THE PUBLIC AND THE GENERAL PRACTITIONER

Red Cross Meeting at the Tri-State Medical Association, Seattle, June, 1923.

“System and Efficiency,”—these watchwords of modern American business life, are beginning to be adopted by what used to be called the “learned professions”; and medicine, in particular, is entering a period in which “organization” and “service” seem destined to play a prominent and perhaps somewhat exaggerated rôle. The introduction of business methods and business phraseology into a profession which has hitherto been singularly free from a business atmosphere is to be explained in part by the general trend of the times, and in part by a praiseworthy attempt to give the public an opportunity to benefit more systematically from the extensive, though often complicated, advances of modern medicine. The function of the physician is no longer regarded as being limited to the care of the sick. “Health examinations” and “preventive medicine” for instance, are phrases as well known to the layman as to the doctor, and the medical profession is very properly preparing itself to offer to the public a new type of “service,” aimed, at least, at limiting the occurrence of disease. In making this broader program of usefulness available, there is every reason to believe that more and better work will be accomplished if the somewhat casual methods of many doctors are supplemented by those of the business world; but it is also of the utmost importance to remember that the experience of the centuries should neither be disregarded, nor subjected to modifications which, because they are new, may be too readily considered good. This conservative attitude applies chiefly, of course, to the age-old function of the physician in his relation to the sick. It may well be, though the question is debatable, that a new field, covering the care of the well, involves or permits something new in the relationship between doctor and patient. There may thus be some justification for the use of methods generally referred to as “putting the patient through the mill,” but there are already indications that the same methods applied to the care of the sick often lead to the patient’s confusion rather than to his peace of mind. And after all, the patient does deserve some consideration!

Any reorganization of the medical profession that threatens the personal bond between doctor and patient is to be viewed with suspicion, even if the object appears at first sight to be more thorough and careful practice. With the exception of the relationship that one may have with a member of one’s family, or with the priest, there is no human bond that is closer than that between physician and patient (or patient’s family), and attempts to substitute the methods of machine or organization, be they ever so efficient, are bound to fail.

Even the most forward-looking medical man must admit that for a long time to come, the main function of the medical profession will be to heal, relieve and comfort those who are sick or in distress, and plans which are devised to readjust the relationship between doctors and laymen must be based primarily on this consideration. New needs and opportunities are to be recognized and met as well as possible, but the chief thing is to be certain that in the name of the newer “Service” with its capital “S,” nothing of the old-fashioned, modest but effective service of doctor to patient is lost. I do not intend to suggest that relations between the layman and the medical profession should remain in the future exactly as they have been in the past. It is perfectly obvious that the manifold developments which have so increased the complexity of the practice of medicine make certain readjustments necessary, but it has become correspondingly clear that we must “watch our steps.” The protests of patients and their families or, to their credit, more often the muffled voice of their complaint, that they are no longer happy or contented in their relations with the medical profession are becoming more and more frequent. “I don’t think my case was handled right” is a phrase very commonly heard from patients who have had a long and varied medical experience, and curiously enough one is quite apt to find that it does not refer to the actual results of treatment. The modern layman of the educated, and often of the comparatively uneducated, classes, seems to have become surprisingly well aware of the fact that specific “cures” are not available for every disease or every symptom, and he is usually remarkably lenient in what he demands in the way of therapeutic results. His dissatisfaction has to do more with the general management of the case in which social and economic considerations are quite as important as its scientific aspects. He has attempted to get the best care, without regard to cost, and he finds that he has wasted his time and money going from one physician to another without finding anyone who can straighten out his troubles, or, what is more significant, is deeply interested in them.

One might be inclined to make little of such criticism, believing that it is the natural lot of every difficult profession, but the truth is that many of us who are in a position to hear of these experiences find that they are becoming more numerous, that they are often serious, and that the majority are quite avoidable. The difficulty seems to arise from a failure of “liaison,” and at first sight it often seems as though a more highly organized medical profession might be better qualified to deal with the situation. The fact is, however, that this type of trouble may arise in exactly those cases which have been in contact with one or more of the most modern clinics, and a careful study of the circumstances makes it perfectly clear that the trouble arises, not from a lack of organization but from lack of personal supervision and responsibility. For some reason or other no one physician has seen the case through from beginning to end, and the patient may be suffering from the very multitude of his counsellors. Of course I do not mean to infer that lack of continual personal responsibility on the part of an attending physician is the sole explanation of the failure of the patient to establish a happy relationship with the medical profession, but the observation of a great many cases in which the patient or his family have felt that the relationship was unsatisfactory, incomplete, remote and cold, makes me feel certain that it is a very common explanation. Those of us who value the high tradition which we have inherited in our profession find much pleasure in the intimate bonds that have always existed between ourselves and our patients, and if any break is threatened we must try to discover and meet its causes as early as possible.

There are unquestionably many explanations for the loosening of the bonds between doctor and patient, but I shall dwell at present on only one aspect of the situation, an aspect that involves the point of view of the layman, and one in the correction of which the layman can play almost, if not quite, as important a part as the medical profession itself.

The layman of the older generation, who has been disappointed in his medical experience and who feels that something has been lacking in the way of warmth, sympathy and understanding of his case as a whole, is very apt to hark back to earlier days. “What we need,” he says, “is a general practitioner! When I was a boy we went to see Dr. Brown if we had anything the matter with us and he always fixed us up. Nowadays there don’t seem to be any general practitioners, and we visit one specialist after another, trying to find the one who happens to know about our particular ailment.” Does this complaint merely represent the normal senescent yearning for those old times which always seem to have been so much better than anything that has come since, or does it rest upon some firmer basis and suggest a possible way out of our present difficulty? At any rate, the question raised is worth serious consideration. Why is it that the general practitioner is being supplemented by the specialist, and where does the responsibility for this shift in emphasis lie? Is the further development of this trend to be regarded as desirable, either from the point of view of the public or the medical profession, and if not what can be done about it?

The fundamental factor in the present increase in specialism is without doubt the progress which has been made during the last two or three decades in the various sciences which underlie the art of medical practice. Researches in anatomy, embryology, physiology, physics, chemistry, pathology, and bacteriology have so extended our knowledge of disease processes in man that, in spite of a lengthening of the period of study, it has become quite impossible for any individual to acquire an intimate understanding of all the broad fields of modern medicine. In the four years’ course of the medical school the student can get little more than an introduction into the so-called premedical sciences, and he learns of them only what is necessary to enable him to grasp the basic facts on which medical practice rests. If he is fortunate enough to be able to pursue his studies for a period of years after graduation, he naturally devotes himself to some limited phase of medicine in which he is particularly interested, and attempts to develop himself as far as possible in this direction. Meanwhile it is quite impracticable for him to keep in touch with the details of other fields and he becomes, by force of circumstances if not by wish, a specialist in what is often a comparatively narrow sphere.

In an era which is so characterized by scientific progress in all directions it would be strange and unfortunate indeed if medical men should lack the instinct for intensive study or for scholarship. Primarily, and in its highest expression, specialization represents the attempt to fulfill an intellectual craving, and as such it is most desirable, both for the tone of the profession itself and for the public which depends on the profession. Such a view of the situation is, however, far from complete, and other motives, of a less disinterested nature it must be confessed explain a considerable part of the tendency of medical men to prefer specialization to general practice. Thus, for example, the life of the specialist sometimes appears to be an easier one than that of the general practitioner, for the latter has less regular hours of work and may be called to his patients at most inconvenient times. If he is successful in his calling it is true that his life can never be called his own. Many doctors whose careers were interrupted by the war said, “I am not going back to continue being at the beck and call of every one by day and night. I’m going to specialize, and do an office practice.” On the other hand, it must be remembered that the life of the specialist is not an easy one. His hours of work can be to a considerable extent regulated, but they are long and exacting, and, if he is worth his salt, he will run up large bills for lighting, since most of his evenings must be devoted to study in a struggle to keep abreast of the advances that are being made in his field throughout the world. Again, the financial rewards of the successful specialist are usually considerably greater than those of the general practitioner, and to some this is unquestionably the determining factor in the choice of a career. Many others, however, are but slightly influenced by either of these considerations in their preference for the limited fields of medicine, and are chiefly affected, not by the new developments in the specialties, but by the fundamentally altered circumstances which at present surround the life of general practice.

Let us approach this question by considering briefly the motives which led men of high grade into the practice of medicine a generation ago or before specialism with all its rewards was widely developed. The motives were, in general, the earning of a livelihood, a specific interest in medical science, and, in the great majority of instances, a very real desire to be of service to one’s fellow men. The chief reward was not the livelihood, which was often extremely meagre, or the satisfaction of scientific interest, but the appreciation, the love, the regard of a community. The physician was the friend and the guide of his patients who turned to him in sickness and in trouble, and he occupied a position among them which was almost unique. His was a life into which any unselfish, high-minded young man might well be drawn, and the reward was all that any man could ask for. Now there is no reason to believe that the type of man who enters the medical profession has altered. A few, of course, take it up purely as a respectable means of getting a living, but the preparation is so long, so expensive, and so laborious, the life itself is commonly known to be so exacting and the financial rewards are usually so moderate in all branches of the profession that the number of men who drift into medicine with no more definite object in view is inconsiderable. A somewhat larger group are drawn to medicine primarily because of a love of science, much as they might be to zoölogy or to chemistry, but this, too, accounts for only a small proportion of medical students. Medical students have a crowded curriculum and work hard during their course of study, but they are not noted for being particularly studious as a class and only a very limited number enter research or teaching, the obvious outlets for those imbued with profound scientific interest. There is evidence for this in the fact that while many excellent opportunities for scientific work have recently been created in teaching and research-institutions the number of applicants qualified for the positions remain seriously low. Interest in science is thus not the compelling factor with most of the men who enter the medical profession and another motive must be sought. To those who, as teachers, watch successive classes of medical students progress in their course of study it is always striking to see how each group responds with enthusiasm when, after a year or two of laboratory study, it reaches the stage where contact with patients begins. This is what they have been working toward and waiting for. Dissecting room, microscope, chemical experiment—these were but means to prepare them for the great end which is the human relationship between the physician and the patient. It is the desire for this human relationship, with its opportunity for sympathetic intimacy and altruistic service, that remains today, as it has been through all the generations, the dominating impulse in drawing men to the study of medicine. The type of man in medicine and his fundamental ideals have not altered. He still retains the instincts that would lead him to general practice and if he does not enter general practice the reason is that he does not believe it is the most effective way to use his life. As he surveys the world about him and the opportunities before him, he finds that the specialist appears to occupy a position in the profession and in the community at large which is more dignified and more respected than that of the general practitioner. Professionally and socially the specialist is often looked up to as on a higher plane, and it is certainly neither unnatural nor discreditable for the young man to desire the career which carries with it the sincere regard of his fellows. It is this factor, rather than the wish for a life of ease or for increased income that so often prompts him to say, “I do not want to be merely a general practitioner.” It is the shift of emphasis on the relative value of the general practitioner and the specialist. Now it is probably true that the medical profession is to some extent responsible for the development of a point of view which exalts the specialist above the general practitioner. Certain trends in medical practice have tended to accentuate it, and many medical teachers and leaders, in their efforts to stimulate research and to promote progress, have laid so much stress on the importance of intensive study that students, often without any particular qualifications, have been directed toward specialized practice. But, granted the truth of this, the brunt of the responsibility for the present-day attitude toward the general practitioner depends upon the general public. It is not the manufacturer who eventually decides the value of his product, nor can any profession determine its own worth to the community. In the last analysis, the price of any article, or the significance of any calling, must depend on its importance to the world at large, and by the same token, the continued existence of the general practitioner will depend on his value to the general public, or, more accurately perhaps, on what the public thinks the general practitioner is worth to it. The supply will depend on the demand.

It may be well, perhaps, to analyze a little more closely this new attitude which the lay public has assumed toward the general practitioner, and which is apparently so potent a factor in directing young physicians away from the general practice of medicine. In thousands of communities and in innumerable individual instances there has been, of course, no change at all in the old relationship between the doctor and his patient, and in the intimate and sympathetic friendship with which the counsel and service of the one are met by the gratitude and respect of the other. Throughout the country, however, and particularly in large cities and the adjacent towns, the bonds of this extremely personal relationship are rapidly breaking down because the public is tending more and more to turn in the first instance to the specialist instead of to the general practitioner. The feeling seems to be that since the specialists know so much and are the ultimate authorities it is foolish to waste time by going elsewhere. Little effort is made to cultivate a relationship with a sound general adviser. “What has happened to the general practitioner?” someone asks, and without waiting for an answer, he runs off to visit a specialist. Whenever there is “anything” the matter, or as soon as one does not immediately recover from his disability, he seeks a specialist, not on the advice of his general practitioner, who might at least know what kind of specialist would be desirable, but on the advice of John or Mary, who had a friend who was cured of what is supposed to have been a similar complaint. In small communities the “City Specialist” wears a particularly brilliant halo, and the country physician must content himself with his lot while his patients seek expensive advice in the metropolis. If this is the situation and if the specialist is regarded with respect well-nigh akin to awe, while the general practitioner is regarded as a useful convenience when one has a cold or has overeaten, is it any wonder that so many of the better medical students wish to prepare themselves for specialism? The public does not seem to want them very seriously as general practitioners.

These are the conditions, therefore, partly inherent in the progress of medical science and partly depending on the attitude of the public which are today determining the rapid increase of medical specialism; and we may now pass on to consider whether this trend toward specialism is really advantageous to the public itself. There can be no question, I take it, that up to a certain point, the development of specialists is not only desirable but necessary if the medical profession is to be thoroughly equipped to prevent the public from becoming sick and to restore them to health when they are suffering. Thus, for instance, in the application of the results of the most modern research in the basic sciences, both to the diagnosis and treatment of disease, it is important that the physician should be thoroughly trained in the principles of the underlying sciences if the patient is to derive the maximum benefit that medicine can confer. It is, therefore, well to have specialists in heart disease who, as students of experimental physiology and pathology, have acquired a knowledge of circulatory disturbances in animals which is subsequently of assistance in treating disease in man; to have specialists in diabetes who are at the same time competent chemists, since their experience in the laboratory is of daily help in regulating the diets of their patients; and to have specialists in infectious diseases who have devoted years to bacteriology because their observations on the course of infections in animals and the effect of sera and vaccines on experimental infections are of practical value at the bedside. There have also been many strictly clinical advances which are the direct outcome of the intensive study of disease in man. Among these may be mentioned the modern highly refined operative procedures. The surgery of the eye, the ear, the nose and throat, or the brain, for example, involves such intricate technical methods and such a high degree of manual dexterity that it is done best by the surgeon with constant experience and practice in the same general type of operation. It is entirely reasonable that all of us prefer to have our tonsils taken out by a laryngologist and not by a general surgeon, and such specialists in medical practice must be available in every community. In another quarter, moreover, and in one which is of vital, although of less immediate concern to the layman, the need of specialists is even greater. This is the field of medical research. Our knowledge of disease has advanced so far that further progress will probably be slow, and little is to be expected except as the result of prolonged and concentrated labor. The nuggets lying on the surface have been picked up and the hidden gold will be found only by him who digs deeply and whose training has taught him where to dig. Here is needed not only the specialist, but the specialist with that unusual gift of vision which belongs to the pioneer and which urges him beyond our present confines.

In these two fields, therefore, in research and in the application to practice of specialized knowledge or complex technical procedures, the expert is absolutely necessary, but the number of men actually needed to satisfy the demands is relatively small and, in the natural course of events, there will always be enough doctors whose intellectual interests direct them to intensive study. The lay public, therefore, need have little anxiety about having sufficient specialists to serve them. The important problem for the public is whether they still have need of encouraging the development of general practitioners. Here is the crux of the situation! Is an attitude which is bound to result in a progressive increase in the number of specialists, at the cost of a progressive decrease both in the number and quality of general practitioners, one which will ultimately be of general benefit? In the light of the development of modern medicine, is the general practitioner an essential factor in preserving and promoting health or is he a makeshift necessary only in communities too small or too poor to support a competent corps of specialists? Can the public get along without the general practitioner? To those who are in a position to see the helpless flounderings of the unfortunates who pass from specialist to specialist the answer is very clear. Never was the sound general practitioner more important than he is today. Never was the public in need of wise, broadly trained advisers so much as it needs them today to guide them through the complicated maze of modern medicine. The extraordinary development of medical science, with its consequent diversity of medical specialism and the increasing limitations in the extent of special fields—the very factors, indeed, which are creating specialists, in themselves create a new demand, not for men who are experts along narrow lines, but for men who are in touch with many lines. The advantages to be derived from advice and treatment by specialists are entirely obvious, but the disadvantages are by no means always so clearly understood. They are inherent in the training, however, for depth is not often combined with breadth, and the enthusiasm which makes one an expert in a limited field is frequently the very factor which prevents him from viewing a situation as a whole. The training of the specialist is in its essence intensive, and he can detect the slightest abnormality in the organ or system which constitutes his field, but man is not merely an aggregation of organs or of systems—he is first of all a human being whose proper care involves an appreciation of his body as a whole, together with the circumstances of his life. Many a sick person, after visiting a series of experts, and being treated for the abnormalities which each discovered in his own sphere, remains an invalid because none of his doctors was accustomed to look at a case as a whole. Many a patient, after going the rounds of the specialists, has found relief in mental healing or New Thought or Christian Science, because he lacked the guidance of a sound general practitioner who understood his physical condition, his nervous temperament and knew the details of his daily life. And many a patient, who on his own initiative has sought out specialists, has had minor defects accentuated so that they assumed a needless importance, and has even undergone operations that might well have been avoided. Those who are particularly blessed with this world’s goods, who want the best regardless of the cost and imagine that they are getting it because they can afford to consult as many renowned specialists as they wish, are often pathetically tragic figures as they veer from one course of treatment to another. Like ships that lack a guiding hand upon the helm, they swing from tack to tack with each new gust of wind, but get no nearer to the Port of Health because there is no pilot to set the general direction of their course.

The latest substitute for the breadth of vision of the general practitioner is that offspring of the American God of Efficiency, the Diagnostic Clinic. What a strong appeal it makes, this apparently ideal combination of a group of specialists so closely affiliated as to afford all the advantages of expert knowledge and at the same time maintain the desirable general supervision! Practically the method seems to work out about like most substitutes—sometimes well and sometimes badly. It all depends upon the men who constitute the group. At its best the patient finds himself in the hands of a wise, broadly trained physician who handles his case personally and refers as occasion demands to intimate and trusted associates who are skilled in special fields. One man has personal supervision over the case and devotes enough time to it to grasp all of its ramifications, so that he can estimate the relative importance of the findings of the specialists on the production of the symptoms in the individual. At its worst, however, the Diagnostic Clinic is a machine, and the patient is automatically passed from one specialist to another and submitted to a series of examinations, so detailed in their nature that it would seem that nothing could be overlooked. The result is a list of so-called “diagnoses”—in reality a list of deviations from the normal, some of which may, and others of which certainly do not have any bearing on the patient’s trouble. The unfortunate thing is that only too often the patient undergoes treatment for some of these unimportant conditions and at the same time, because of the lack of some one man who understands the situation as a whole, the real underlying difficulty is entirely overlooked.

The truth of the matter is that the practice of medicine is intensely personal and no system or machine can be substituted for the personal relationship. The proper interpretation of symptoms involves not only a comprehension of the causes of symptoms but also of the person in whom the symptoms arise. Every experienced physician knows that when one of his patients complains of a pain in the stomach it is probably a very trivial matter and when another makes apparently the same complaint it is probably a very serious matter. It all depends on the type of patient, and the better the physician knows his patient the better will he be able to decide on the proper treatment. Skilled physicians, gifted with peculiar insight into human nature, can often estimate a personality with remarkable accuracy in a few minutes or even seconds, but in general the more a doctor knows of his patient’s background the greater advantage he has in handling the case. That is the great advantage which the general practitioner has always possessed and still possesses. He knows the patient from childhood up—his physical health, the nervous and mental strain to which he has been subjected, the conditions of his social, business and domestic life, and, more even than this, he may have the same detailed knowledge of the patient’s parents and of the circumstances of their lives. Now all this kind of information, which is difficult to obtain except as the result of years of intimacy, has an infinitely important bearing on the question of health and disease. Not to have it is an enormous loss, and the loss falls, of course, primarily on the patient. He is the one who suffers. The only person who can really gather together this fundamental knowledge of his patients is the general practitioner.

In the trend toward specialism the pendulum is swinging too far, and it is the duty of medical educators and leaders to indicate to their students the importance of general practice and the high professional attainments that are necessary for success in it. But this alone will not suffice. In the last analysis it is the attitude of the public which will determine the careers of many of our future medical men. If the public will but realize that it can have no greater asset than a close and continued personal relationship with a wise, sound, general adviser, it may rest assured that there will always be an adequate response to the call for service. In order to get the best type of medical men to turn to general practice, however, it is necessary for the public to understand that the qualifications for general practice are at least as high as those which are requisite for specialism, and to appreciate that the general practitioner is worthy of its respect and confidence.