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From General Surgery News, April, 2012:
An Optimistic Curmudgeon

By Jon C. White, MD

Over the past two years I have written multiple editorials for General Surgery News cataloging the many challenges we have in health care today, including the obesity epidemic, the dysfunctional medical tort system, workforce shortages, the medical arms race and the unsustainable growth of the health care industry. With each problem I have tried to outline potential solutions. I don’t know if any of my naive suggestions will be strategies that we ultimately adopt, but the important concept is that most problems have solutions. If we look back through the history of medicine in the United States, we will see that we have had a succession of problems, but they have always been solved. Often the solutions themselves engender new problems but, in time, these new problems also get solved. Consequently, there have been continuous changes in the way we practice medicine for our entire history.

The Practice of Medicine

It also is true that the pace of changes in medicine is accelerating and that the most significant changes have occurred relatively recently. If we go back only 100 years, we were practicing medicine that still embraced flawed concepts, such as therapeutic bleeding that had its origins with Hippocrates and Galen more than 2,000 years earlier.

After two millennia of near quackery, we have experienced dramatic changes in our profession over the past century. Many consider the Progressive Era in the early 1900s to be the beginning of the modern age of medicine. Scientific discoveries such as germ theory and radiography, which originated in Europe, became very influential in the United States where physicians recognized that anecdotal medicine should be replaced by medicine based on legitimate science. American educator Abraham Flexner did his seminal study of medical schools in the United States in 1910, and his recommendations for changing the education and training of physicians were quickly adopted by both the government and the American Medical Association. For the first time, physicians were required to have some college education and then undergo a defined medical school curriculum based on scientifically proven, evidence-based facts. Predictably, there was an immediate improvement in the training of physicians and in the quality of services they provided, but there also were unintended negative consequences. The number of graduating physicians was sharply curtailed by the stringent medical school admission criteria, and practicing physicians were limited to college graduates who had matriculated to recognized medical schools. Because they were college graduates, the majority of them were affluent white men. Women and minorities, who had been trained in the proprietary trade schools of the pre-Flexner days, were no longer accepted. This adversely affected access to medical care in many areas of the country, insofar as the new, better-trained doctors concentrated their practices in urban areas, affluent suburbs and other places where this demographic group chose to live.

This problem of exclusivity, created by a solution to the problem of poor physician education, is slowly being solved. College education, as well as medical education, is no longer the province of wealthy white men alone. Women, minorities and those of modest means are better represented in medical schools these days. Access to care, although still a problem in certain urban and rural parts of the country, is being addressed by programs such as public health scholarships for practitioners who agree to practice in underserved areas. It is also important to recognize that dramatic improvements in transportation and communication make local areas more uniformly served and remote areas more connected.

The Science of Medicine

Another area in which we have made enormous strides is the science of medicine. The story of controlling infectious diseases provides a good example. Pathogenic microbes, which were unknown and unsuspected by the medical community until only recently, were the scourge of the early years of our country. At the beginning of the 19th century, retired President George Washington contracted a sore throat, which was most likely streptococcal or viral in nature. His doctors were quick to recommend bleeding. He didn’t survive their ministrations and died of his sore throat, which was probably caused by a relatively innocent microbe. Later in the century, President William Henry Harrison served the shortest term as president when he died of pneumonia, probably contracted during his inauguration. His doctors treated him with leeches, Virginia snakeweed and opium, which, surprisingly, didn’t save him. Toward the end of the century, President James Garfield was shot in the chest by an assassin. His bullet wounds were not immediately fatal but he died 11 weeks later, most likely from infection introduced by doctors repeatedly probing his wounds with unsterile fingers and contaminated instruments. It was not until the beginning of the 20th century that physicians first began to suspect the presence of microbes as pathogens.

When recruits for World War I were struck with a virus, it wasn’t quite as innocent as those that had killed the presidents, and went on to infect and kill as many as 100 million worldwide. This time, however, the response of the medical community was quite different. The blood and tissues of patients, both living and dead, were examined under the microscope. Respiratory microorganisms were detected and, although specific treatment wasn’t available, physicians ordered bed rest and hydration rather than bleeding. Sick patients were isolated and people on the streets wore masks for protection. Scientific observation and reasoning had finally entered the medieval world of medical practice and, although millions died, most likely millions more were saved.

Now, almost a century later, most pathogenic microbes have been successfully contained or treated with vaccines and antibiotics. Recently, a new strain of retrovirus emerged and the scientific and medical communities have come together to isolate, control and treat this deadly threat. The best minds in medicine who once bled George Washington to death in 1799 are now facing off against a far more sinister and devious microbial opponent and, this time, [they] are winning. There is truly something to be optimistic about.

The Business of Medicine

Reimbursement for physicians at the beginning of the 20th century was a problem and many practitioners had a second job or business to make ends meet. Although many physicians work long hours and feel they are not adequately compensated, there are very few who have to resort to a second profession to support their families. Looking at tables of what physicians and other allied health professionals earn on average, you would have to conclude that many of us are quite comfortable. There are some specialties that are experiencing financial difficulties and the distribution between specialties might not be entirely equitable, but in these days of double-digit unemployment, we should be grateful that there are very few health care workers who are not employed.

Health care is, in fact, still considered a growth industry. I remember something Joseph Fisher, MD, chairman of the Board of Regents of the American College of Surgeons, said to our local chapter several years ago. He was encouraging us to talk to our congressmen about health care issues that were important for surgeons. He warned us, however, not to focus on reimbursement, because at the time the average general surgeon in mid-career was earning more than $300,000 while a congressman earned $165,000. He did not think that voicing concerns over our earnings would find a sympathetic audience. He was right then and his advice is still right today. The president earns what a successful, mid-career general surgeon does ($400,000), but the vice president ($230,000), chief justice ($223,000) and speaker of the House ($230,000) all earn much less. Congressmen these days earn $174,000. Although we are concerned about our mounting overhead and the trajectory of our salaries, we are still outpacing the lawmakers and most other professions.

Access to Medicine

Access to health care has been a chronic problem. At the beginning of the last century, the practice of medicine was anecdotal, usually ineffective and not worth purchasing. As a result of the Flexner Report and the scientific discoveries made during the Progressive Era, health care became more effective, but also more expensive and less accessible. With the introduction of private health insurance in the 1930s and 1940s and Medicare and Medicaid in the 1960s, health care became accessible to a progressively larger segment of the population but still left some with less-than-adequate coverage. Medicare and Medicaid continue to extend their coverage but it is becoming increasingly clear that providing uniform coverage to all will be difficult, both financially and politically. Although coverage is not yet universal, more people in the United States are covered today than during any other period in our history.

The Arc of Our Universe

When you step back and take a look at where we have come from and where we are likely to go, this is really a glass half-full or half-empty situation. It is important to recognize our problems when they arise, but it is equally important to celebrate our successes when they occur. Medicine is like other great social trends. Few people today would argue that movements like civil rights and women’s rights, despite occasional setbacks, have not made enormous strides. Martin Luther King Jr., PhD, for one, took the long view on these moral issues and said on more than one occasion, “the arc of the moral universe is long, but it eventually bends towards justice.” You might say that he was an optimist.

In reviewing the history of health care in the United States, it is easy to detect a bend in our universe as well. Even in my relatively brief career, I have seen the introduction of technologies that have been nothing short of breathtaking, such as minimally invasive surgery, complicated transplantation, invasive radiology and gene therapy. In the past 20 years, we also have seen a greater emphasis on quality management, patient safety and evidence-based medicine. During this same time, there has been a profusion of inventive health care purchasing options including HMOs, PPOs, IPOs and health care accounts. Taken together, these trends tend toward the positive.

So, like Dr. King, I am an optimist. I would say that the arc of the health care universe also is long and fortunately it is bending toward efficacy, patient safety and increased access. The seemingly insurmountable problems that we see now, such as incomplete coverage, workforce shortages and the unsustainable expense of this enterprise, also will find solutions. These solutions will create problems that will need to be solved by our generation and future generations of medical professionals.

We should all be optimists to ensure that the health care universe continues to bend in a favorable direction. And this is not the time to be reserved. I don’t believe in being cautiously optimistic. Bold solutions and incautious optimism should be the order of the day. The main challenge for our immediate future will be financing our ever-improving health care system, and the first thing in our universe that we will have to bend is the cost curve.