This is the full text of the Kate McMahon Lecture delivered by Dean Robert H Ebert MD of Harvard Medical School at Simmons College, Boston, on October 19, 1967.
Much has been written in recent years about medicine and the physician. In keeping with the “Madison Avenue” approach of our culture, a good deal of rhetoric has been lavished on the “image” of the doctor, and even more on the dramatic advances in the science of medicine. A cursory survey of what has been written in newspapers as well as weekly and monthly magazines permits the conclusion that medical science comes off rather well and the doctor’s image not so well. One gains the impression that doctors as a group are motivated by money, are becoming less and less interested in patients as people, and are socially irresponsible.
More often than not an author will point out that his own doctor is a good fellow but that the remainder of the profession is grasping, money- hungry and dehumanized. There are gross inaccuracies in what has been written about the medical profession, just as there are in what has been written about big business and labor unions. But it is more important to ask why there is so much interest in the doctor than to evaluate critically what has been said about him.
I believe it stems from an uneasiness on the part of both the public and the medical profession. The public has been indoctrinated to believe in the miracles of modern medical science, but the reality of delivery falls short of the expectation. The doctor is uneasy because his traditional role seems to be changing. He can no longer act solely as an individual, for he has become increasingly dependent upon others — other doctors, others in the health field, and above all upon the many people who work in the hospital. This changing role is related to his changing social responsibility and he is ill-prepared for the change.
The doctor is a frequent target for attack because he is said to lack a feeling of social responsibility. I believe this to be unfair, for in my opinion the average physician has a strong sense of social responsibility but it is a highly individualistic feeling which is largely invisible to the critical public. There is, as one might expect, great individual variation in the degree to which this feeling is developed but the same can be said for any other group in our society. How is the sense of social responsibility displayed by the physician? It is primarily manifest in the relationship between doctor and patient. Traditionally, the physician assumed a total responsibility for the health of the individual patient who sought his care. This relationship was maintained until the doctor discharged the patient or until the patient discharged the physician. As we shall see, this relationship is no longer quite so simple, but in one way or another the physician continues to assume that this one-to-one relationship between doctor and patient represents his primary responsibility toward society.
There are two other traditional ways in which the physician has sought to discharge his social responsibility. The first is by the provision of free care to the poor; the second is by teaching without financial reward. But these roles are also changing, and part of the modern physician’s dilemma is the impending loss of this highly personal kind of giving. Let us examine what changes have occurred, which have affected the physician’s social role. The most profound has been caused by scientific and technological revolution in medicine.
Medicine is a far more complex art today than it was a generation ago, and the omnipotence of the individual physician in providing for all the needs of his patient has been lost. The science of medicine is changing at a logarithmic rate; therapy, whether manipulative or pharmaceutical, is becoming more specific, more potent, and more dangerous, and no physician today would claim that he can keep up equally well in all fields of medicine, even if he were to devote full time to such an endeavor. The physician has been forced to specialize because he cannot maintain competence in every field, with the result that today only 14 per cent of medical graduates plan to enter general practice.
Inevitably, these dramatic changes in the science of medicine have affected the manner in which the physician discharges his primary social responsibility — that is, the care of the patient. In a simpler age, the physician knew not only his patient but the patient’s family; he was familiar with the patient’s social and economic background, and he was able to provide care with a kind of personal understanding often absent today. The physician was able to do far less medically than he can today but no one could do much more; the general practitioner could safely provide most of the care needed by a family.
Understandably, there is a nostalgia for this kind of relationship and it is reflected in many of the articles written about the changing image of the doctor. Where is the understanding, fatherly physician of another generation? Why has the physician changed, and why has he become coldly scientific and uninterested in the “whole patient?” These are the questions asked again and again. The answer, of course, is relatively simple. The physician did not change because he wanted more money or was dissatisfied with a role enjoyed by a past generation. He changed because medicine changed and society changed. And in many ways the physician is as uneasy about the change as the public seems to be.
No longer can he provide for every need of the patient. He must call for help from a variety of experts, or if he is expert in one area himself he restricts his practice to that one area. Even if he is a general practitioner, he lives in a more complex society and is likely to know less about the patient’s role in the community than did his counterpart a generation ago. The result is a more specialized and a more fragmented kind of medical care, often with no one coordinating the total care for the individual, much less the family.
The physician is often accused of abdicating his primary responsibility for the patient. This is an oversimplification. He continues to assume a very real responsibility for that part of the medical care which he feels competent to provide, and he is usually willing, if asked, to recommend other specialists. Often he is not asked to do so, and here the system breaks down. We have a system of medicine predicated on the concept of a family physician who refers to the specialists only for rare and unusual disease. We have developed a science of medicine which requires the skills of specialized medicine in everyday practice.
The concept of family medicine and the reality of specialized medicine are in conflict, with the result that the public is confused and the physician frustrated. Not all physicians provided free care for the poor, but the tradition was a strong one and more physicians participated in this method of giving than the general public realizes. My father was a physician and he always provided free care for members of the clergy, and nurses as well as for physicians. In addition, he spent two half-days a week at the County Hospital, giving his time without remuneration. This was his way of giving and he felt personally rewarded by providing free care. Nor was he unique. Many physicians took the “Robin Hood” approach toward the economics of medical care. They charged the rich more than those with middle incomes and provided free care for the poor. The advent of health insurance changed this approach. Now Medicare and Medicaid seem destined to end the provision of free care in the office and the clinic. Teaching has been linked with free care in the clinic and in the hospital ward, and this, too, seems likely to change now that the system of payment has changed.
In an article by Michael Halbestan in The New York Times Magazine section for August 13, 1967 the author quite eloquently editorializes on what the loss of his opportunity to provide free care and to volunteer his teaching services on the wards of the Washington D.C. General Hospital would mean. In commenting on the care of ward patients he sees on teaching rounds, he states “If I were paid for this work by Medicaid, I do not think I would be too happy about turning over my fees to anyone or anything else — Congress, after all, meant the money for me. On the other hand, I do not think that my care of patients would be changed one way or another by the fact that I was being paid for what I formerly did free.”
The author is not hypocritical; he is truly distressed that his traditional way of providing free care and teaching on the charity wards is changing with the advent of social legislation. He is a socially responsible physician who is now being told that his method of giving is outdated. The problem we face is not how to provide the physician with a feeling of social responsibility but how to substitute successfully a broader kind of responsibility for one which has been intensely personal.
The Social Problems of Medicine:
There is no lack of problems to preoccupy the physicians who wish satisfaction from personal involvement in the health field. In my opinion the social problems are of greater magnitude than those which are strictly medical. Not only is there a place for the physician in the approach to these problems but he must be involved if they are to be solved. Let me describe what I believe to be some of the pressing social issues that involve the medical profession.
The utilization of medical resources:
No social institution has been more subject to the winds of change than has the hospital, and none is more critical in planning for the health needs of our citizens. It is well to remember that hospitals were created as eleemosynary institutions, dedicated to the care of the sick poor, and turned to the care of the more affluent members of society in the relatively recent past. This fact is important, for our thinking about the hospital is colored by its past. In the 19th century, and even at the beginning of the 20th century, it was usually safer to be cared for at home than in the hospital. The primary purpose of the hospital was domiciliary and those in greatest need of beds and nursing care were the poor.
With the discovery of the principles of asepsis, the refinement of anesthesia, and the improvement in the science of surgery a new role for the hospital developed. It was no longer possible to provide care in the home of equal quality as in the hospital, and the more affluent now sought hospital care. Voluntary hospitals built private pavilions for the care of those who could pay, and private hospitals were built in community after community stimulated by the demand from the public and encouraged by the physician. Curiously, even those hospitals which cared only for private patients continued to assume the role of charity institutions seeking subscription from the community.
The most substantial change in hospital financing was accomplished by health insurance. After a slow start in the 1930’s voluntary hospitalization insurance became the predominant method of paying for hospital care, and even many patients admitted to charity wards had hospitalization insurance. Today, with voluntary health insurance. Medicare, and ultimately Medicaid, the vast majority of patients will be able to pay for hospitalization. It is not the purpose of this lecture to discuss the economics of medical care, and this brief review is given only to provide a better understanding of the modern hospital as a social institution.
The hospital was created not only to provide for the needs of the sick poor but also as a convenience for the physician. It was easier for physicians to provide free care within the walls of the hospital, or its dispensaries, than to visit the sick at home. This convenience now extends to the private patient, but the modern hospital is more than a simple convenience today. It is a vital necessity for the physician. Modern diagnosis and treatment demand a variety of skills and a complicated technology which cannot be duplicated in each doctor’s office. The result is that more and more services are concentrated in the hospital or the medical center and the modern hospital has become the primary focus of medical care. And yet it continues to be used by the physician as though it were there for his primary convenience as an individual physician.
The organization of the hospital reflects this attitude for the administrative staff and the medical staff are usually quite separate. Most physicians look upon the administrative staff as the housekeepers, the board of trustees as money-raisers, and the medical staff as the permanent, rent-free tenants of the hospital. The result of this divisive organization is an institution singularly handicapped in planning for the health care of the community which it serves. Here, then, is an area for responsible social action which is new to the physician, which is less personal but which demands his participation. I do not mean that the physician should spend his time operating the hospital, but I do suggest that some of the energies he now devotes to the matters of how professional fees are paid might more profitably be directed toward planning for the hospital.
Let me use the example of internship and residency programs to illustrate my point. Prior to World War II, many community hospitals had successful internship programs and some had residency programs. Residency training was greatly expanded following the war and during the late Forties and early Fifties larger community hospitals came to depend upon the services of a house staff. Interns and residents provided a significant amount of the care of hospitalized patients, and new physicians for the community were recruited from among graduates of the residency programs.
About the mid-Fifties, it became progressively more difficult for the community hospital to recruit American graduates for internship and residency programs, partly because there were far more internships and residencies offered than could be filled with American graduates, partly because of the internship matching plan and partly because the medical school graduate learned that he could have a better educational experience in a university teaching hospital. Following World War II, it became popular for graduates of foreign medical schools to seek additional training in this country, and with the relative shortage of American graduates many community hospitals came to rely almost entirely on the services of foreign interns and residents. Even this supply now seems inadequate, and many community hospitals have either lost accreditation or are threatened with the loss of accredited programs for training interns and residents.
Remarkably little insight has been displayed by the medical staffs of community hospitals in solving this problem. Many physicians seem to feel that they have the “right” to have interns and residents and blame medical schools for not sending graduates to community hospitals. It was seriously suggested by a number of medical societies that all university internships be discontinued since university hospitals could rely on the services of medical students. Note the word, “services.” They never suggested that the graduate might have a better educational experience in the community hospital. Here is a problem of the modern hospital which must be solved ultimately by physicians.
The care of seriously ill patients in the hospital requires the availability of
physicians’ services 24 hours a day. This is why interns and residents are in demand. But there clearly are other solutions. The staff, itself, could assume the role — on a rotating basis — or fully trained physicians could be brought into the community hospital on a fulltime basis to fulfill the resident function. But hospital staffs are not well-organized for joint activity, nor do they tend to view this as a primary responsibility of staff physicians. Surely this is an area of social responsibility which the physician could assume — in fact must assume.
The distribution of medical care:
Closely linked to the evolution of the modern hospital is the problem of the distribution of medical care. There are two groups who have suffered from the changing pattern of medical practice: the rural population and the urban population occupying the central city. Both groups present special problems, and both require new approaches to solutions. Most of you are familiar with the problem of the rural community. Here the general practitioner is the mainstay of the medical care system, but as he grows older he is not being replaced. Community after community attempts to recruit new family physicians only to find that young physicians do not wish to practice alone in a small town. The reasons are not hard to find. Most young physicians specialize and are unwilling to practice alone; they are more and more dependent upon the well-equipped modern hospital, and finally their wives worry about the availability of good schools. Once again, curiously little imagination has been exercised in seeking solutions to this problem. In an age of modern transportation, when the evacuation of wounded from the jungle by helicopter is routine, it should not be too difficult to plan the care for rural communities. It would take a different kind of organization of physicians, however, and would require a kind of teamwork with other members of the health professions which physicians have been reluctant to provide except within the walls of the hospital. It also would demand a new role for the regional community hospital. The central city presents a different problem and one of greater magnitude. Few of the general practitioners who practiced in the city have been replaced, and the modern specialist serves the suburbs more than the city. The city or county hospital or large urban voluntary hospital provides most of the care for the urban poor. Often the actual medical care is good, particularly for the acutely ill patient, but too often it is care without dignity. Service is frequently fragmented among different hospitals for members of the same family, and even when paid for it tends to retain the trappings of charity. It is not surprising that the urban poor have sought a different kind of solution. The medical programs sponsored by OEO [Office of Economic Opportunity] can be criticized on many grounds but they have endeavored to give the community itself a voice in how it is to receive care — and the community does not want the charity clinic. Columbia Point [the first Federally Qualified Clinic] is too expensive to replicate, and it has not solved the problem of its relationship to hospitals. But it has demonstrated a number of important points.
First, the health problems of the urban poor are intimately linked with their socio-economic problems, and they cannot be solved by imitating the care given in the suburbs.
Second, more than the physician alone is required to provide these services; a well-organized team is essential.
Third, the community itself profits from a sense of active participation in the project.
These are important lessons, and the physician can display a new kind of social responsibility in contributing to the solution of the problems of urban health.
The organization of health care:
The provision of medical care in the rural community and in the central city will require a different kind of organization of medical resources than has existed in the past. The physician must learn to work more closely with social workers, nurses, visiting nurses, in fact all of the members of the health professions. There must be a sensible division of labor so that the physician performs those services which only he can do, and other duties are delegated to appropriate members of the health team. To a degree this has already been accomplished within the hospital, but team effort must be extended to provide care at all levels. This is not an easy problem for it will be necessary to make the most efficient use of expensive manpower and still maintain the personal nature of medical care. I believe this can be done but it will take innovation and will require of the physician a new kind of responsible social action. Care for the chronically ill and for the elderly, who so often suffer from chronic disease, is a particular case in point. Chronic illness is increasingly common and it cannot be handled effectively if it is thought of as an exclusively medical problem. The social, emotional and economic impacts of chronic disease must be understood and intelligently dealt with. Here the physician must share the responsibility with others who have special skills to offer.
The United States is a great world power. With this power goes responsibility for people in other parts of the world. There are two areas which relate directly to medicine: the training of foreign physicians in this country; and aid in the development of medical schools and medical programs in underdeveloped countries. We have done a very poor job of training the graduates of foreign medical schools. It was noted in the discussion of internship and residency programs that we have exploited the foreign physician to provide service in our community hospitals. We have not done much better in our universities, for the training a foreign physician receives in a research laboratory is too often related more to the needs of the foreign physician. It accomplishes little to train a man in the use of the most sophisticated scientific technology if there is no comparable laboratory to which he can return and little chance to establish such a laboratory in his own country. There are, of course, some excellent international programs sponsored by private foundations and universities but the American medical profession has never looked upon inter-national medicine as an area for which it might assume responsibility.
It is apparent from this brief listing of social problems affecting medicine that there is no lack of projects for the socially-motivated physician. Why has the physician displayed so little interest in them? I suspect the answer lies in the manner in which he has been educated.
The Education of the Physician:
The social values of the physician come from the environment of the medical school and the hospital in which he receives his internship and residency training. He does not learn them in the classroom but rather from his preceptors. He is likely to assume the social values of those he respects and for the remainder of his professional life he imitates what he has seen and experienced as a medical student and as a house officer. To some extent these values may be molded by one or another of his basic science instructors, but the impact of his clinical teachers is much more profound. His opinions are formed in the clinic, and it is here that he ultimately comes to accept whatever social responsibility he carries.
Those students or house officers who had the good fortune to learn from men of great wisdom, such as Francis Peabody ’03, Soma Weiss, Howard Means ’11 and Walter Bauer could not help but be influenced for the remainder of their lives. Those students taught by men of narrower vision accepted more limited horizons for American medicine. Unfortunately, more students are taught by teachers of limited vision than by the “greats,” and for this reason the actual environment in which teaching is done has a narrowing influence. What does the student (and house officer) actually see within the modern teaching hospital? Let me preface these remarks by saying that there are exceptions, but the experiences which I will describe are all too common.
First of all, he is likely to see a sharp separation between the care of the private patient and the charity or ward patient. True, this sharp division is beginning to blur but the approach to these two populations of patients remains quite different.
He sees enormous preoccupation with the scientific care of the acutely ill patient but the relative neglect of the same patient once he or she is discharged from the hospital. I say “relative” because many teaching hospitals remain ill-equipped to handle the ambulatory patient and there may or may not be good continuity between the care provided within the hospital and the OPD. In any case, the student is unlikely to see the patient once he is discharged, and even the house officer might not see the patient again.
The out-patient department is often a depressing place to work and neither students nor faculty enjoy this experience as much as the in-patient service. Too often patients are treated without appropriate dignity and it is common for a patient to wait most of the day for a visit with the doctor and for various laboratory tests. It is here that the contrast between private and clinic care is the sharpest and it is here that the idea is likely to be fixed that there is one kind of care for the poor and another for the more affluent. A student placed in this environment has little opportunity to examine the socio-economic problems of his patients. He is likely to look upon the medical social worker as someone who helps in the “disposition” of patients discharged from the hospital and not as someone with very special skills which apply to all classes of patients.
In short, the student and the house officer are likely to think that the ward and the OPD patients are a convenience for him during the learning process and not a group for whom he has any long-term social responsibility. Ultimately, when he goes into practice, he will care for a different group of people — patients with middle-class backgrounds like his own — so there seems little point in learning much about this particular group of urban poor. Little of his medical school or house officer experience prepares him for anything more than responsibility for the individual patient. He has almost no exposure to the overall problems of delivery of health service to a particular population, and he tends to remain curiously detached from any commitment to the overall community which the teaching hospital serves.
The result is a willingness as a practicing physician to work in the OPD but not to assume that his responsibility extends beyond the individual patient for whom he provides care. The student and house officer should not be blamed for these attitudes, for by and large they reflect a past lack of community interest on the part of many teaching hospitals. Most hospitals felt that they were discharging their function if they provided the ward and OPD facilities for the care of the poor. But change is beginning to occur. Medical schools are coming to realize that the environment in which they teach is not entirely appropriate.
Further, they are beginning to display an interest in the community as well as in the individual patients provided for in their teaching hospitals. Even those not prompted by intellectual interest realize that soon almost all patients will have the ability to pay and when this occurs the “charity environment” must disappear as well.
Much more needs to be done. More able people are needed in the medical school environment who devote their attention to the social problems of medicine. There must be study of the needs of particular communities, and innovative plans introduced by the teaching hospital to test new ways of organizing medical care. There must be a greater integration of effort of physicians, social workers, nurses and others, both in the hospital and in the community.
Above all, the student must actively participate in such programs. He can learn from lectures and seminars but he must experience a new kind of social responsibility within the clinic if he is to be influenced in the future. He must see experiments in the delivery of health care. He must be made aware that the practice of medicine is now a group responsibility and he must learn to work closely with others. He must be made as aware of the social problems of medicine as he is of the biological problems.
I think that this will happen, and one reason for my optimism is the attitude of many medical students today. These students come to medical school dissatisfied with the manner in which society has handled the problems of the poor and of the Negro. They are concerned about social problems abroad as well as at home, and above all they wish to become actively involved in seeking solutions. I predict that they will provide the necessary prod to a conservative profession and to a conservative educational process.
© Harvard Medical School Alumni Association 1968, Preparation by Dean Robert H. Ebert, M.D.