Forty Years of Progress in American Medicine

Alexandre Yersin

Nobody ever mentions Alexandre Yersin when candidates are asked during Presidential debates who their heroes are. Sometimes, a politico will dredge up "Jonas Salk," to show he is capable of appreciating something and someone who is not just about political or military power, but nobody ever mentions or every will mention Yersin.

Yersin would not play well because he was a German and French speaking Swiss, and very few Americans have ever heard of him. He was the guy who single handedly discovered the cause, the "etiologic agent," of the Black Death  (plague),  the bacteria which killed half of Europe in the 13th century or thereabouts, which terrifies mankind still. He was also the first human being to successfully treat plague, in an era before antibiotics, by raising an effective vaccine against it.

He never practiced ordinary clinical medicine, i.e., never did "private practice," because, as he explained, "To charge for my services, for treating an ill person would be like saying, 'Your money or your life.'"

Such words would not endear him to the American Medical Association, or to all those  idiotic savants, all those confident pundits, those economic sophisticates who insist the best model for delivering health care is free enterprise, market forces, unregulated business and no government involvement.

Recently, the Phantom was asked to comment on the major changes in medicine and medical practice on the anniversary of his graduation from medical school, 40 years ago.

There were some obvious things, like the advent of drugs (first the H2 blockers, then the proton pump inhibitors) which meant an end to that most harrowing of all medical admissions for the average medical intern: The GI bleeder.  No more nights pumping 15 units of packed Red Blood Cells into patients yorking up liters of blood from their bleeding ulcers.  That's what we did in the United States, but that's not what they did in the United Kingdom 40 years ago--but more on that later.
 
Of course, the advent of fiber optics meant endoscopy and laporoscopic surgery could revolutionized gastroenterology and general surgery, which became entirely different specialties, attracting entirely different sorts of people with different skills altogether from those who preceded them.

Radiology and imaging are so changed they hardly seem like the same specialty since the advent of MRI and CT scans. Advances here transformed other specialties: Neurology went from a painstaking specialty of "Where's Waldo?"  in which methodical bedside examination was used to localize lesions, to a specialty of imaging, and visual anatomy. Imaging has become so dominant that autopsies, once deemed essential, are now a rarity in general clinical practice. There are other forces driving this abandonment of the post mortem exams--they do not generate much money. They were done for the generation of understanding and knowledge but they could not be "monetized" so that avenue of learning has been largely abandoned.

 Ultrasonography has transformed endocrinology making thyroid nodule assessment more scientific and adding a surgical component to the endocrinologist's gig. It has also transformed obstetrics to the extent fetal activity can be seen at very early stages. 

One thing which has not changed much, sadly, has been the relentless toll taken by that family of malignancies we call breast cancer--but this will be a topic for another day. Some cancers have been stunningly conquered: Testicular cancer the notable poster child for success in cancer research.

And, of course, there has been the remarkable AIDS story.

But the really revolutionary changes have been in the sociology of medicine--with the entry of women into medicine, and the displacement of men by women in certain fields like obstetrics, with the advent of physicians assistants, nurse practitioners, nurse midwives, nurse anesthetists--all  sets of practitioners now functioning without direct supervision or with only minimal supervision by doctors, the idea that you can break down the tasks the doctor does into discrete parts and pay these practitioners only a fraction of what you'd have to pay a doctor. The application of the business model to medicine, thoroughly and down to the last detail.

With these changes came the idea that what the doctor used to do by himself can and should be divided among a team of shift workers, the assembly line idea, the Henry Ford model of streamlining the production, each worker responsible for only a part of the ultimate product--forget that cobbler who made the whole shoe-- so "hospitalists" now admit patients to hospital  and the patient does not see his own doctor from the community once he is admitted to the hospital. Soon there will be "laborists," who will deliver babies in the hospital rather than the obstetrician. 

And medical school classes are no longer made up of 22 year olds, having just graduated from college after four arduous years of organic chemistry, physics and biology, having survived the gauntlet, to hurtle forth into the next four year trial by fire. Medical school classes are not compromised of young, restless, energetic, stallions, straining at the bit. No, now men and women in their 30's, 40's and even 50's are admitted to medical school, after they have had other careers or pursued other interests.  Applicants are accepted to medical school and then defer matriculation while they spend a few years at Goldman Sacks.

"Dedication" is no longer a word heard much around doctors. In the 1970's doctors were afraid, at first, to complain about the structure of medicine. But with revolution in other aspects of American values, doctors began to revolt too. Why should we have to go to Grand Rounds at 10 AM Saturday and miss our kids' soccer games? Why could we not schedule these professional activities at times which allowed for more family life?  The answer from the powers that were used to be, "Your profession comes first. Medicine. Surgery come first. You are a parent second, a doctor first. What you are, is a doctor. Everything else comes after that. Your identity is now with the profession." No more. You can't tell that to the man who used to command a submarine and is now a first year medical student.  You can't even say that to the 26 year old Goldman Sacks alum, who is now beginning his first year in anatomy. He is going to use his MD to start a health care system, the next Kaiser or Oschner Clinic. He is a businessman first.

When women could say, "I'm just as committed to raising my children, to my role as a mother, as I am to being a good surgeon, cardiologist, obstetrician, pediatrician..." well, then things changed dramatically.

Which brings the Phantom back to his original observation: What's happened over the past 40 years in American medicine is we have finally arrived at where medical practice was in Great Britain in the 1970's--patients there did not expect their GP's to admit them to hospital. The hospital doctors took care of you and sent you back to your local GP later.  You got one unit of blood for your bleeding ulcer and you got put to bed and the house officers made rounds in the morning, to see how you had done, to see if you were still alive. And, actually, mostly, you did survive, because as recent studies have suggested, if you do not pump in that 15 units of blood, your blood pressure drops, and you stop bleeding. 

Back then, the Brits were using a technique for cardiac catheterization using an artery in the arm, rather than the groin; American invasive cardiologists have finally adopted this as safer and less fraught with complications.

The British doctors used to joke, "Well, they don't pay us anywhere close to what you Yanks get, but then again, we don't work too hard either."

Now, American medicine has come around to the British way of thinking--except, the American twist is--we do work pretty hard, just not doing the same complex things we used to do. We just grind through more billable procedures, make sure we get paid for every band aide.  Our computers allow us to track every suture, every gauze pad and every aspirin and to make sure the patient and his insurance company get the bill.

That, the Phantom reckons, is progress.


The shift has been from the practice of medicine as a calling to the practice of medicine and surgery as a business. Our commitment to the patient ends when the next shift begins, when the next consultant arrives. It's not two aspirin and call me in the morning; It's go to the Emergency Room and they'll charge you $300 for that two aspirin.