A half-century of change

Reminiscing about the world of medicine my colleagues and I entered 50 years ago is like flipping through old Life magazines. Not only has everything changed, but the rate of change continues to accelerate. I have seen these changes in my work as a laboratory director at an inner-city teaching hospital, where I have been responsible since the early 1960s for introducing new technologies. I have also been an ambivalent witness to the extraordinary transformation of the landscape in health care delivery.

My first clinical laboratory was really an extension of those encountered in college premedical programs. There were guinea pigs, frogs and rabbits for microbiology. Photometers were just replacing the human eye for evaluating the color changes in chemical reactions. Of the 40 tests we offered, we had done about half as medical students. Fast forward: like most middle-size hospitals, mine now offers more than 2,000 diagnostic tests, with 375 done in-house. Analytical systems are automated, from order entry to printing charts. Units of measure have shifted from grams to picograms or parts per billion. The original “big three” studies in radiology—the chest film, gall bladder series and barium enema—have been replaced by MRIs, PET and CT scans.

When I graduated from Yale in 1956 the physician-patient relationship was usually one-on-one. House calls were common. There were eight medical specialties. Physicians generally knew all 20 or so major drugs. Office records were kept on 5-by-7 cards, and $3 in cash covered an office visit. My original malpractice bill for $100,000 per incident/$300,000 per year was $24. Bureaucracy and paperwork were minimal and overhead expenses negligible. Insurance companies paid fees without hassle, and the clinician had autonomy to make medical decisions.

By the ’60s and ’70s massive expenditures in research began to generate new knowledge, new technologies and sometimes unrealistic expectations. Younger, procedure-oriented subspecialists were riding the crest of the wave. However, the bulk of physicians, mostly older generalists, were less fortunate. Many found themselves caught in a tangle of double-digit overhead expenses, fixed reimbursement schedules, new mandates, audits, benchmarks, business models in which patients are “customers,” electronic records, “keeping up” and gloves-off competition for patients. By the late ’80s, for some clinicians, compensatory mechanisms that had allowed them to maintain the status quo began to break down, sweeping away the lives they had known. Once unthinkable, “denying access” became a reality. Symptoms of “burnout” were growing. Some clinicians have retired early. Some, though disgruntled, plod on. Others have, for the first time, become active politically, especially to effect tort reform. Many physicians warn students not to go into medicine!

The two great forces that changed our professional lives—new knowledge and limited resources—will have an even greater impact on those now entering the system. Consider this: The best estimates are that, worldwide, $90 billion annually is being spent on research and development in the biological sciences—producing some 8,500 articles per day! And with the national debt growing and with the fiscal integrity of Social Security, Medicare and Medicaid threatened, massive increases in health care funding are unlikely. These two forces will keep the lives of young physicians in perpetual turbulence.

Yet I do not see the future of medicine as bleak. The core mission of medicine, enunciated throughout the ages, endures. The basic needs of the human race are not changing. What will continue to change are the technology and the organizational framework, including financing, by which the potential of this technology will be made available to society as a whole. Fortunately those entering the system are already developing the necessary survival skills: they know they must keep learning and adapting, and they have expectations attuned to the current system. Some will come to understand the need to get active politically. They will not be caught unprepared, as our generation was, for the rapid transformation of health care. They enter the profession expecting change.