions that meet the needs of all the people for health care. Finally, the third failure has been in our medical schools. The nature of the scientific advance has been such that, increasingly, the control of medical training has fallen into the hands of those men who themselves have specialized beyond the point where they can any longer appreciate the public needs. But they bear the primary responsibility for training physicians to meet these same needs. The acme of physician training has been to give experience in the treatment of that tiny segment of the population suffering from sophisticated and rare disorders. Far more important to society is the sophisticated management of everyday problems. The ability to recognize a common problem has greater social impact than the ability to cure a rare disease.
A House Divided The essential and interdependent nature of medicine's divided house is the main theme. Coordinated cooperation between both groups is necessary for the public good. The crisis has arisen from the practical obliteration of the philosophy that it might be better for 100 per cent of the people to get "90 per cent care" than for 10 per cent of the people to get "100 per cent care." The government has recognized the inequity of medical care distribution today. There can be no solution to the problem of poverty that does not include the provision of health care for poor people and that does not also include a kind of medical insight into their educational needs. Governments do not have this sort of insight, and their actions so far have unwittingly contributed to the crisis in medical education and medical organization. Interest and talent go where the money is. Grants and research funds have shifted much of medicine's orientation away from the everyday needs of everyday patients. They have had an especially telling effect in the early years of a physician's training, before he has ever gotten to know intimately the scope of these needs. How has society managed in the face of these failures? Our hospitals as institutions of learning-as well as of patient care-have given crisis care, and when there is a real crisis, there is no better place that medicine could devise. But crisis care without follow-up, without proper experienced guidance, without human feeling, breeds public discontent, increases expense, and results only in more crisis care.
THE CRISIS IN MEDICAL CARE
777
A Bold Attempt People know that something is wrong. Their physicians can tell them what it is, but not what to do about it. Government has taken a bold action and struck at what appeared to be the heart of the medical care dilemma. This was done by providing money for personal medical care. The announced intention was to do away with multiple standards of patient care, a principle to which any practicing physician would prefer to adhere. It would mean that all of the people would receive that standard of health care that represented the best that science could devise. But, as in all programs, the best that science can devise is limited in its application by the money that society is willing to spend. In everyday patient care the economic factor is inseparable from the making of a sound medical judgment, but we all know that the traditions of medicine, and of this country, are that cost shall not be a concern. It is to the everlasting credit of private medicine in this country that the government has chosen it as the system that would be most effective. The initiative of government has been required to start the ball rolling, but the future direction of the delivery of health care is now up to physicians themselves. Guidance and implementation of medical care for everyone rests with those members of the medical community who know what it takes to deliver the 99 per cent of doctor-patient contacts mentioned earlier. Money alone does not ensure that care is available, or that no double standard will operate. One action of government cannot make up for three failures of medicine.
What Is Required First, each individual physician must feel personally responsible for helping to meet the total need of the public. He cannot do this by refusing Medicaid patients. Medicaid standards, however, must closely approximate reasonable private fees, if a double standard is not to creep in. The physician, of course, is only one man, and there are limits to his available time. Better organization, in groups and with efficient use of ancillary personnel, is required if he is to meet the community's need for medical care. Second, organized medical societies must support the individual physician in his efforts to provide care for all the people, and must be willing to approve of changes in delivery systems from what they currently appear to be. Organized medicine must be philosophically committed to the principle of providing care to everyone. Third, medical schools must commit themselves to the principle that physicians should be trained, at least in part, for that activity for which there is the greatest professional need. Training programs must include exposure to a model system of patient care that is both scientific and economically feasible. To separate professional training, even at that specialty level that is now expected to meet the demand for continuing care, from contact with the realities of community needs is to be untrue to science. Most of this training today has been without adequate guidance in an entirely unrealistic format.
778
JOHN
W.
ABBUHL
Fee-far-service practice, which is the essence of private practice, is the one mechanism that can provide the public with the performance and dedication needed to get a difficult job done. Anything in medical training that undermines the ethics of this approach decreases the availability of physicians who are willing to practice, and ultimately increases the cost of medical care. Our society has traditionally operated on the law of supply and demand. With overabundance of a service, greater excellence or efficiency has won the day; with undersupply, the reward has gone up, and increased numbers of talented men have entered the field. In medicine, training programs have discouraged high-volume patient contact. Instead of showing how it can be done, they have tended to neglect the obvious need and to show instead why it should not be done. By comparison with advances in other professional or industrial endeavors, modern medical practice is archaic-not because it is not scientific, but because the giving of individual service cannot be completely automated. It takes a special kind of dedicated and extremely energetic man to make a success of medical practice. The breed is vanishing along with the comparative rewards. Physicians have tended in increasing numbers to seek salaried positions with regular hours and the usual benefits. Fewer are starting practice, and many who have tried it are leaving. Salaried positions are essential for the special man whose time is spent in those unmeasurable activities of teaching, research, administration, and seeing those special few patients who could not possibly afford his services. These men must be salaried, because they must be shielded from patient demand if they are to accomplish their basic tasks. Service to patients on a volume basis-a service which can become all-consuming - cannot be provided by a salaried physician. Fee-forservice is essential, or there will be a tendency to gradually withdraw from service and fill one's time with other activities that are also essential but that do not involve meeting patient volume or patient demand. Patients are then seen only when they meet the special needs of a research project or a teaching program. Society cannot yet afford the luxury of removing from the private sector the greater part of the volume of patient care. If the needs of the community are to be met, there must be intense dedication, resourcefulness, and initiative - provided most effectively by those methods that have over the years proved to mak~ the difference in this country's achievements. A Plan of Action What is needed, then, is a plan of action: action taken in concert by all parts of the medical community. This action should complement the first bold step already taken by the government. It must correct those inequities of the present system of medical education and delivery that are known to all physicians, both those who deliver continuing patient care and those who participate in medical education. This action must meet squarely the one over-riding reality of health care delivery todaythe overwhelming demand. Any professional activity that removes a physician from his primary responsibility leaves the public in a difficult
THE CRISIS IN MEDICAL CARE
779
situation. When the physician spends his time away from practice in a professional pursuit such as teaching that does not necessarily allow him to contribute his particular talents to a new generation of physicians to replace him, then the public dilemma is all the greater. Three major goals for this plan of action may be listed. 1. To make health care available to all patients at all times. 2. To provide clinical training for that part of medicine that must concern itself with volume care. 3. To facilitate clinical research.
The aim is to reverse the trend toward a diminishing availability of medical care, and in fact to provide a model example of volume practice, both to meet community needs and to offer realistic training. The proposals for implementation are as follows: 1. Establish fee-for-service clinics in teaching hospital environments. These clinics will be based on the assumption of private responsibility for all patients. 2. Recognize the principle that the fee for professional service should be adequate to compete with private practice out of the hospital. A portion of this fee should be allotted for reasonable overhead and other professional personnel. Properly adjusted, such a fee would favor that professional activity that meets the public need for continuing care on a volume basis. 3. Physicians in charge to be associated as in a group practice and to remain continuously in charge in the manner of a private practice. 4. Residents in training to be under the direct personal supervision of the physician in charge. S. Residents to be associated with such a model practice for a minimum of 12 months. This does not preclude their having other hospital responsibilities. 6. Consultation to be continuously available by specialized research staff, both for the benefit of patients and for the continuing education of physicians directly in charge of patient care. 7. Institute automatic data processing of patient information. This will provide valid information on the relationships between professional time, qualifications, laboratory data, and cost, on the one hand, and quality of care on the other. Such information, having scientific validity, does not exist today for the 99 per cent of doctor-patient contacts that constitute continuing first-call care.
The recent Medicaid legislation represented a sincere attempt on the part of the federal government to try to make private medical care more generally available. It was the first significant act in the economic field that could serve this end. The implementation of such a program must still rest with the physician. The government provides the means to prime the pump of patient care, but only physicians can man those pumps. If funds so honestly provided could be siphoned away by the very same administrative structures that have been responsible for directing physicians away from private practice, then what hope can there be of providing the new and vital programs that will be necessary to provide the ever-increasing volume of care? We can see now that Medicaid, in its present form, is not the final answer. Noone really expected that it would be. The government was not prepared to believe that expenses would be so great, and the public was not ready to pay such a large bill for the help of so small a group. It now appears that some form of universal health insurance, perhaps with indemnity features, will be the next step in trying to find an acceptable legislative solution to the problem of paying for medical care.
780
JOHN
W.
ABBUHL
Physicians who deliver health care must somehow be consulted in the formation of this future legislation. Our Medicaid experience has taught us that only a relatively few physicians in large ghetto communities are willing to make the changes in their practices that will be necessary to accommodate future demand. What it takes to encourage this accommodation is well known by those who have tried. Certainly, inviting public ridicule, assuring increased man-hours of work, and reducing fees-for service and for increased overhead-is not the right way to encourage a job that must be done. What is needed by the public is not more medical training, or less training, but physicians trained differently. A physician must be trained to be more efficient as well as more scientific and even more humanistic. The physician must be trained in a significant degree by those who know intimately the problems of providing continuing first-call care, and who know best how to organize their services to be consistent with science as well as with economy and humanity. Medical utopia is not an arbitrary set of desires uninfluenced by economic and sociologic facts. A community comprises a mass of people with predictable problems. Those problems are initially met by manhours of doctor-patient time spent together. Experienced practitioners in general fields of medicine must contribute more toward the training and philosophy of the physicians of the future. We need physicians who will aspire to earn their livings by seeing, or overseeing, large numbers of patients. We need physicians whose measure of excellence comes from competently picking out those problems that will need the special investigations of others. We need him to represent medicine to the public in its highest image. His talent and respect must be of the highest order, if future physicians-in-training are to take their place in serving this first and most important need of the people. 450 New Scotland Avenue Albany, New York 12208
In October 1966, before the American Academy of Pediatrics at its annual meeting, the Surgeon General of the U.S. Public Health Service stated that by 1980, half of all medical college graduates would have to enter pediatrics in order to maintain the existing pediatrician-topatient ratio. It was not necessary for him to refer to the similar needs of many other specialties. There are two broad categories of activities that may occupy the time of a physician. Each requires special training, talents, and interests. Today, these talents and interests have so far diverged that the two kinds of activities have become to a large extent mutually exclusive. The first activity category includes super-specialization, research, teaching, and administration, and the second includes the 99 per cent of physician-patient contacts that make up what might be called first-call or continuing care. The difficulties, the required talents, and the rewards of each kind of activity need not be enumerated here. Statistically obvious is the fact that an increasing number of medical students gravitate to the first category as they advance through their training. The general practitioner, in the sense that he represents a man of lesser training for a lesser job, is vanishing. As his numbers have diminished, however, the need that he fulfilled has not changed. It has, in fact, become greater, along with the increasing medical sophistication of the public. In a brief la-year period, the dictates of science and necessity have changed much of the old pattern of medical care delivery. The pediatrician, especially, has had to spend a much greater amount of time in his office, and the house call has almost disappeared. Surgical emergencies have uniformly been referred to those specialty colleagues who work in emergepcy rooms or in the hospital setting. Where group practices have been feasible, they have helped to increase efficiency. But these are mere holding actions when viewed against the broader aspects of the problem. The relative numbers of internists and pediatricians - the "specialists" who have replaced general practitioners in the broadest medical areas-are also being diminished by the attractiveness of still other and more highly specialized fields. Pediatric Clinics of North America- Vol. 16. No.4, November, 1969
775
776
JOHN
W.
ABBUHL
The cnSlS in medical care today has resulted from three major failures, and from one bold attempt in a nonmedical field to correct the inequities. The first failure has been that of the physician himself. He has been unable to meet the demand of the public for total care of all of the people. He has not even assumed that he has had an individual responsibility for the total public. This is not to say that he has not individually worked to his capacity, but working to capacity has not been enough. The second failure has been that of organized medicine. Collectively, in our broad professional societies and in our narrow specialty groupings, we have not been able to promulgate plans and actions that meet the needs of all the people for health care. Finally, the third failure has been in our medical schools. The nature of the scientific advance has been such that, increasingly, the control of medical training has fallen into the hands of those men who themselves have specialized beyond the point where they can any longer appreciate the public needs. But they bear the primary responsibility for training physicians to meet these same needs. The acme of physician training has been to give experience in the treatment of that tiny segment of the population suffering from sophisticated and rare disorders. Far more important to society is the sophisticated management of everyday problems. The ability to recognize a common problem has greater social impact than the ability to cure a rare disease.
A House Divided The essential and interdependent nature of medicine's divided house is the main theme. Coordinated cooperation between both groups is necessary for the public good. The crisis has arisen from the practical obliteration of the philosophy that it might be better for 100 per cent of the people to get "90 per cent care" than for 10 per cent of the people to get "100 per cent care." The government has recognized the inequity of medical care distribution today. There can be no solution to the problem of poverty that does not include the provision of health care for poor people and that does not also include a kind of medical insight into their educational needs. Governments do not have this sort of insight, and their actions so far have unwittingly contributed to the crisis in medical education and medical organization. Interest and talent go where the money is. Grants and research funds have shifted much of medicine's orientation away from the everyday needs of everyday patients. They have had an especially telling effect in the early years of a physician's training, before he has ever gotten to know intimately the scope of these needs. How has society managed in the face of these failures? Our hospitals as institutions of learning-as well as of patient care-have given crisis care, and when there is a real crisis, there is no better place that medicine could devise. But crisis care without follow-up, without proper experienced guidance, without human feeling, breeds public discontent, increases expense, and results only in more crisis care.
THE CRISIS IN MEDICAL CARE
777
A Bold Attempt People know that something is wrong. Their physicians can tell them what it is, but not what to do about it. Government has taken a bold action and struck at what appeared to be the heart of the medical care dilemma. This was done by providing money for personal medical care. The announced intention was to do away with multiple standards of patient care, a principle to which any practicing physician would prefer to adhere. It would mean that all of the people would receive that standard of health care that represented the best that science could devise. But, as in all programs, the best that science can devise is limited in its application by the money that society is willing to spend. In everyday patient care the economic factor is inseparable from the making of a sound medical judgment, but we all know that the traditions of medicine, and of this country, are that cost shall not be a concern. It is to the everlasting credit of private medicine in this country that the government has chosen it as the system that would be most effective. The initiative of government has been required to start the ball rolling, but the future direction of the delivery of health care is now up to physicians themselves. Guidance and implementation of medical care for everyone rests with those members of the medical community who know what it takes to deliver the 99 per cent of doctor-patient contacts mentioned earlier. Money alone does not ensure that care is available, or that no double standard will operate. One action of government cannot make up for three failures of medicine.
What Is Required First, each individual physician must feel personally responsible for helping to meet the total need of the public. He cannot do this by refusing Medicaid patients. Medicaid standards, however, must closely approximate reasonable private fees, if a double standard is not to creep in. The physician, of course, is only one man, and there are limits to his available time. Better organization, in groups and with efficient use of ancillary personnel, is required if he is to meet the community's need for medical care. Second, organized medical societies must support the individual physician in his efforts to provide care for all the people, and must be willing to approve of changes in delivery systems from what they currently appear to be. Organized medicine must be philosophically committed to the principle of providing care to everyone. Third, medical schools must commit themselves to the principle that physicians should be trained, at least in part, for that activity for which there is the greatest professional need. Training programs must include exposure to a model system of patient care that is both scientific and economically feasible. To separate professional training, even at that specialty level that is now expected to meet the demand for continuing care, from contact with the realities of community needs is to be untrue to science. Most of this training today has been without adequate guidance in an entirely unrealistic format.
778
JOHN
W.
ABBUHL
Fee-far-service practice, which is the essence of private practice, is the one mechanism that can provide the public with the performance and dedication needed to get a difficult job done. Anything in medical training that undermines the ethics of this approach decreases the availability of physicians who are willing to practice, and ultimately increases the cost of medical care. Our society has traditionally operated on the law of supply and demand. With overabundance of a service, greater excellence or efficiency has won the day; with undersupply, the reward has gone up, and increased numbers of talented men have entered the field. In medicine, training programs have discouraged high-volume patient contact. Instead of showing how it can be done, they have tended to neglect the obvious need and to show instead why it should not be done. By comparison with advances in other professional or industrial endeavors, modern medical practice is archaic-not because it is not scientific, but because the giving of individual service cannot be completely automated. It takes a special kind of dedicated and extremely energetic man to make a success of medical practice. The breed is vanishing along with the comparative rewards. Physicians have tended in increasing numbers to seek salaried positions with regular hours and the usual benefits. Fewer are starting practice, and many who have tried it are leaving. Salaried positions are essential for the special man whose time is spent in those unmeasurable activities of teaching, research, administration, and seeing those special few patients who could not possibly afford his services. These men must be salaried, because they must be shielded from patient demand if they are to accomplish their basic tasks. Service to patients on a volume basis-a service which can become all-consuming - cannot be provided by a salaried physician. Fee-forservice is essential, or there will be a tendency to gradually withdraw from service and fill one's time with other activities that are also essential but that do not involve meeting patient volume or patient demand. Patients are then seen only when they meet the special needs of a research project or a teaching program. Society cannot yet afford the luxury of removing from the private sector the greater part of the volume of patient care. If the needs of the community are to be met, there must be intense dedication, resourcefulness, and initiative - provided most effectively by those methods that have over the years proved to mak~ the difference in this country's achievements. A Plan of Action What is needed, then, is a plan of action: action taken in concert by all parts of the medical community. This action should complement the first bold step already taken by the government. It must correct those inequities of the present system of medical education and delivery that are known to all physicians, both those who deliver continuing patient care and those who participate in medical education. This action must meet squarely the one over-riding reality of health care delivery todaythe overwhelming demand. Any professional activity that removes a physician from his primary responsibility leaves the public in a difficult
THE CRISIS IN MEDICAL CARE
779
situation. When the physician spends his time away from practice in a professional pursuit such as teaching that does not necessarily allow him to contribute his particular talents to a new generation of physicians to replace him, then the public dilemma is all the greater. Three major goals for this plan of action may be listed. 1. To make health care available to all patients at all times. 2. To provide clinical training for that part of medicine that must concern itself with volume care. 3. To facilitate clinical research.
The aim is to reverse the trend toward a diminishing availability of medical care, and in fact to provide a model example of volume practice, both to meet community needs and to offer realistic training. The proposals for implementation are as follows: 1. Establish fee-for-service clinics in teaching hospital environments. These clinics will be based on the assumption of private responsibility for all patients. 2. Recognize the principle that the fee for professional service should be adequate to compete with private practice out of the hospital. A portion of this fee should be allotted for reasonable overhead and other professional personnel. Properly adjusted, such a fee would favor that professional activity that meets the public need for continuing care on a volume basis. 3. Physicians in charge to be associated as in a group practice and to remain continuously in charge in the manner of a private practice. 4. Residents in training to be under the direct personal supervision of the physician in charge. S. Residents to be associated with such a model practice for a minimum of 12 months. This does not preclude their having other hospital responsibilities. 6. Consultation to be continuously available by specialized research staff, both for the benefit of patients and for the continuing education of physicians directly in charge of patient care. 7. Institute automatic data processing of patient information. This will provide valid information on the relationships between professional time, qualifications, laboratory data, and cost, on the one hand, and quality of care on the other. Such information, having scientific validity, does not exist today for the 99 per cent of doctor-patient contacts that constitute continuing first-call care.
The recent Medicaid legislation represented a sincere attempt on the part of the federal government to try to make private medical care more generally available. It was the first significant act in the economic field that could serve this end. The implementation of such a program must still rest with the physician. The government provides the means to prime the pump of patient care, but only physicians can man those pumps. If funds so honestly provided could be siphoned away by the very same administrative structures that have been responsible for directing physicians away from private practice, then what hope can there be of providing the new and vital programs that will be necessary to provide the ever-increasing volume of care? We can see now that Medicaid, in its present form, is not the final answer. Noone really expected that it would be. The government was not prepared to believe that expenses would be so great, and the public was not ready to pay such a large bill for the help of so small a group. It now appears that some form of universal health insurance, perhaps with indemnity features, will be the next step in trying to find an acceptable legislative solution to the problem of paying for medical care.
780
JOHN
W.
ABBUHL
Physicians who deliver health care must somehow be consulted in the formation of this future legislation. Our Medicaid experience has taught us that only a relatively few physicians in large ghetto communities are willing to make the changes in their practices that will be necessary to accommodate future demand. What it takes to encourage this accommodation is well known by those who have tried. Certainly, inviting public ridicule, assuring increased man-hours of work, and reducing fees-for service and for increased overhead-is not the right way to encourage a job that must be done. What is needed by the public is not more medical training, or less training, but physicians trained differently. A physician must be trained to be more efficient as well as more scientific and even more humanistic. The physician must be trained in a significant degree by those who know intimately the problems of providing continuing first-call care, and who know best how to organize their services to be consistent with science as well as with economy and humanity. Medical utopia is not an arbitrary set of desires uninfluenced by economic and sociologic facts. A community comprises a mass of people with predictable problems. Those problems are initially met by manhours of doctor-patient time spent together. Experienced practitioners in general fields of medicine must contribute more toward the training and philosophy of the physicians of the future. We need physicians who will aspire to earn their livings by seeing, or overseeing, large numbers of patients. We need physicians whose measure of excellence comes from competently picking out those problems that will need the special investigations of others. We need him to represent medicine to the public in its highest image. His talent and respect must be of the highest order, if future physicians-in-training are to take their place in serving this first and most important need of the people. 450 New Scotland Avenue Albany, New York 12208