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Thursday, February 24, 2005

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"

1 comment:

Anonymous said...

"Health care providers" replaced physicians the same day that patients became "clients of the health care system" and "consumers of health care."