American Medicine: Trailing in the Wake of Great Britain

Julio Frenk, Harvard School of Public Health

                           

When the Phantom was a 4th year medical student, he was lucky enough to wangle a boondoggle rotation in London.  Medical students in that year, 1972, considered the 4th year of medical school a wonderland, an unsupervised, romp. We were still on our parents' dollar, and we had no grades, and we could sign up for 6 week rotations in any specialty we wanted to learn about, or even in specialties we had no particular interest in but had rotations in really attractive places--like London.

So the Phantom chose London, and had to come up with a place, and lucked into a Cardiology rotation at the Royal Brompton Hospital for Chest Diseases in South Kensington.

It was  a child's fantasy, playing doctor, or at least medical student, among all these pretty nurses in their quaint nursing uniforms and flirting with them, in their own native tongue. 

In those days, English nurses wore blue wool capes with red lining, starched blue blouses with white collars and they all looked beautiful to the Phantom.

The English hospitals looked as quaint as the nurses' uniforms:  There were mostly open wards, with screens pulled around a patient when he or she needed to be examined.  The cafeteria in the basement had linen tablecloths and linen napkins.

The British invasive cardiologist who did all the cardiac catheterizations used a quiet little technique he called a Sonne's approach, feeding his catheter through the right arm rather than using the femoral artery in the groin.  He made it work for him.

Once, a visiting professor, brought in to pay some attention to all the medical students cluttering up the wards, mostly Americans, arranged for a visit for us to an outlying hospital in Uxbridge. 

There, we tagged along after the Registrars, the English equivalent of medical residents and we were horrified to see the apparently lackadaisical way they treated patients. In America, the most arduous, exhausting admission in those years was a GI bleeder, vomiting up liters of blood from a bleeding gastric or duodenal ulcer. It would keep you up all night, running up and down stairs to the blood bank for units of packed red blood cells, following the patient's response, his hematocrit and by morning, if he hadn't stopped bleeding, and if he had received 15 units of blood, you called the surgeons to take him to the operating room. But you had to give him a "trial of medical therapy" first and it was considered a "save" if you could avoid the operating room for the patient.

In Uxbridge, they gave the patient a unit of blood, and went to bed. They made rounds in the hospital, the next morning,  to see if the patient was still alive. We were horrified. The Brits reassured us, "Well, they always are alive in the morning. Well, mostly."

Well, I thought, this is National Health Care. This is rationed medicine. This is socialized medicine with central planning and limited resources. 

Doctors in England were not paid well. They lived in genteel penury,  if not poverty, modestly middle class. Of course, they went into medical school right out of high school and they became "general practitioners' when they graduate medical college with a M.B., a bachelor's in Medicine. There were only a fraction of the specialists we had in America. Fellowships in the specialties were severely limited and highly competitive.

There were for profit hospitals in London, outside the National Health Service, where the Harley Street consultants admitted their rich patients, mostly Saudis. The consultants could make real money in these hospitals where they could charge whatever the traffic would bear there, but they could then come back and admit patients to the NHS hospitals.

Not that doctors actually "admitted" patients to hospital the way American doctors did. In America, your doctor who took care of you in the community did the work of admitting you to the hospital when you needed it, and he called in consultants and he did rounds on you every day, collecting the opinions of the specialists and acting on their advice. In England the local doctors were nowhere to be seen in the hospitals. I asked a patient when she expected her doctor to arrive and she looked at me and said, surprised, "What? You mean my G.P.? Dr. Jones? Come to the hospital? Why would he do that?"  English patients expected to be cared for by hospital doctors and returned to their own doctors after discharge, with a full report.

An English professor of medicine listened to me presenting a patient on rounds one day, with a dreamy expression on his face. Later, he sat down at my table in the cafeteria and said, "Oh, what I'd give for a dozen like you, like any of you Americans."

I was astonished. I thought the British medical students were very bright, better at physical examination and observation than most of us Americans. They were just younger, and they disappeared after five o'clock, while the American medical students were still laboring away on the wards. "Well, we don't work so hard," one British student remarked, "But then again, they don't pay us much either." 

Now, forty years later, we Americans have GP's doing primary care in the communities, who have not gone to medical school--called Nurse Practitioners or Physician Assistants, just as the Brits did then. The American physician's assistants and nurse practioners of today practice very much as English GP's did then, triage-ing, treating the non threatening simple things, referring the more complicated, dangerous things on. 
Today in America, we have hospitalists delivering care in the hospitals while the Primary Care Physicians do not visit, just as the English did in 1972--GP's remained home in the community and patients were treated by doctors they did not know at the hospitals.
We do not limit GI bleeders to one unit of blood, but we rarely see GI bleeders since the advent of drugs like Nexium, the proton pump inhibitors.
 And we are doing the Sonne's technique for cardiac catheterization, even if we do not call it that. At our hospital today, the cardiologists are "discovering" the technique the Brits were using back in 1972,

CAT scans and a whole spate of medical innovations have come out of the British National Health system, and 99% of patients are well taken care of and happy with their care. The other 1% pay premium prices at the swank hotel/hospitals connected to Harley street. 

So, after nearly half a century, America is finally catching up with Great  Britain in medical care and public health. 

We have Atul Gawande writing articles in the New Yorker catching the eye of President Obama, suggesting all we need to do to cut costs sufficiently is to root out the over spending over test ordering fringe of high cost doctors. We have a school of Public Health at Harvard which has not managed to bring American medicine up to the level of quality a country a third our size manages to deliver across the ocean.

Are the Brits that much smarter than us?