Retired doc's suggestions for medical curriculum-part 2

To appropriately counter balance the propaganda aimed at convincing everyone of the virtues of a single payer system, med students should have a few lectures properly characterizing the British NHS. The NHS's recent admission-though they don't really admit it is an admission-regarding the terrible job they did with mammograms should be required reading for medical students. Doctor CCB has an excellent posting on that issue. I have spent some time with young physicians from Great Britain in recent years and I will send them this information in the hope that their patronizing antagonism to screening might be rethought.Former senator Phil Grahm-ever the master of the sound bite-said in the era of the spectre of Hiliary care-that they wanted to redo American medicine in the image of the post office.Better the post office that the image of the NHS.I also have had occasion in recent years to treat Brits on assignment in the US.Typically,they have indicated when they return home they will purchase private health insurance.

Professional Courtesy,Once the Rule- now illegal

Even as a medical student I enjoyed what was known as professional courtesy.I developed the med student disease of having every disease we read about and became alarmed about a nevus on my back. I saw a general surgeon who removed it in the office and scribbled "N.C."on my routing papers. Wow ! I was in the fraternity already. For many years it was estabished practice for physicians to not charge physicians and their families.40 years later,no such NC appeared on my papers as I checked out of a orthopedic group's office.Twenty dollars is no big deal;the big deal is once again the insurance industry wins out over physicians. Basically-in at least some states- the insurance lobby has passed legislation making it in some instances insurance fraud for a doctor to not charge a patient the co-payment. The Attorney General in Texas has issued a ruling clarifying the Insurance Code indicating doctors cannot waive the copay at least in the situation where it could be construed as an effort to entice patients. The Texas Medical Association in its practice managment publication states that according to Texas law it is fradulent to submit an insurance claim that does not disclose the intent to waive a copay for a patient.The insurance companies want to make patients pay a copay to discourage utilization. They wish to not allow doctors to offer waving copays to attract patients.They also present the following bogus argument. If a doctor nominally charges $100 and the insurance pays 80% the plan is for the patient to pay $20.If the doctor waives the twenty he in effect is only "charging" 80 so insurance "should" only pay 64.The insurance company will allow waiving of copayment in cases of financial hardship but typically insists the doctor notify them of the situation.Now the physician may be able to simply forgo all payments and not even file, but the old practice of charging insurance only is becoming a thing of the past.

When did Health Care Providers replace Physicians?

The landscape is so different. When I left training to spend two years in the Army, I had spent 6 years in post medical school training. One year internship(as it was called then),three years of internal medicine residency and two years of pulmonary disease fellowship.As I think back, in that time I could have become a cardiovascular or neurological surgeon,but I thought of internal medicine as the thinking physician's field.If it still is or ever was is in question. When would a general internist now have time to think?

The current lists of required proficiency items did not exist and the residency program was much more self directed.You did not have to get your liver biopsy card signed or anything like that, yet we all learned to do them and much more. The role of the internist,although probably just as obscure to the general public then as now,was in part to take care of the complicated cases, the very ill and to be in general an expert about internal medicine (which was basically everything except surgery.
At least-among my peers- choice of which medical career was not driven by expectation of future earnings although we all felt financial security would never be a problem.Now the latter proposition may not be true as managed care is one arm of the pincher and family practice and nurse practioners is the other squeezing the general internist's revenue stream.
There were no health care providers,only physicians and nurses and technicians.There were no published guidelines.(Some residency programs did have guidelines-more like rules-authored by the chief of service that were carried in lab coats pockets in little black books.(for some reason there were all black)).Many house officers did not have malpractice insurance.(I did-for about $50 a year because we knew of an ob-gyn resident moonlighting in the hospital admitting clinic was sued).
There was no control on the hours that house staff worked. In fact,surgery residents frequently did quasi elective surgery at all hours of the night just to get the experience. That's right,they actually worked more that was required and medicine residents roamed the wards looking for indication to do liver,kidney or pleural biopsies. Our chief told us we had access to a large county hospital with all the disease in the world, a great library, a knowledgable faculty with whom we could consult and ask questions and the rest was up to us and the "cream would rise to the top"
It is not surprising that physicians nutured in this setting chaff against guidelines,managed care control and the myriad ways in which the physician 's independence had been lessened.
What I did not learn in those years is the fragility of medical knowledge and how provisional and subject to revision much of it is.That would come much later.
With the proliferation of guidelines and the at times unreasonable faith placed in systematic reviews and the like.I think that the current crop of trainees will only learn that lesson as I did by playing the game for a long time and seeing firsthand today's paradigms become yesterday jokes and be discarded like the amps of bicarbonate that used to litter the floor in a room where ACLS (not called that then) was performed as "an amp every five mintues" was the guideline de jure at the time not that long ago.
By the way the answer to the tittle question is "When managed care manipulated the language to blur the difference between physicians and less trained"health care workers" who would work for less money"

Physician as Agent of the patient: Agent of Society

In the 1960s the idea that a physician would play a dual role, ie patient advocate AND stewart of "society's scarce medical resources" was not a topic for discussion.
 Of all the changes in the past 35 plus years this is the one that I find most disturbing and antithecal to what a physician is about.
Is it coincidental that the movement for social justice in the United States parallels the ascendancy of managed care. The American College of Physicians speaks of the need for a fair distribution of medical resources as if the activities and skills of thousands of health care professionals were a fungible entity that simply needed to allocated by central planners in spite of the obvious fact that this fictious entity is not owned by any one person let alone by the abstraction "society" Do these "spokesmen" of one element of organized medicine speak this way because they do not realize the fallacious argument and rhetoric involved ? Or do they speak that way in spite of the fact that they do understand what they are saying and realize the unreasonable effectiveness of that type rhetoric ?

Most people would not object to something done in the name of the "good of society" . Most people do not realize the bogus nature of the concept.

There are voices speaking out against the social justice fallacy and its partner utilitarian ethics including the physicians at the Association of Physicians and Surgeons, analysts at Cato Institute and the occasional blogger.

What do years of medical boot camp produce?

As I reflect back to the years of medical school and house officer training, several motifs emerge.
I was taught to believe what I was learning and what I would do was very serious and very important and was a awesome responsibility.

Feelings of inadequacy permeated all of the med school years and it was not until well into the residency program that I felt equal to the job at hand and enjoyed some confidence. Medical school was frightening and at times mind numbing and the excitement and sense of satisfaction occurred only in house office years and beyond. Now some forty years later I look back on that and on all the changes in medicine since those formative years.
In this blog I hope to express some of the thoughts that come to mind from my current vantage point about what has changed, what has not changed and what should not change.