Bioethics Discussion Blog: 50 Years of Medical Practice: Changes, Benefits, Costs, Dilemmas

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Sunday, April 13, 2008

50 Years of Medical Practice: Changes, Benefits, Costs, Dilemmas

Last evening I attended the medical alumni reunion representing 50 years since we all graduated from the UCLA School of Medicine. Obviously, the first thing we all noted was that we were getting older and the graduation pictures on our badges were only a memory of how we looked and behaved then.
I am sure that most of us must have had also a moment of reflection about how the practice of medicine changed over the intervening 50 years. I certainly did and I decided to take more than a few moments to write some comments about this on my blog.

For medicine and medical care it has been a changing and challenging 50 years in many ways and by many events both in the realm of basic science, applications of science, development and general use of new tools for diagnosis and treatments and the specifically in the United States the way that medical care is provided (or not provided) to the public. During the past 50 years, we have gone from the development of the cardiac pacemaker to open heart surgery and heart transplant. We have gone from vaccines for polio and mumps, the global eradication of small pox to fighting a new pandemic HIV/AIDS. In the United States, Medicare and Medicaid didn’t exist when I graduated in 1958 but was part of the practice of medicine when passed by Congress in 1962 and a couple decades later the treatment of patients migrated from full control by physicians to the “employment” of physicians in what has been known in the U.S. as HMOs (health maintenance organizations). There is so much to show as a timeline regarding innovations and changes in medical practice between 1958 and 2008 that I can’t and won’t list them all here. However, for those who would to systematically go over the changes throughout the interval between those years, here is a link to Medical History Timeline for the clinical and some social events.

Tom Mayo, a lawyer, teacher and ethicist has provided me with a timelinewhich he uses as a teaching tool for his health law class. It covers the social, legal, economic and political changes which affected healthcare starting in 1700 but continuing on to detail what was going on in our past 50 years.

From my point of view as a physician but also a hospital ethics committee representative, teacher of first and second year medical students and writer of a bioethics blog, it is in the area of medical ethics and professionalism that much has changed along with the other clinical and governmental policy changes. Can you believe that when I graduated medical school there was no generally accepted concept of patient autonomy? Patient autonomy came as medical consumerism became an underlying concept within the doctor-patient relationship. When I graduated it was the paternalistic directions by the physician as the basis of decisions applied to the patient. There was no such thing as a patient being allowed to make a decision for life supportive treatment to be withheld or discontinued. This all came later when the potential for sustaining life but without curing the condition or returning of the patient to their desired quality of life was made available by the development of the ICU (intensive care unit) environment with the CPR (cardio-pulmonary resuscitation) responses, modern ventilators, hemodialysis machines, pacemakers and a host of other supportive yet not necessarily curative treatments.

The presence of hospital ethics committees were created and began to become available to help sort out ethical dilemmas that were beginning to appear. They began as ordinarily fatally ill babies with severe birth defects were found, through technology, to be able to be kept alive for varying periods of time, when it was not clear whether terminating life support represented killing, when conflicts began to occur between decisions of patients or their family surrogates with the healthcare team such as continuing life support in an otherwise terminal cancer patient or refusing life saving blood transfusions. With the acceptance of patient autonomy, the attention to the issue of informed consent and the introduction of advance directives has led to such conflicts to which ethics committees began to handle.

My entry into the 1950s world of medicine included my understanding of death and under what circumstances I would pronounce a patient dead. It was the presence of an unresponsive patient who was not breathing and who had no heartbeat or pulse. Later, with the advent of organ transplantation, the need for more organs to transplant into the increasingly larger population of potential recipients, criteria for pronouncing death changed. The heart could continue to be beating but if the patient met neurologic criteria of whole brain death including the brain stem with no spontaneous breathing, the patient could then be pronounced dead and the organs procured. This additional definition required ethics committees and others to establish ethical as well as clinical guidelines for incorporation into the protocol for selecting the donor candidate. This involvement of ethics committee protocol writing, consultation and supervision was also needed for procurement of organs from terminal patients who wished to have their life support ended and was observed without support until the heart stopped for 5 minutes, pronouced dead and organs quickly procured.

I could go on and on regarding the changes in medical practice in the past 50 years. For more about the development of medical ethics in these years, read the chapter “History of Bioethics as Discipline and Discourse” by Albert R. Jonsen, page 3, in “Bioethics” by Jecker, Jonsen and Pearlman and available as a Google book reproduction with only a couple pages missing from the chapter.

There have been many changes, many benefits, much cost and with the changes, dilemmas. Have these changes given those of us living in the United States the best in medical care? Not with the millions of people in the United States who have no medical insurance and may not be able to take advantage of all the benefit from the technical successes in this last half century. This is not at all an isolated issue only for the United States. In fact, the reader might want to read about the upcoming April 15th 2008 Public Broadcasting System television presentation of FRONTLINE titled “Sick Around the World”. You can get further information at this link and if you are reading this blog after that date, you should be able to view the entire program online at that same link.

I would be very much interested in reading from my older visitors who remember what medical practice and care was like in the 1950s and earlier, what changes they have noticed personally in their medical care experience as a patient in current times and what needs yet to be improved. (No names please.) ..Maurice.

10 Comments:

At Sunday, April 13, 2008 10:10:00 PM, Blogger Christian Sinclair, MD said...

Thanks for sharing your view on the changes in medical history. It is nice to get a view from on the ground, and some of us newbies only practicing for 5 years can get a sense of change.

Christian

 
At Monday, April 14, 2008 4:46:00 AM, Blogger herbert said...

This June will be my 48th anniversary since med school graduation. I am not sure that there is one change but the entire information technology explosion deserves a place as a candidate. Electronic imaging both structural and functional, information transfer including instant access to information on the internet, robotic surgery, fiberoptics, the application of technology to the genome, the application of technology to neurochemistry suggesting neurological basis for behavior and the concept of neuroethics, t, are only a few examples. The conclusion I come to is that it gets increasingly difficult to treat patients as real, breathing, feeling humans. We acquire so much information so quickly – and that is good for treating the disease – that we are provided an opportunity to forget treating the person who is the patient. Maybe it was always so but I think it is easier today.
Herbert Rakatansky, MD

 
At Monday, April 14, 2008 1:40:00 PM, Anonymous Emily said...

I am a female in my 60's. I have no memory of professional medical care in my youth because I never went to a doctor (dentists were the exception) until I was 17. And that was a dermatologist. My mother thought going to a doctor to treat adolescent skin problems was frivolous. "You'll outgrow it". So I had to spend my Christmas money for that visit. I think the bill was $20.

We were a typical middle class family. Dad went to work with a lunch bucket everyday. Mom stayed at home and raised my brother and I. We kids had a nice life. There was money for college , but not for medical doctors. When we came down with colds or chest congestion, it was remedied by holding a towel over your head while breathing in the steam from a pot of hot water. Aspirin, tea with honey and bedrest to bring down a fever. Sore throat? Gargle with salt water. Constipation? A double helping of oatmeal for breakfast. Spend money on a doctor for these ailments? Nope. In those days, most moms put on their nurse's hat and dispensed with health remedies passed down through the generations. It's interesting that I don't recall my mother getting sick though. Well, maybe she just suffered through her ailments silently.

I remember my friends getting routine tonsillectomies whether needed or not. The reward being all the ice cream you wanted. I also remember the big scare of polio. A couple of my schoolmates were whispered to have come down with it. They mysteriously disappeared from the scene. There was tremendous debate at the time about the safeness of the polio vaccine. But all the kids eventually got vaccinated by school nurses. Maybe it was mandatory, I can't recall, but I'm sure it was free.


When I was 22 and employed, I was among a group that became the first recipients of a medical plan initiated by the large company where I worked. I believe $7 a week was taken out of our paychecks as our part of the contribution. My first "serious" doctor visit was to a general practitioner at age 24 for an infection that home remedies couldn’t cure. I was prescribed antibiotics, my first serious medicine.

Fast forward to the present...with all the operations and doctor visits under my belt, my medical chart is as thick as a phone book. My adult children have doctor specialists for every body part. And their children as well. I'm sure we're all better off with the advantages that today's modern medicine has to offer, but I do think back with some wonderment to my parents who never went to doctors until Medicare came around. Even then, it was used sparingly. Dad died instantly from a stroke, and mom from heart failure. They lived to 89 and 90 respectively. Except for giving birth, neither had spent a day in a hospital. There was no expectation or feelings of entitlement to professional health care. Self reliance was the rule. When that stopped working, your time was up. And that was that. It was a uncomplicated time back then.

 
At Monday, April 14, 2008 3:22:00 PM, Blogger Maurice Bernstein, M.D. said...

Emily, a wonderful recollection. And you know, I think that you and your family's experience with doctors was probably more the norm than not. Part of the reason I think that folks didn't just rush off to the doctor was because there was less discussion (or none) of diseases in the public media--certainly not cancer, venereal diseases or psychiatric illness. Who would have thought of a pill to ensure an erection or contraceptive pills to prevent its ultimate consequence? The active and effective treatments for high blood pressure were not yet fully available except for phenobarbital sedation and heart attacks were even managed at home, there being no intensive care facilities in hospitals. Though cholesterol and athersclerosis was known there was no medical drugs to make a difference in their presence. The antibiotic of the 40s sulfa and penicillin were still mainstays of 50s along with the newly developed tetracycline in 1953 as treatments for infection. Though antibiotic resistence was yet to come, still not all infections were found to respond to the few antibiotics available especially in the critically ill patient.

Actually,though medicine was about to take off, based on World War II discoveries and beginning medical technology, use in general medical care had not yet arrived full blast. Doctors had less tools to work with and further along with the absence of widespread insurance programs and with the absence of direct to consumer advertising than compared with now, one can find an explanation on that basis why staying at home with an illness and trying home remedies was a reasonable and common behavior.

Are patients better off now than 50 years ago? Yes and no. Think about it. ..Maurice.

 
At Monday, April 14, 2008 10:17:00 PM, Blogger Maurice Bernstein, M.D. said...

By the way, for those who want to read a bit of history but also self-praise about my UCLA medical school accomplishments, celebrating their 50th anniversary in 2001, just click on this link. ..Maurice.

 
At Monday, April 14, 2008 11:38:00 PM, Anonymous martin donohoe said...

Falling between the newly-graduated and the seasonsed veterans, having completed medical school in 1990, I have noticed that while there have been some changes in patient management (availability of ARBs for ACEI-allergic patients, amiodarone for arrythmias, minimally-invasive surgery, etc.), that there has unfortunately not been any healing of the schism between medicine and public health, no increase in the recognition by medical students and physicians of the precautionary principle, no increase in emphasis in medical education on public health/social inequalities, no improvements in the delivery of health care in the US (if anything, things are worse now), and no significant change in the focus of medical ethics (i.e., most focus on end-of-life, informed consent, minimal focus on global bioethics, environmental health, etc.).
martin
Martin Donohoe, MD, FACP
http://www.publichealthandsocialjustice.org
martindonohoe@phsj.org

 
At Tuesday, April 15, 2008 7:28:00 AM, Blogger Maurice Bernstein, M.D. said...

Here is a Comment submitted by a medical school classmate who also went to the reunion. His "different" view of the intervening 50 years is actually one that I can understand and is not a whole lot different than what I hold. . ..Maurice.


I, too, attended the UCLA reunion and am eager to comment on the changes wrought by 50 years. My perspective differs somewhat from Maurice's, in part because we followed different paths. I pursued a career in research for a few years before entering general practice and eventually finding fulfillment in what's now termed "integrative" medicine. Fifty years ago, the source of my dissatisfaction with medicine arose from what I perceived as a disconnect between basic science and clinical practice--the art of medicine just didn't seem very scientific, being based more in authority and tradition. The exalted status of too many physicians seemed more consonant with their own sense of self-esteem than with the social benefits they provided.

Now, it's just the opposite. Humbled by the interposition of third parties into the doctor-patient relationship, and by the necessity of making quasi-Faustian deals with HMOs and insurers, physicians have smaller egos nowadays. They have vastly more powerful scientific and technological tools in their grasp, but less of that old-fashioned art of medicine. To judge from the slapdash physical exams that are so common these days, one must conclude that physical diagnosis is a dying art--most likely the result of economic pressures to see lots of patients quickly. Creative thinking among rank-and-file practitioners is discouraged, which is ironic in view of the fact that only the best and brightest are chosen for medical school.

I could go on at some length about the rise of the pharmaceutical-insurance-government complex, and in particular the ills brought by the ascendancy of Big Pharma, but I think I've made my point. The health care system is broken, and we doctors didn't break it, although if we had been a bit more prescient we might have salvaged more of the good from our past. I'd like to see doctors dealing directly with patients instead of with intermediaries, and having enough time to be healers as well as technologists. I'd like tried-and-true, old remedies (check the N.F. in the early 1940s) to compete on an equal footing with the latest patented drugs. I'd like to see a lot more respect for biochemical individuality in place of our notion of the statistically average human. So much more could be done with genetics and epigenetics! So much is not right, but it could be so much better if only our social institutions were a match for our technology. --RPH



Richard P. Huemer M.D.

http://www.huemer.com/mysig.jpg

 
At Tuesday, April 15, 2008 8:52:00 AM, Anonymous bob koepp said...

My memories of interacting with the medical system are similar to Emily's. And I'm very skeptical of claims that "modern" medicine has greatly improved our lot. Below, I'm pasting a screed that I wrote in response to a different blogger's questioning whether we get "our moneys worth" from the medical system...


Here in the US, the interplay between manufacturers, health care deliverers and consumers, all of whom behave irresponsibly, has created a medical dystopia.

Physicians tend to practice a very aggressive form of medicine that is most appropriate for medical crises. They show little to no understanding, let alone respect, for vis medica naturae, and consequently employ very powerful and dangerous interventions to treat even self-limiting health problems. This results in many medications being prescribed for the sole purpose of controlling side effects from other meds.

Most medical manufacturers are in it strictly for the money. They stoke consumer demands for the very latest, most expensive meds with little or no net benefit when compared to last year's (expired patent) model. And they employ very smart people in their marketing departments who know how to push the buttons of MDs and consumers. When they have a drug on the shelf that isn't effective against any known disease, they manufacture new diseases where the drug will be "effective." They lie (or at least, don't tell what they know) about the risks associated with their products. And despite all this, they operate with profit margins that loan sharks can only dream about.

Consumers are willing participants in the charade, claiming "entitlement" to whatever the latest medical fad might be -- the more expensive, the better. The one thing consumers will not tolerate is leaving their doctor's office without a prescription. This is just a perverse form of keeping up with the Joneses.

And what do we get for committing about a sixth of our GDP to this game? Well, if you look to the WHO statistics on health status around the world, we are _marginally_ ahead of countries that spend very little on medical care, but do manage to provide decent public health services. In other words, if you have a reasonably clean environment, good nutrition, and then provide decent prenatal and postnatal care (up to the age of about 5 or 6), there's not a lot more benefit (on the scale of populations) provided by US style "healthcare."

 
At Tuesday, April 22, 2008 6:40:00 AM, Anonymous Shaheen Lakhan said...

It's amazing how the legal industry has retained it's payment schemes for ages, yet the medical profession takes on huge dips. Recently, Dr. JC from the GNIF Brain Blogger wrote on this issue and makes a basic call to "incentivize" physicians to work more effectively. Thank you.

Sincerely,
Shaheen

 
At Saturday, November 21, 2009 1:42:00 PM, Anonymous Anonymous said...

Although I am not in the medical profession I am an older student 41to be exact pursuing my Bachelors in Healthcare Management and in researching your blog and other papers on Physician autonomy there are alot of similarities as to what many physicians have faced over the last 50 years and I am very happy that you provided this knowledge to those of us who really have not seen all the drastic changes. As a kid growing up in the early 70's we went to see the physician got treated and it was covered by insurance or my parents paid for the services. Today insurance takes care of that but at a price. Thank you for sharing this!!! MN.

 

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