Money and Medicine

...In smaller communities in particular, the general practitioner frequently does almost everything...

...I was not at all surprised at the findings of the study," said a nationally known Boston physician who has had many years of experience in medical practice, education, and administration...

...Leroy E. Burney, the U.S...

...This type of practice has many other advantages...

...The practicing physician cannot know everything about therapy nor evaluate the very optimistic claims made for the many medications pressed upon him...

...But perhaps its most unfortunate consequence has been the decline in the status—and very often in the competence— of the general practitioner.Since more than half of the doctors in this country are still engaged in general practice, the professional isolation of the general practitioner is having momentous effects upon the quality of medical care received by millions of Americans...

...They're doing the best they know how...

...As long as remuneration is based on the type and frequency of procedures, the doctor has to fight off the tendency to put the emphasis there...

...Above all, he must have the stimulation of working closely with other physicians...

...Because specializing means greater income and prestige, there has been a steady trend in this direction...

...How prevalent are similar conditions in medical practice in other states...

...He has a wide range of medicine to keep up with but less time and, even more important, less professional stimulation to do so...

...The report of the North Carolina survey emphasizes that the physicians whose work was studied appeared to be typical of general practitioners...

...There are now 30 recognized medical specialties and sub-specialties, each of which requires special training and certification by a specialty board...

...The report of the study of general practice in North Carolina has some enlightening comments about the average physician's difficulties in keeping up with the avalanche of medical literature...

...Once a man obtains a license to practice medicine, he can usually do anything he wants, short of criminal abortion, as long as he can find the patients...

...Among the most important are that it makes doctors responsible not just for treating illness as it occurs but for the total health care of the insurance plan's subscribers, and that it eliminates the economic barrier inherent in fee-for-service practice...

...It is out of this situation that the reportedly not uncommon practice of fee-splitting between general practitioners and surgeons and other professional abuses arise...

...A physician's ability to keep up with medical advances obviously affects the quality of his work and the extent to which he can give his patients the full benefits of the experience and progress of medicine...

...Aside from their numerical preponderance in the profession, general practitioners have a vital function to perform...

...And does the average doctor have enough time to try to keep abreast of new developments in medicine...

...While the overall ratio of doctors to population in the United States has declined in the past 25 years, the number of specialists has in the same period quadrupled...

...As far as evaluating the quality of one's work and keeping up to date, the important thing to bear in mind is that no one can do it himself...

...The more of them he does, the more money he makes...

...A serious question, however, is whether it would be feasible to require such re-examinations in view of the solid opposition to be expected from the profession and of the difficulties involved in setting up adequate and fair criteria for measuring the competence of men long out of medical school...

...In prepaid group practice you not only eliminate this factor of ability to pay but the doctor has continuous responsibility for comprehensive care, without which there can be no good medicine...

...Just what can be done about this is admittedly a tough problem...

...Nor does it make for good medical care under the handicaps within which the general physician is often forced to practice...

...I expect that, to a greater or lesser extent, this situation holds true generally...

...The march of science has profoundly affected the whole system of the organization of medical practice...

...Group practice prepayment removes both the fee-for-service deterrent to good medicine and the professional isolation of the solo practitioner...

...The doctor's judgment is based on the question whether the patient can afford many procedures...

...But much of the most significant medical service takes place in the home and in the office, where the original diagnosis is made...

...Money and Medicine by SELIG GREENBERG ARE DOCTORS in North Carolina of a breed wholly different from those in the rest of the country...

...It has a far higher standard of living than most states in the South and good medical schools and hospitals...

...North Carolina is not a typical Southern state...

...Some of the top authorities in the health field hold that one of the most serious weaknesses of the prevailing system of medical practice is that there is no means for maintaining standards, except within the broad limits set by licensing and laws against malpractice...

...But several distinguished authorities in the field of medical care with whom I have discussed this question have told me they saw no reason to think that the situation found in, North Carolina is an isolated phenomenon...

...This question is inevitably raised by the high ratio of incompetent performance among general practitioners in that state disclosed by a study jointly sponsored by the Rockefeller Foundation and the University of North Carolina whose findings I reported in the September issue of The Progressive...

...This is done in the last two years of the physician's medical school education and during his internship and residency...

...One of the merits of group practice— and particularly the kind of joint practice associated with a comprehensive insurance plan, such as the Health Insurance Plan of Greater New York—is that it provides for control of the standards of medical care within the professional family...

...To an even greater degree it is provided by group practice...

...Furthermore, there are few, if any, specialists available in many smaller communities...

...it also calls for new patterns of thought and action...

...At his best, he is the family physician who provides not only medical care but the integration of this care with the personal interest and psychological support of such great value to the patient...

...Consciously or subconsciously, this question of what the patient can afford to pay has a great deal to do in the doctor's mind with the kind of treatment provided and the degree to which such treatment meets the patient's needs...

...It is not uncommon for a physician to see as many as 15 to 25 patients in the course of an afternoon, and, in addition, hold office hours several evenings a week...

...Some experts advocate more rigorous policing of professional conduct and, specifically, relicensing examinations for all physicians at intervals of five or ten years...

...The Academy of General Practice, which was established a few years ago as something of a counterpart to the specialty boards, says that the competence of the general practitioner extends to whatever he feels he is capable of doing...

...It takes the day-to-day interplay with one's peers on an organized basis...

...This is a question which is certain to produce more heat than light when it is discussed with most doctors...

...The family doctor can no longer take care of everything, and the patient must now frequently be passed on to one or more specialists for diagnosis and treatment...

...It can therefore be stated with considerable assurance that in terms of medical education and training the physicians who participated in this study are not evidently different from general practitioners at large...

...The more things medicine can do, the more splintered and expensive it gets—and the more difficult for the average physician to keep up with scientific advances...

...One distinguished physician summed up the medical care situation in a recent interview this way: "The important thing in medical practice today is not just the doctor's training, knowledge, and conscience...

...A good conscientious doctor may easily fail to keep up with the vital new knowledge in medicine...

...If you have recently kept an appointment in your doctor's office, you may have wondered how he stands the pace...

...And this framework is based on the fact that the physician's remuneration is directly dependent on the number and complexity of procedures he performs...

...Such an opportunity for continued education, for pooling knowledge and learning from one another, is offered by the better hospitals...

...At what point does a doctor decide that he is seeing too many patients, that he is getting too tired, that he can't do a good job...

...Walter Bauer, chief of medical services at Massachusetts General Hospital in Boston and professor of clinical medicine at Harvard Medical School, who feels the public "has a right to satisfy itself concerning the continued competence of doctors...

...Surgeon General, that change in the medical field "not only produces new products...

...A study made jointly by the American Medical Association and the U.S...

...And some nights he is liable to be out until all hours on house calls...

...Close professional association in one form or another tends to maintain both technical and ethical standards...

...Whether we get good or poor medical care is determined by a great many things, almost all of which basically involve the economics of medical practice...

...Many doctors, the report says, are increasingly coming to depend for information regarding medical progress on digests put out by the big drug companies and on drug salesmen, who are known in the trade as detail men...

...In view of the tremendous complexity of today's medicine and the wide range of skills it requires, this is a pretty big order...

...All of which underlines the cogency of the statement by Dr...

...North Carolina doctors are no different from doctors elsewhere...

...This not only deprives him of an important source of income but of an extremely valuable opportunity for teamwork, a form of continuing education essential in modern medicine...

...A vexing problem for all doctors, and especially so for the usually overworked general practitioner, is how to keep u p with the rapidly changing and constantly expanding body of medical knowledge...

...Equally important is the framework within which he practices...

...The North Carolina survey was the first of its kind ever made, and there is no equally documented evidence to show whether the quality of medical care is better, as bad, or even worse elsewhere...

...In the mornings he usually makes his hospital rounds...

...He is the winner of the Associated Press Managing Editors Association Award for his series of articles on the problems of the aged...

...There is reason to believe that the general physician, who is more and more becoming a medical jack-of-alltrades and master of none, sometimes tries to do things for which he is not qualified because of fear that if he makes a referral to a specialist he will never see the patient again...

...Present provisions for professional regulation offer the public little protection against incompetent doctors...

...Among these factors are the fragmentation of medicine as a result of specialization, the growing professional isolation of the general practitioner, the size of a doctor's practice and its effect on the quality of his work and his ability to keep up with medical advances, whether there are enough doctors in a community, and the even more controversial issue of whether there are effective mechanisms for assessment and control of the quality of medical care...

...It is true that this isolation is counteracted to some extent for many physicians by the work they do in hospitals—which, by the way, provide the doctors at public expense with an indispensable workshop, with the necessary tools, to a degree which doesn't hold true of any other profession...

...It was apparent from observation and statements from physicians that their practices in regard to medication and therapy are influenced significantly by the information and products supplied by the drug salesman," declares the report, adding that this is a far from desirable state of affairs, "since the detail man's function is not to provide education but to sell pharmaceutical products...

...He has no required graduate education program, is looked down upon by the specialist, and is frequently isolated from the mainstream of medical developments...

...There is no getting away from the fact that the element of the patient's ability to pay is all-important and that it leads to many compromises...

...It's a tough temptation and it may warp judgment...

...As a rule, he works longer hours than the specialist, and his income is considerably lower...

...The general practitioner is the first-line diagnostician...

...One of those favoring such a step is Dr...

...Often the investigation recommended is very much tailored to the patient's ability to pay, not only in the direction of overdoing but even more so in the direction of underdoing...

...SEUG GREENBERG, writer on medical problems for the Providence Journal and Evening Bulletin, has twice been honored by the tasker Foundation for distinguished writing on medicine...

...The training taken by these doctors," the report says, "is similar to the training taken by doctors in the country at large...

...What are the criteria— in terms of activity and performance...

...Out of a "representative" sample of 88 physicians whose work was carefully examined in the survey, 39 were classified as "poor," 27 as "average," and only 22 as "good" or "outstanding...

...The stampede toward specialization has had several results which thoughtful observers regard as disturbing...

...They had received their training in a wide variety of hospitals in all parts of the United States...

...Department of Commerce, in which information was collected from more than 30,000 doctors, established that doctors were working an average of 60 hours a week...

...The obstacles now frequently standing in the way of adequate professional performance underscore the danger stemming from the public's lack of proper safeguards against poor medical care...

...The solo practitioner, on the other hand, is completely on his own...

...The physicians studied came from many medical schools and had exhibited all degrees of academic success, so there is no reason to assume an adverse selection...

...He is often barred from hospital staff appointments or is relegated to the courtesy staff...

...The American Academy of Pediatrics reported after a nationwide survey that 20 per cent of the general practitioners interviewed saw more than 30 patients a day, and five per cent saw more than 50...

...But the growth of specialization and of the system of postgraduate training set up for specialty certification has created a caste system within medicine, putting the general practitioner on the defensive and relegating him to an inferior status...

...The result is that in all parts of the country, but particularly in the smaller and more isolated communities, there are general practitioners who still practice much the same medicine they learned in their student days...

...The introduction of each new medication, it notes, "is accompanied by a mass of literature which descends upon the physician's desk each day showing him the presumptive virtues and excellence of each...

...If he is to do so, the doctor must have time to read some of the professional journals, to attend medical meetings and lectures, and perhaps occasionally to take some postgraduate refresher courses...

...The study brought to light a truly appalling proportion of medical services of a quality falling far short of generally accepted standards of professional competence, which means that many patients fail to get the kind of care they are entitled to...

...It's not a question of the individual...

...T h e nature of the work of general practitioners, one of the excellent reports published periodically by the New York Academy of Medicine has said, "calls for unusually broad knowledge, but they are most often so taken up with their practice—and generally isolated from hospitals and other medical centers—that they have little time for continued training...

...Then it stops...

...Under the prevailing system of solo, fee-for-service medical practice, there is, above all, the question of the patient's ability to pay...

...It frequently leads to piecemeal medical care, to excessive resort to expensive procedures, and to the kind of concentration on a single organ in which, the doctor loses sight of the patient as a person...

...This inevitably affects the quality of medical service...

...it's the system...

...While such long hours undoubtedly entitle many physicians to their generous income, they raise two important questions: Is the average doctor able, under these circumstances, to give his patients the amount of time they should have for adequate treatment...