Rx FROM THE PATIENT: Physician, Heal Thyself

FEW more intimate relationships exist, outside the family or the church, than that of the average person with his doctor. Each year, nearly one billion visits are made to the U.S.'s 225,000 practicing doctors, or about five visits for every American. Each visitor expects not only medical care but comfort, sympathy, relief, reassurance and solace. There was a day when he could be sure of getting all these: the day, not too far past, of the family physician who often knew as much about his patient as he did about an illness. Today, Americans get far better medical care than ever before; as for the rest, they are often lucky to get as much as a hurried smile. The result is a troubling paradox: at a time when medical skill has reached new pinnacles, the doctor-patient relationship has badly deteriorated. It is a situation that both irritates the patient and worries the medical profession.

The fact is that the doctor's role has radically changed. In a famous painting by Sir Luke Fildes--which still hangs in many a doctor's office--a rumpled and exhausted physician keeps home watch over a comatose child while her worried parents hover anxiously in the background. The doctor has obviously been up all night, brooding, worrying, waiting--probably in part because he did not know what else to do. In today's medicine, both the scene and the sentiment are badly out of date. The child would be in an oxygen tent in a hospital, festooned with tubes, watched over by bustling nurses or electronic monitors, banished from her parents (visiting hours, 9-11 a.m.), and lucky to get a brief visit from the doctor once or twice a day. Instead of Old Doc's bedside manner, the modern physician depends on a panoply of new skills, drugs and facilities that save many a patient his predecessor would have lost. The father image has been supplanted by the skilled technician whose head is far more important than his heart. Trouble is, the patient misses the heart.

A Great Strain

The deprivation is only partly the doctor's fault. For the very reason that medical knowledge is expanding in quantum leaps, a modern doctor must spend much more time simply keeping abreast of his profession, thus has less time for individual patients. Moreover, his new skills can best be employed not in the home, but in the office or hospital, where equipment is available. With growing affluence and insurance, more and more people can afford what he has to offer. Since the overall ratio of doctors to population has remained roughly the same--one doctor for 760 people--the result is that the patient-load on doctors has doubled in just a few years. Because the patient is increasingly sophisticated about medicine, thanks to better reportage of medical advances, he is also likely to demand more of his doctor. Says Jerome Pollack, professor of medical economics and associate dean at Harvard Medical School: "People are aware of the explosion of medical knowledge, and they use doctors more. There is a great strain on doctors."

One result of all this change is a growing impersonality in the practice of medicine that has created a breach in the traditional doctor-patient relationship. For patients, it is difficult to relate to a doctor who is only glimpsed behind a surgical mask. For doctors, a patient seen in the office, one of perhaps 30 patients in the course of the day, does not assume the same identity as a patient seen in a home. And the excitement inherent in current medical research makes many doctors more preoccupied with the disease than with the patient. Admits Dr. Martin Cherkasky, director of The Bronx's Montefiore Hospital: "There is a lessening of the personal commitment to the individual patient."

The patient's concern, his uneasiness, about doctors and doctoring is deeply ingrained. Because mankind has been so utterly and helplessly dependent on him, the doctor touches man's profoundest anxieties, eliciting both nervous humor and distrust. Said Voltaire: "Doctors pour drugs of which they know little to cure diseases of which they know less, into human beings of whom they know nothing." George Bernard Shaw gibed that doctors score only triumphs, since their mistakes are always buried. Over the ages, doctors have compounded both the awe and the anxiety by acting as a self-anointed priesthood whose rites and methods (complete with prescriptions in Latin) were beyond the understanding of any outsider. Even today, physicians are a powerful and self-protective group that bridles at criticism, maintains an arcane authority by telling the patient as little as possible and thus, of course, provides little basis on which it may be judged.

A Question of Concern

Although the American doctor ranks high in prestige (just below a U.S. Supreme Court Justice) and pay (average: $28,380), he has lately been dislodged from his old status as the grand panjandrum. In the bestselling Intern, the mysterious Dr. X--who well knew the necessity of shielding himself from his colleagues' vengeance--admitted that doctors learn only by committing "colossal blunders" that sometimes prove fatal. The profession's official and aggressive opposition to medicare marred the doctor's image among many Americans--and raised bothersome questions about how the profession will treat the huge influx of new patients, all of them old people who particularly need human comfort. While most patients profess esteem for their own doctors, people have become more critical of the profession as a whole. "The public now tends to view the physician as something less than an individual on a pedestal," says Walter McNerney, president of the Blue Cross Association. "The doctor finds himself the subject of judgment."

That judgment is embodied in a growing number of complaints that have less to do with the quality of medicine than with the quantity of the doctor's personal interest in his patients. The commonest complaint is about the doctor's increasing inaccessibility. At night and on weekends or holidays, few doctors, at least in urban areas, are available. Says Dr. Amos Johnson, president of the American Academy of General Practice: "From 6 p.m. until 9 a.m. daily and from Friday evening until Monday morning, the emergency rooms of hospitals are doing all the practice of medicine today." The house call is becoming as obsolete as the midwife, and in urban areas are hardly made at all; their usual advice to the patient is to come to the office or to go to the hospital. Even in the office, the doctor does not give a patient as much time as he or she would like. Patients complain of having to wait long periods in the doctor's anteroom even when they are on time for an appointment, then of being put on an assembly line--stripping, weighing, etc.--from which they emerge for only the briefest visit with the great man himself.

This process may have to be repeated many times, since the word in medicine today is specialization--a different doctor for every ill. The trend toward specialization, for all its obvious merits, can extend to the point of absurdity, as in the case of the obstetrician in Chicago who refused to treat a pregnant wife for pneumonia a day or two before she was to give birth. "He said I wouldn't expect him to treat a broken leg, so why should I expect him to treat colds?" Mothers complain that pediatricians have become so specialized that they will accept children of different ages only on different days and hours, necessitating a separate trip to the office for each child. The joke is that the day is fast approaching when otolaryngologists will begin specializing in only one nostril or one ear.

There is, of course, the old feeling that doctors make too much money at the patient's expense, but the complaints are becoming noisier these days. Doctors can point out that their fees have risen just about on a par with the general cost of living in recent years. Still, though the really staggering rise has been in the cost of hospital care, the doctors' interlocking system of specialization also produces a proliferation of fees that contributes to higher medical costs. It also causes resentment; no patient likes to pay $10 or $20 to a doctor for the advice that he should go to somebody else. The resentment is compounded by the obvious affluence of today's doctor--his Bentley or Rolls-Royce in the driveway (deductible as a business expense), the plush vacations chronicled in the local paper, the conventions that he always seems able to find in Miami (in winter) or in Europe (in summer). There is no reason, of course, why the doctor should not enjoy his income like anyone else, but his patients often seem to feel that his Hippocratic oath of service should bind him to an austere life.

Though everyone has his horror story about medical negligence or slipups, there seems to be a tone of special aggrievement in the current crop. There was the woman in Illinois who complained that she did not feel well, was advised by telephone to take aspirin, and was dead within the hour. There was the Washington child with the crushed hand that no doctor would agree to see until a neighbor promised to pay for treatment. There was the rash that expensively baffled two experts--until the lady in question discovered bedbugs. Though such examples are exceptions, the profession itself admits enough errors to give people pause. Doctors confess that too many unnecessary operations are performed--at attractive fees. After a study of 6,248 hysterectomies, Dr. James C. Doyle concluded that one-third "seemed to be unwarranted." Harvard's Dr. Osier Peterson, assistant visiting professor of preventive medicine, notes that tonsillectomies, "which most academicians agree is a useless operation," make up 6% of all U.S. operations--while they comprise only a fraction of 1% in Sweden.

Excellence & Shortfall

While doctors themselves are ready to admit that they can make mistakes, they generally react to criticism by pointing out that their patients 1) are getting just about the best medical care anywhere, and 2) are foolishly sentimental about the "old days." The U.S. will spend an estimated $44 billion on its medical care this year, and is currently spending over $1 billion in research. Its surgical skills and lab techniques are unsurpassed. As for complaints about the decline in home care, most doctors frankly think that the oldtime house call was largely a waste of time. They point out that a doctor can see ten people in his office in the time it might take him to make one house call. Says Dr. Lindsay Beaton, a practicing physician who is also chairman of the American Medical Association's Council on Mental Health: "I don't want to go out on a call at 2 a.m. to somebody who is dying of a myocardial infarction out at his home. I want the person brought to my hospital where he can be put in an intensive care unit. Going to the home just wastes time." If the variety of specialists makes some people feel that their body is being treated like a diagram in a butcher's shop, U.S. doctors retort that this is only the necessary fragmentation of a science advancing too fast and grown too complex for any one man to know all there is to know. Even so, the average doctor works 60 hours a week, and one out of three works a 70-hour week.

For all the doctor's hard work and all the medical advances, the U.S. still has plenty of room for improvement. In incidence of infant mortality, it stands twelfth among all nations. The life expectancy of U.S. men is only 18th in the world. In ratio of doctors to population, the U.S. ranks 15th. This low rating for the world's richest country is partly due to the fact that U.S. doctors tend to cluster in urban areas, where there are better hospital facilities and more opportunity for consultation, leaving a lethal shortage in remote and rural areas. Another reason is that the poor, the Negroes and other minority groups do not get the medical care available to most of the population.

At the root of this paradox of special excellence and overall shortfall is the very fact that is responsible for so much of the grumbling among today's patients: the decline of the general practitioner, both in status and number. Twenty years ago, there were 110,000 family doctors in the U.S.; today there are only 72,000. There were four general practitioners for every specialist in 1945, but today only one doctor in three is a G.P. According to the most recent figures, only 18% of the U.S.'s 8,000 fourth-year medical students professed an intention to become general practitioners. This reluctance is caused by the glamour attached to specialization and by the knowledge that G.P.s work longer hours and usually cannot allow themselves long vacations, but it has no economic base: G.P.s make as much as or more than internists or pediatricians.

U.S. medicine is now recognizing that the general practitioner fills a need that is not being met. He tends to serve in rural areas, and to be the mainstay of the poor and the slum dweller, who cannot afford the several specialists many families now have for their varied ills. Most of all, the family doctor, available in greater numbers, would help restore the oldtime warmth to the doctor-patient relationship.

Back to Prominence

The medical profession is busy with dozens of plans to bring the family doctor back to prominence. One device designed to save doctors time and make more expertise accessible is group practice; the number of groups has risen from roughly 100 in 1959 to more than 5,500 today. Group practice brings together in one building, besides family doctors, a whole spectrum of specialists to whom the patient can quickly be referred. By rotating duty, the group can also assure a patient that one of them will always be on call.

To attract more students to family doctoring, the American College of General Practice hopes to restore the dignity of the general practitioner by making him a kind of specialist himself--a "generalist" is one term proposed. To gain accreditation from the college, a "generalist" would be required to take residency-internship training in family practice for three years, encouraged to work with outside doctors in family practice, and get added training in sociology and psychology. "Family doctoring is a more complex field than anyone gives it credit for, since it encompasses a whole range of intellectual, medical and nonmedical problems," insists Harvard's Dr. Robert Buxbaum. With an eye to the impending demands of medicare, the University of California last week acted to accept qualified general practitioners for the teaching staff of its medical school and to set up a course in family medicine.

Many doctors are talking of training more "paramedical" people who could handle administrative problems, take histories, and even, like Navy corpsmen, give shots and help in operating rooms. Computers are being used more widely to help in diagnosis, and Philco recently developed a "medi-chair" that can read a patient's pulse, check his respiration rate and skin response, and produce an electrocardiogram 20 seconds after he sits down in it. These and other processing techniques can leave the doctor more time to offer what no computer can--judgment and sympathy. As Montefiore's Dr. Cherkasky says: "The patient still needs the nurturing qualities that help fight disease--compassion, understanding and support."

In a word, the U.S. medical profession is trying hard to get back to a principle as old as Hippocrates'; it is rediscovering that there is still healing power in the laying on of hands. In an area where the stakes are life and death, but where the modern doctor knows that nothing is finally certain, he can still only say to his patient: "Trust me." Today's patient, who is sophisticated enough to realize his doctor's limitations, is willing to extend that trust--but in return he wants some understanding and sympathy, the vital ingredients that nowadays are too often missing. That exchange should be a compact between the patient and his doctor. It is a compact less complete than the old one, which was based on the patient's total faith and on far less knowledge, but it is a more realistic one.

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