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.