- Email: [email protected]
The doctor—Third parties
The doctor-Thi rd parties Harold Schulman, M.D. Bronx, New York
Whenever one assumes this position, the first and dominating concern becomes the presidential address. These presentations have covered a spectrum of interests including pure clinical science, historical review, and assessments of the role of the society in our professional lives. I have decided to speak to you about the dramatic changes which are occurring in our professional lives and offer some suggestions for the direction in which our thinking and activities should move. The subject to be discussed is entitled "The Doctor-Third Parties." (AM. J. OBSTET. GYNECOL. 149:624, 1984.) The phrase "third party" generally invokes an association with insurance payments for medical care. However, there are now a number of other third parties in the physician's life. These include committees which direct training and education, government, practice competitors and patterns, society and consumers, and the legal profession. I should like to comment upon all these elements or, as some might call them, "intruders." I am sure that one of the reasons that many of us were attracted to medicine as a career is because of the freedom and independence it seemed to offer. Education and training
In the past two decades there has been an extraordinary formalization of the education and training of physicians interested in obstetrics and gynecology. Several forces have contributed to this current state of affairs. Most prominent was the decision by the (former) American Association of Obstetricians and Gynecologists to use the interest income from an endowment from the Kennedy Foundation to further education in obstetrics and gynecology. Under the leadership of Dr. Charles Hunter, then at the University of Washington in Seattle, a liaison was established with professional educators to assist faculties throughout the United States to teach more effectively. 1 Regional workshops were established in which we were taught a basic educational triangle. The three points were: (1) state your From the Department of Gynecology and Obstetrics, Albert Einstein College of Medicine of Yeshiva University. Presidential address, presented at the Meeting of the One Hundred Nineteenth Year of The New York Obstetrical Society, May 10, 1983. ReceivedAugust4, 1983; revised December 7, 1983; accepted]anuary 10, 1984. Reprint requests: Harold Schulman, M.D., Department of Gynecology and Obstetrics, Nassau Hospital, 259 First St., Mineola, NY 11501.
624
educational objectives, (2) provide the resources for the achievement of these objectives, and (3) provide a straightforward testing situation to see if the educational objectives were achieved. A committee of the Association of Professors of Gynecology and Obstetrics (APGO) developed educational objectives; these have now been developed for residency education and for preparation for certification in maternal-fetal medicine, oncology, and endocrinology. The Council on Resident Education in Obstetrics and Gynecology (CREOG) offered the first residency training in-service examination in 1970. The examination was originally designed as a self-assessment test. However, with the aid of consultants, the difficulty, discrimination, and reliability indices have improved to the point that many residency program directors are requiring minimal achievement levels such as 30% or greater on the multiple choice questions for a physician to remain in good standing. A notable feature of the examination is the attempt to give the resident direct computer-programm ed feedback on the incorrect answers. This may also assist faculty in identifying program weaknesses. 2 Also of interest is that when faculty took the examination it was found that their ability to answer multiple choice questions declined with the passage of time but their patient management skills remained at a high level. In other words, after we complete our residency program, education diminishes but clinical skills or training persists. Two significant events have occurred this year which deserve our attention. These are the initiation of the special requirements of the Residency Review Committee and the enactment of limited Board certification. The Residency Review Committee requirements are comprehensive and appropriate. They identify 15 areas of study which would seem to be in concert with Hunter's philosophy of stating the objectives and expecting the program to establish the resources. The committee will attempt to decide from the site visitor's report whether the resources have been adequately provided. My early experiences as a specialist site visitor suggest to me that the committee is moving too hard and too fast. However, assuming the requirements and recommendations are reasonable, we should all welcome the goals and strive to meet them. A final effort to upgrade our knowledge or perhaps our image is the proposal that Board certification be a
The doctor-Third parties 625
Volume 149 Number 6
limited award. The reason stated is that " ... expansion of medical knowledge has been so rapid that it has become impossible for physicians to remain highly competent .... "3 Although fears and threats in the form of an examination are a time-proved academic technique of forcing people to study, I had hoped different directions would prevail. The electronic-information age should stimulate our organizations to create resource materials that work for the practitioner. Videotapes and home computer-assisted teaching programs offer a promise of deterring the informational erosion demonstrated by the CREGG testing program and also provide tools for surveillance of the individual's participation.
Government In this century, physicians in the United States have successfully prevented government from interfering significantly in their professional activities. Starr4 hypothesized that much of this success was produced by our acquisition of cultural authority. Science gave us remarkable tools to make diagnoses and provide medical and surgical remedies. The rapidity of the creation of this new tower of medical information gave the physician an enormous advantage over lay persons and created the exalted doctor-patient relationship: a paternalistic authoritarian figure and a dependent, trusting, distressed individual. Financing of medical care in this country remains uniquely different from that in most other developed countries. Although the American Medical Association vigorously opposed third-party insurance programs, we know now that this presumed intrusion has been turned to our advantage. The private enterprise system predominates. The budget problems of medicare, medicaid, and social security plus the deficiencies of the Canadian and British health systems make it unlikely that state or national government will assume control of physician services or payment structure in the near future. Some states have enacted legislation requiring a certain number of continuing medical education credits for renewal of licensure. Whether these misguided efforts are actually being enforced is uncertain. I think most of us know that the amount of learning in the usual continuing medical education program is minimal. Exposure to information does not fulfill the necessary triad of the educational process.
production and child-rearing means a need for more regular hours to carry out her family and professional obligations. This implies working in groups, clinics, and hospitals. It also suggests that work will be carried out for lesser wages, because the physician-mother is not likely to be the sole earner in the family. Walk-in medical care clinics are a new wave worthy of attention. Recent surveys indicate that at least one third of Americans do not have a personal physician, nor are they interested in having one. They have been attracted to the convenience of walk-in medical services and have been satisfied with the service rendered. Couple this trend with a recent survey by the American College of Obstetricians and Gynecologists of the office activities of obstetrician-gynecologists, and a potential problem is evident. The survey revealed that two thirds of the practitioner's time is spent on the annual examination or health checkup. 5 It is clearly a dichotomy to spend 4 years in a residency program fulfilling the special residency training requirements, become Board certified from an examination designed to test one's expertise as a consultant, and then spend the majority of one's time carrying out a series of simple tasks. The success of nurse-practitioners, midwives, and family planning and abortion clinics testifies to the validity that many of our activities could be carried out as well and cheaper by trained assistants. If gynecologists do not organize these patterns of care, other organizations will. A foremost force on the horizon is the hospital corporation. Starr has predicted that corporate structure will eventually consume the private practitioner. Within the past 25 years we have seen hospital leadership pass from the physician's hands to those of the administrator, cost-effective accountants, and a board of directors. The delicate and difficult fiscal issues of maintaining a balanced budget plus meeting the accountability needs of third-party, governmental, and legal agencies have made the doctor's personal needs of secondary priority to the hospital. In urban areas most hospital beds are filled so that the physician's power of not admitting patients is now blunted. Good hospital leadership requires an identification as a humane, progressive, and modern institution. Hospitals that fail to compete effectively will be consumed by the corporate structure. The consequences of this for physicians may be the final chapter in their reign of power and the threat is that they will become occasional advisers and employees.
Practice The practice of obstetrics and gynecology is on the brink of significant change. There are a number of factors which portend the likelihood of this change. The large number of women being recruited into our specialty will undoubtedly change practice patterns. The woman's ultimate responsibility in re-
Law Malpractice litigation has profoundly influenced our professional lives. It has become the singular most talked about topic among physicians. To some degree we have passed from the wounded ego stage to the knowledge that we will inevitably be sued if we practice
626
Schulman
obstetrics and gynecology. A positive aspect of the malpractice phenomenon is a better awareness by physicians of the limits of their decision-making freedom. We simply do not have the right to make decisions of which we are not certain. Standards of practice are paramount, appropriate workup and consultation are necessary, and careful documentation is mandatory. It must be conceded that all of our colleagues do not meet appropriate standards of practice, and our peer review process is defective. The negative aspects of malpractice include the financial rewards, the many injustices, and the emergence of the bargained contract euphemistically called a "settlement." The major impact of the malpractice issue is the cost of yearly premiums. The cost has approached the point where the solo practitioner or small group simply cannot afford to bring in a new associate. The graduating resident will increasingly be forced to work in a group clinic or hospital-based structure. Again it is a force which will diminish the potential income of the physiCian. Society
Two powerful forces are changing the image of the doctor in society, and obstetrics-gynecology has been a primary focus. These forces are the media and feminism. The women's movement has been spectacularly successful in critiquing the male-female roles in our society. As a consequence we have become more sensitive to our attitudes and language in dealing with women. Prepared childbirth and parenting is no longer an interesting movement, but it represents a necessity of adequate prenatal care. Breast-feeding is not a relic replaced by technology but represents an essential health activity for mother and baby. Birth control techniques are not panaceas to be prescribed without reflection about consequences to health and life. Chaperones in the examining room may be an undesired invasion of privacy. The woman is not looking for a father or lover in her doctor but is seeking respectful complete information. Television and the media have probably changed our image most. Starr believes that one of the major reasons physicians had assumed such a powerful authoritative position was our knowledge of biology and science. The person seeking medical help was awed by the miracles promised by biochemistry, physiology, pharmacology, and engineering ingenuity. The patient was in no position to disagree, and many physicians were comfortable with the authority role. Witness the behavior of some of our colleagues to nurses or their petulance when patients disagreed, did not follow orders, or dared to seek another opinion. The media now
July 15, 1984 Am. ]. Obstet. Gynecol.
provide ample medical information for all. The major television networks report weekly on the lead article in The New England journal of Medicine, and there are innumerable features and special reports. Most of us learned about toxic shock syndrome from television and newspapers. The patient is no longer in awe. Our advice is measured against that which is read or heard and is even compared to that of others. For example, there are now 23,000 women who call themselves childbirth educators, and their clients use them frequently as informational resources. A proscription
A large segment of society is dissatisfied with us, and many physicians are frustrated, annoyed, and confused about their image and what is expected of them. It is naive for us to continue to pose as scientists. Our courses in college and 2 years of basic science in medical school do not make us scientists. There is no denying, however, that we acquire an enormous amount of information in our 8 or more years of medical training. We are also the recipients of some extraordinary technical skills. The act of surgery today with the assistance of anesthesia, antibiotics, cleverly designed instruments, and beautifully synthesized sutures and needles is breathtaking. To correct a complete uterine and vaginal prolapse in a 70-year-old woman in 2 hours and have her home and cured in a week or less is a professional skill which has to be satisfying. Thus we are a repository of information and have acquired incredible technical skills. However, we are not scientists, guardians of society, or even providers of health. We have the capacity to help allay anxiety, improve comfort, and postpone death. We are not medical nemeses and our pedestals are not made of clay. 6 • 7 We are, I believe, very special managers. The fact that we are given the right to ask intimate, personal questions and place our hands freely upon strangers' bodies make our position unique and our responsibilities greater. John Nesbitt, 8 the author of Megatrends, believes: "In time of great changes, the individual's power and leverage are enormous. We can either become victims of the great changes coming or we can make them work for us to accomplish extraordinary things." He, like others, believes we are changing from an industrial age into an informational age. Physicians then must recognize that this is indeed our role. When a woman presents a complaint to us, we should gather a comprehensive informational base, the history. Physical examination provides additional data that lead to the next managerial step, the laboratory. She will be referred to our technologic allies and have appropriate chemistry studies, probably by an automated analyzer or imaging ultrasound, roentgenography, and eventually nuclear magnetic resonance. We
The doctor-Third parties
Volume 149 Number 6
also may elect to procure a piece of tissue for light or electron microscopic evaluation. Having completed the full informational search we can now recommend a program of therapy based upon probabilities, and we are likely to have the medical and surgical tools to effect a solution. If we posture as medical managers, we should find the compromise presently needed. We do not have all the answers, and we cannot always provide the solutions. However, we are highly skilled and our face to the public should highlight the basic medical managerial process: (1) collection of personal information, (2) confirmation or classification by technology, and (3) logical remedies based upon properly carried out clinical trials. This information should be transmitted by modern-day communicative methods, something most of us have barely begun to think or know about. If we understand that this is our role, the patient will be more comfortable approaching us, have appropriate expectations, and know that it is reasonable and appropriate to seek another manager when the first does not serve her interests. We should move ahead rapidly and begin to improve our teaching techniques to students and residents and introduce managerial and communication concepts to them. This means a rephasing and reorientation of attitudes. Knowing the pH of a fetal scalp blood sample does not make one a scientist because, as we know, most doctors could not even begin to discuss the Henderson-Hasselbach equation. Knowing what to do is the role of the physician. Retrieval of information
627
then become paramount. Computers and videotapes will be our essential resources for learning and dissemination of information. There is no need for pessimism, skepticism, or grieving about our lost golden age. 9 The doctor in a sense is the role model of the professional of the future, a storehouse of information. If we fail to respond to the challenges which are reshaping our society, then we are at risk of being absorbed by government or corporate structures, and the adventure, romance, and creativity of medicine will be diminished. REFERENCES I. Hunter CA. Methodology and evaluation of undergrad-
2.
3. 4. 5. 6. 7. 8. 9.
uate curriculum in obstetrics and gynecology. AMJ OBSTET GYNECOL 1969;104:220. Easterling WE. In training examinations for residents in obstetrics and gynecology. 1975-1978. AM J OBSTET GvNECOL 1979;133:733. Dignam WJ. Board certification: past, present and future. AM j 0BSTET GYNECOL 1983;146:253. Starr P. The social transformation of American Medicine. New York: Basic Books, Inc., 1982. Pearse WH, Mendenhall RC, Radicki S, et al. Manpower for obstetrics-gynecology. III. Contributions to total female care. AMJ 0BSTET GvNECOL 1982;144:322. Illich I. Medical nemesis. New York: Panthean Books. Random House Inc., 1976. Preston T. The clay pedestal. A re-examination of the doctor-patient relationship. Seattle: Madrona Publishers, 1981. Nesbitt J. Megatrends. New York: Warner Books, Inc. 1982. Burnham JC. American medicine's golden age: what happened to it? Science 1982;214:1474.
Whenever one assumes this position, the first and dominating concern becomes the presidential address. These presentations have covered a spectrum of interests including pure clinical science, historical review, and assessments of the role of the society in our professional lives. I have decided to speak to you about the dramatic changes which are occurring in our professional lives and offer some suggestions for the direction in which our thinking and activities should move. The subject to be discussed is entitled "The Doctor-Third Parties." (AM. J. OBSTET. GYNECOL. 149:624, 1984.) The phrase "third party" generally invokes an association with insurance payments for medical care. However, there are now a number of other third parties in the physician's life. These include committees which direct training and education, government, practice competitors and patterns, society and consumers, and the legal profession. I should like to comment upon all these elements or, as some might call them, "intruders." I am sure that one of the reasons that many of us were attracted to medicine as a career is because of the freedom and independence it seemed to offer. Education and training
In the past two decades there has been an extraordinary formalization of the education and training of physicians interested in obstetrics and gynecology. Several forces have contributed to this current state of affairs. Most prominent was the decision by the (former) American Association of Obstetricians and Gynecologists to use the interest income from an endowment from the Kennedy Foundation to further education in obstetrics and gynecology. Under the leadership of Dr. Charles Hunter, then at the University of Washington in Seattle, a liaison was established with professional educators to assist faculties throughout the United States to teach more effectively. 1 Regional workshops were established in which we were taught a basic educational triangle. The three points were: (1) state your From the Department of Gynecology and Obstetrics, Albert Einstein College of Medicine of Yeshiva University. Presidential address, presented at the Meeting of the One Hundred Nineteenth Year of The New York Obstetrical Society, May 10, 1983. ReceivedAugust4, 1983; revised December 7, 1983; accepted]anuary 10, 1984. Reprint requests: Harold Schulman, M.D., Department of Gynecology and Obstetrics, Nassau Hospital, 259 First St., Mineola, NY 11501.
624
educational objectives, (2) provide the resources for the achievement of these objectives, and (3) provide a straightforward testing situation to see if the educational objectives were achieved. A committee of the Association of Professors of Gynecology and Obstetrics (APGO) developed educational objectives; these have now been developed for residency education and for preparation for certification in maternal-fetal medicine, oncology, and endocrinology. The Council on Resident Education in Obstetrics and Gynecology (CREOG) offered the first residency training in-service examination in 1970. The examination was originally designed as a self-assessment test. However, with the aid of consultants, the difficulty, discrimination, and reliability indices have improved to the point that many residency program directors are requiring minimal achievement levels such as 30% or greater on the multiple choice questions for a physician to remain in good standing. A notable feature of the examination is the attempt to give the resident direct computer-programm ed feedback on the incorrect answers. This may also assist faculty in identifying program weaknesses. 2 Also of interest is that when faculty took the examination it was found that their ability to answer multiple choice questions declined with the passage of time but their patient management skills remained at a high level. In other words, after we complete our residency program, education diminishes but clinical skills or training persists. Two significant events have occurred this year which deserve our attention. These are the initiation of the special requirements of the Residency Review Committee and the enactment of limited Board certification. The Residency Review Committee requirements are comprehensive and appropriate. They identify 15 areas of study which would seem to be in concert with Hunter's philosophy of stating the objectives and expecting the program to establish the resources. The committee will attempt to decide from the site visitor's report whether the resources have been adequately provided. My early experiences as a specialist site visitor suggest to me that the committee is moving too hard and too fast. However, assuming the requirements and recommendations are reasonable, we should all welcome the goals and strive to meet them. A final effort to upgrade our knowledge or perhaps our image is the proposal that Board certification be a
The doctor-Third parties 625
Volume 149 Number 6
limited award. The reason stated is that " ... expansion of medical knowledge has been so rapid that it has become impossible for physicians to remain highly competent .... "3 Although fears and threats in the form of an examination are a time-proved academic technique of forcing people to study, I had hoped different directions would prevail. The electronic-information age should stimulate our organizations to create resource materials that work for the practitioner. Videotapes and home computer-assisted teaching programs offer a promise of deterring the informational erosion demonstrated by the CREGG testing program and also provide tools for surveillance of the individual's participation.
Government In this century, physicians in the United States have successfully prevented government from interfering significantly in their professional activities. Starr4 hypothesized that much of this success was produced by our acquisition of cultural authority. Science gave us remarkable tools to make diagnoses and provide medical and surgical remedies. The rapidity of the creation of this new tower of medical information gave the physician an enormous advantage over lay persons and created the exalted doctor-patient relationship: a paternalistic authoritarian figure and a dependent, trusting, distressed individual. Financing of medical care in this country remains uniquely different from that in most other developed countries. Although the American Medical Association vigorously opposed third-party insurance programs, we know now that this presumed intrusion has been turned to our advantage. The private enterprise system predominates. The budget problems of medicare, medicaid, and social security plus the deficiencies of the Canadian and British health systems make it unlikely that state or national government will assume control of physician services or payment structure in the near future. Some states have enacted legislation requiring a certain number of continuing medical education credits for renewal of licensure. Whether these misguided efforts are actually being enforced is uncertain. I think most of us know that the amount of learning in the usual continuing medical education program is minimal. Exposure to information does not fulfill the necessary triad of the educational process.
production and child-rearing means a need for more regular hours to carry out her family and professional obligations. This implies working in groups, clinics, and hospitals. It also suggests that work will be carried out for lesser wages, because the physician-mother is not likely to be the sole earner in the family. Walk-in medical care clinics are a new wave worthy of attention. Recent surveys indicate that at least one third of Americans do not have a personal physician, nor are they interested in having one. They have been attracted to the convenience of walk-in medical services and have been satisfied with the service rendered. Couple this trend with a recent survey by the American College of Obstetricians and Gynecologists of the office activities of obstetrician-gynecologists, and a potential problem is evident. The survey revealed that two thirds of the practitioner's time is spent on the annual examination or health checkup. 5 It is clearly a dichotomy to spend 4 years in a residency program fulfilling the special residency training requirements, become Board certified from an examination designed to test one's expertise as a consultant, and then spend the majority of one's time carrying out a series of simple tasks. The success of nurse-practitioners, midwives, and family planning and abortion clinics testifies to the validity that many of our activities could be carried out as well and cheaper by trained assistants. If gynecologists do not organize these patterns of care, other organizations will. A foremost force on the horizon is the hospital corporation. Starr has predicted that corporate structure will eventually consume the private practitioner. Within the past 25 years we have seen hospital leadership pass from the physician's hands to those of the administrator, cost-effective accountants, and a board of directors. The delicate and difficult fiscal issues of maintaining a balanced budget plus meeting the accountability needs of third-party, governmental, and legal agencies have made the doctor's personal needs of secondary priority to the hospital. In urban areas most hospital beds are filled so that the physician's power of not admitting patients is now blunted. Good hospital leadership requires an identification as a humane, progressive, and modern institution. Hospitals that fail to compete effectively will be consumed by the corporate structure. The consequences of this for physicians may be the final chapter in their reign of power and the threat is that they will become occasional advisers and employees.
Practice The practice of obstetrics and gynecology is on the brink of significant change. There are a number of factors which portend the likelihood of this change. The large number of women being recruited into our specialty will undoubtedly change practice patterns. The woman's ultimate responsibility in re-
Law Malpractice litigation has profoundly influenced our professional lives. It has become the singular most talked about topic among physicians. To some degree we have passed from the wounded ego stage to the knowledge that we will inevitably be sued if we practice
626
Schulman
obstetrics and gynecology. A positive aspect of the malpractice phenomenon is a better awareness by physicians of the limits of their decision-making freedom. We simply do not have the right to make decisions of which we are not certain. Standards of practice are paramount, appropriate workup and consultation are necessary, and careful documentation is mandatory. It must be conceded that all of our colleagues do not meet appropriate standards of practice, and our peer review process is defective. The negative aspects of malpractice include the financial rewards, the many injustices, and the emergence of the bargained contract euphemistically called a "settlement." The major impact of the malpractice issue is the cost of yearly premiums. The cost has approached the point where the solo practitioner or small group simply cannot afford to bring in a new associate. The graduating resident will increasingly be forced to work in a group clinic or hospital-based structure. Again it is a force which will diminish the potential income of the physiCian. Society
Two powerful forces are changing the image of the doctor in society, and obstetrics-gynecology has been a primary focus. These forces are the media and feminism. The women's movement has been spectacularly successful in critiquing the male-female roles in our society. As a consequence we have become more sensitive to our attitudes and language in dealing with women. Prepared childbirth and parenting is no longer an interesting movement, but it represents a necessity of adequate prenatal care. Breast-feeding is not a relic replaced by technology but represents an essential health activity for mother and baby. Birth control techniques are not panaceas to be prescribed without reflection about consequences to health and life. Chaperones in the examining room may be an undesired invasion of privacy. The woman is not looking for a father or lover in her doctor but is seeking respectful complete information. Television and the media have probably changed our image most. Starr believes that one of the major reasons physicians had assumed such a powerful authoritative position was our knowledge of biology and science. The person seeking medical help was awed by the miracles promised by biochemistry, physiology, pharmacology, and engineering ingenuity. The patient was in no position to disagree, and many physicians were comfortable with the authority role. Witness the behavior of some of our colleagues to nurses or their petulance when patients disagreed, did not follow orders, or dared to seek another opinion. The media now
July 15, 1984 Am. ]. Obstet. Gynecol.
provide ample medical information for all. The major television networks report weekly on the lead article in The New England journal of Medicine, and there are innumerable features and special reports. Most of us learned about toxic shock syndrome from television and newspapers. The patient is no longer in awe. Our advice is measured against that which is read or heard and is even compared to that of others. For example, there are now 23,000 women who call themselves childbirth educators, and their clients use them frequently as informational resources. A proscription
A large segment of society is dissatisfied with us, and many physicians are frustrated, annoyed, and confused about their image and what is expected of them. It is naive for us to continue to pose as scientists. Our courses in college and 2 years of basic science in medical school do not make us scientists. There is no denying, however, that we acquire an enormous amount of information in our 8 or more years of medical training. We are also the recipients of some extraordinary technical skills. The act of surgery today with the assistance of anesthesia, antibiotics, cleverly designed instruments, and beautifully synthesized sutures and needles is breathtaking. To correct a complete uterine and vaginal prolapse in a 70-year-old woman in 2 hours and have her home and cured in a week or less is a professional skill which has to be satisfying. Thus we are a repository of information and have acquired incredible technical skills. However, we are not scientists, guardians of society, or even providers of health. We have the capacity to help allay anxiety, improve comfort, and postpone death. We are not medical nemeses and our pedestals are not made of clay. 6 • 7 We are, I believe, very special managers. The fact that we are given the right to ask intimate, personal questions and place our hands freely upon strangers' bodies make our position unique and our responsibilities greater. John Nesbitt, 8 the author of Megatrends, believes: "In time of great changes, the individual's power and leverage are enormous. We can either become victims of the great changes coming or we can make them work for us to accomplish extraordinary things." He, like others, believes we are changing from an industrial age into an informational age. Physicians then must recognize that this is indeed our role. When a woman presents a complaint to us, we should gather a comprehensive informational base, the history. Physical examination provides additional data that lead to the next managerial step, the laboratory. She will be referred to our technologic allies and have appropriate chemistry studies, probably by an automated analyzer or imaging ultrasound, roentgenography, and eventually nuclear magnetic resonance. We
The doctor-Third parties
Volume 149 Number 6
also may elect to procure a piece of tissue for light or electron microscopic evaluation. Having completed the full informational search we can now recommend a program of therapy based upon probabilities, and we are likely to have the medical and surgical tools to effect a solution. If we posture as medical managers, we should find the compromise presently needed. We do not have all the answers, and we cannot always provide the solutions. However, we are highly skilled and our face to the public should highlight the basic medical managerial process: (1) collection of personal information, (2) confirmation or classification by technology, and (3) logical remedies based upon properly carried out clinical trials. This information should be transmitted by modern-day communicative methods, something most of us have barely begun to think or know about. If we understand that this is our role, the patient will be more comfortable approaching us, have appropriate expectations, and know that it is reasonable and appropriate to seek another manager when the first does not serve her interests. We should move ahead rapidly and begin to improve our teaching techniques to students and residents and introduce managerial and communication concepts to them. This means a rephasing and reorientation of attitudes. Knowing the pH of a fetal scalp blood sample does not make one a scientist because, as we know, most doctors could not even begin to discuss the Henderson-Hasselbach equation. Knowing what to do is the role of the physician. Retrieval of information
627
then become paramount. Computers and videotapes will be our essential resources for learning and dissemination of information. There is no need for pessimism, skepticism, or grieving about our lost golden age. 9 The doctor in a sense is the role model of the professional of the future, a storehouse of information. If we fail to respond to the challenges which are reshaping our society, then we are at risk of being absorbed by government or corporate structures, and the adventure, romance, and creativity of medicine will be diminished. REFERENCES I. Hunter CA. Methodology and evaluation of undergrad-
2.
3. 4. 5. 6. 7. 8. 9.
uate curriculum in obstetrics and gynecology. AMJ OBSTET GYNECOL 1969;104:220. Easterling WE. In training examinations for residents in obstetrics and gynecology. 1975-1978. AM J OBSTET GvNECOL 1979;133:733. Dignam WJ. Board certification: past, present and future. AM j 0BSTET GYNECOL 1983;146:253. Starr P. The social transformation of American Medicine. New York: Basic Books, Inc., 1982. Pearse WH, Mendenhall RC, Radicki S, et al. Manpower for obstetrics-gynecology. III. Contributions to total female care. AMJ 0BSTET GvNECOL 1982;144:322. Illich I. Medical nemesis. New York: Panthean Books. Random House Inc., 1976. Preston T. The clay pedestal. A re-examination of the doctor-patient relationship. Seattle: Madrona Publishers, 1981. Nesbitt J. Megatrends. New York: Warner Books, Inc. 1982. Burnham JC. American medicine's golden age: what happened to it? Science 1982;214:1474.