William P. Longmire, Jr

The American Journal of Surgery

PRESIDENTIAL ADDRESS

American Surgery beyond the Bicentennial William P. Longmire, Jr, MD, Los Angeles, California

Three hundred years ago (a hundred years before the Declaration of Independence) in the earliest colonial days, life was physically hazardous and demanding from the medical standpoint; not only were there fevers of unknown origin and uncontrollable infections, but there was also the constant specter of malnutrition. It was indeed a life in which only the fittest survived. As our history books teach us, half of the Pilgrims died during the first winter at Plymouth. Giles Heale, the ship’s surgeon who served on the Mayflower, was licensed as a barber-surgeon in London, but he returned there with his ship, leaving the colony without a formally licensed practitioner. What little medical knowledge existed on this continent in those early days was dispensed by the more educated members of the local population, who ranged from the ministers of New England to the owners of southern plantations. There were no medical schools, licensing laws or medical societies in the colonies at that time. Transportation back to England was expensive, hazardous, and lengthy. Medical education and training were obtained almost exclusively through individual apprenticeships. We must remember, however, that Harvey’s revolutionary theory of the circulation of blood was less than fifty years old, and the use of quinine, which had been introduced into Europe from Peru in 1640, was scarcely available in the New World. Although better organized and with some beginning semblance of standards, actual health care at that time in England and Europe was not significantly more effective. The great plague had killed more than 68,000 in London alone in 1665 and was undoubtedly checked largely by the great fire of London in 1666, which destroyed most of the city’s disease-ridden dwellings. Parisian medicine during the late seventeenth century was in a state of disarray; its physicians, From the Department of Surgery, UCLA School of Medicine, Los Angeles, California 90024. Reprint requests should be addressed to William P. Longmire, Jr, MD, UCLA School of Medicine, Department of Surgery, Los Angeles, California 90024. Presented at the Seventeenth Annual Meeting of the Society for Surgery of the Alimentary Tract, Miami Beach, Florida, May 25-26, 1976.

Volume 133. January 1977

wrote Garrison, had become “sterile pedants, redheeled, long-robed, big-wigged, pompous and disdainful in manner.” In lieu of medical treatment, they attempted to overawe their patients with “an adroit barrage of technical drivel.” The most important concern of the Paris faculty was to guard its rights and privileges against all comers, yet within the faculty’s own august ranks, intrigue and petty jealousy flourished. The ensuing century fortunately brought progress, and a hundred years later, under the American apprenticeship system, the training of physicians flourished. The physiciampatient ratio shortly before the founding of the republic had reached 1:600, and this substantial number of practically trained apprenticeship graduates diagnosed disease, dispensed drugs, and performed surgery. The differentiation between university-trained physicians and the barber-surgeons never really developed in this country as it had overseas. Only eleven years before the Declaration of Independence, the first American medical school was established at the College of Philadelphia in 1765 with a faculty composed entirely of graduates from the Edinburgh School of Medicine. Doctors educated in Europe continued to emigrate to America and many American doctors were beginning to study medicine abroad, particularly in London and Edinburgh. Stevens [I] comments: “By 1776 . . . the average [American] doctor practiced medicine, surgery, pharmacy and midwifery. While there was no rigorous specialization, there was an informal grading of practitioners according to education and experience.” The dislocations wrought by the American Revolution and the assimilation of waves of diverse types of immigrants temporarily replaced the concern for different kinds or levels of practicing physicians with the more basic issue of who was a doctor and who was not. It was during this period that John Hunter, often called the Father of Scientific Surgery, was in his prime, and it was one of his pupils who became Surgeon General of the American Revolutionary Army. 3

Another student, John Morgan, became a founder of the first medical school in America. Doctor Hunter later suffered an angina1 attack during an acrimonious board meeting at St, George’s Hospital and died on October 16,1793, the very same day that in revolution-torn France, Marie Antoinette lost her head on the guillotine. In view of the current newspaper attacks on the medical profession generally, there may be some solace in the knowledge that the profession has weathered even more vigorous attacks in the past, for a period of widespread public distrust of orthodox doctors occurred during the postrevolutionary era. The public disliked the doctors’ drastic therapeutic measures, they feared their professional power, and they were horrified by the atrocity stories about grave-robbing and the anatomic dissecting rooms. Notwithstanding these adversities, in 1876, 100 years ago, the medical profession was submerged in a flood tide of new proprietary colleges. A total of 114 medical schools were established during the period from 1873 to 1890 in this country, and it has been estimated that more than 400 were founded between 1800 and 1900. Most of these were individually chartered by the states and held no connection with any educational institution. The massive outpouring of poorly trained physicians from these schools, however, was in part justified because they served the purpose of providing some kind of medical attention to the hundreds of isolated communities springing up in the Midwest as well as to the influx of immigrants arriving in the East. After an age when Jacksonian democracy rose to its height and all forms of licensing and regulation were abandoned to the process of trial and error (and to survival in the marketplace), a new movement appeared at the time of the Centennial to reform American medical schools into genuine universitytype institutions. This movement, ultimately highlighted by the Flexner Report in 1910, was implemented in large part by the Council on Medical Education of the American Medical Association. Proprietary schools were closed and medical colleges were finally linked to institutions of higher learning. Admission was limited to a small number of highly qualified students and the educational programs vigorously emphasized a scientific curriculum. State licensing boards have subsequently been given complete authority to determine who may participate in the delivery of all forms of health care. Specialty boards and professional societies, although purely voluntary, have significantly influenced the preparation of specialists and the quality of care they render. Hospitals have been subjected to inspection and appropriate credentialling. 4

The year 1976 finds the United States in the forefront of scientific medicine throughout the world, but that position is threatened as the concerns of the public and the energies of the profession are turned elsewhere. What are these important problems that absorb us today? Simply stated, for society they are: (1) inability to get a doctor when one is needed and (2) the high and constantly rising cost of the doctor and the care he prescribes once he is found. For the physician they are: (1) concern regarding his status, for although the individual physician retains his position of esteem with his patients, doctors as a genus are being assailed with a barrage of criticism and abuse reminiscent of that early postrevolutionary period; (2) his ever-increasing interface with regulations, restrictions, and requirements of government; and (3) the need to cope with the tremendous mass of important scientific information requisite to practicing effective and reliable medicine today. The medical problems of our society might be attended to rather promptly, at least on a temporary basis, if our total political orientation were changed. An omniscient Central Committee or group could be empowered to analyze carefully the total health needs of the country, and then proceed with the authority and the power to alter the entire health care system with a single objective in mind-namely, to fulfill these “committee-determined” needs. We can see just how effectively such a mechanism can function when we review the dramatic changes that have been brought about in the Peoples Republic of China, a nation of 800 to 900 million inhabitants whose overwhelming health needs stemmed from such basic considerations as sanitation, control of endemic diseases, personal hygiene, and nutrition. By central direction, medical schools burgeoned both in number and in the size of their enrollment; not only did new schools of traditional Chinese medicine open, but a whole host of paramedical personnel were created. Millions of health workers and barefoot doctors who have undergone the most cursory health indoctrination today permeate the countryside, to dispense information on matters of sanitation, inoculation, and birth control and to be available for emergency and sick call triage. Evidence of the effectiveness of the system is apparent everywhere. Although this simplistic solution by Central Committee direction has been suggested frequently as a ready means of correcting all faults in our medical care system, we must ask ourselves, “Can it really work?” Moreover, are we, as a free society, prepared to accept the application of this philosophy to one numerically small but functionally important segment of our society? I believe the answer to both of these questions must be “no.” One cannot apply the

The American Journal of Surgery

Presidential Address

same corrective measures that have been used in a society emerging from ages with minimal health care to a society that is grappling with an effort to transform an excellent health care system into one that is the most superior. Nevertheless, we are imminently facing the problem of having central committees established by government with the mandate to direct medical manpower from the cradle to the grave. The granting of essential federal appropriations (upon which practically every medical school now depends) has quickly been followed by proposed legislation that would regulate, in varying degree, the number of students who might enter medical school, the manner in which they would be selected, the subjects they should be taught, the place they would go to be trained and in what field, where they may practice (at least temporarily), and finally, what they should be paid. Effective informational efforts directed to our legislative bodies by many individuals and organizations (notably the American Medical Association and the Association of American Medical Colleges) have thus far modified or eliminated these proposals for the time being. However, the attempts at regulation on the part of our governing bodies are, of course, stimulated by the very problems of society that we initially proposed to solve: to help the average American get a doctor when he or she needs one, and at a cost he or she or the government can afford to pay. Thus far, our government has tried to meet this demand by increasing the output of physicians and, indeed, the number of students being graduated from our medical schools has increased from 6,994 in 1960-61to 11,613in 1973-74.The source of an even greater enlargement of our physician manpower pool has been the striking increase in foreign medical graduates (FMGs) entering this country since the elimination of the “national origins quota” restriction on immigration in 1965. This is readily apparent from the fact that the number of FMGs licensed in 1968 (2,185) more than tripled in five years (by 1973), when 7,419 were licensed. Notwithstanding these figures, such sources of new physicians, although ameliorative, seem already to have demonstrated that additional physicians do not provide the answer to the problem of having a doctor available whenever Americans need one. In the recent report published by the Macy Commission on Physicians for the Future, Stevens [2] comments: “The United States is already training a relatively generous supply of physicians. Under present arrangements there is no evidence that an increased supply of physicians will help those members of the population who are most in need of medical care. More physicians merely add to the Volume 133, January 1977

medical care expenditures in public and private programs.” Having explored “doctor production” as an answer to “Why can’t I get a doctor ?” and found this solution wanting, legislators and advisory groups are currently concentrating on the regulation of residency programs (type, size, number, and location) as the next readily available mechanism that will provide everyone access to a doctor. Without further substantiating evidence than the fact that during past decades doctors tended to practice where they were trained, experienced legislators have been willing to weld into law this simplistic approach to the highly complex matter of physician distribution. One need only recall the influx of hundreds of physicians of all kinds, including surgeons, into Southern California after World War II (when there were fewer than a half dozen surgical training programs in the area) to realize that site of training is only one factor and not necessarily the most important one in determining physician practice location. There will always be those young physicians who will not “leave the nest” whether it be east, west, north, or south, but the majority are looking for a place where their hard earned knowledge and skills can be utilized with what they consider to be appropriate compensation, as well as an environment that is acceptable to them and their families. Training in Omaha is not going to keep the surgeon out of Southern California if the surgeon wants to go there. Simply because the number of residency positions has doubled in Muskegan and halved in Los Angeles in itself will not affect physician distribution. It is only when there is freedom to establish training programs (based on the availability of proper facilities and qualified training personnel) in sufficient numbers to accommodate most of those who wish to practice in a certain area that the training site/practice location sequence is necessarily a significant factor. Arbitrary legislative redistribution of training opportunities, particularly since quality of training is almost certain to be affected, will quickly destroy this fragile training site/practice location relationship. Residency reshuffling is a tangible objective that may well serve diversionary political goals for a few years, but anyone who believes that such action by the government will significantly alter patterns of practice or get American citizens a doctor if they do not already have one gravely underestimates the complexity of the problem. Moreover, with such naivete, many good or excellent training programs will unfortunately be supplanted with those of inferior quality before the failure of this approach becomes self-evident. We know that the profession has not been un5

Longmire

mindful of these problems and has been working diligently to assemble data upon which to make sound judgmental decisions. For example, five broadly based organizations representing the medical profession and hospital administration have united to form the Coordinating Council on Medical Education (CCME). One of its subcommittees, the Liaison Committee on Graduate Medical Education, is charged with the responsibility of seeking solutions on a voluntary basis for problems relating to residency type, size, number, and location; they realize that the previous controls of residency training programs must be adjusted and strengthened to become truly responsive to future national needs. It is imperative, however, that such changes be made flexibly and voluntarily rather than with the inflexibility of a monolithic federal legislative action. Indeed, changes in the type and number of residency training programs are regularly being made under our present voluntary system. Although the CCME, only recently established in 1972-73, has already been criticized as having limited effectiveness because of its limited accomplishments, we could point to PSRO or HMO legislative developments for examples of the tedious progress of governmental programs in these highly complex areas. There is every reason to believe that the CCME, with its broadly based constituency, will ultimately prove more effective than a governmental agency or some nonrepresentative, self-perpetuating commission. My plea is to insure that medical education (and most specifically medical training) will be supervised by a concerned profession and not by federal statutory regulations or quasigovernmental self-appointed supervisory bodies. It is assumed (probably with some justification) that if a higher percentage of our 311,000 active physicians were in family or primary-care practice, rather than pursuing medical or surgical specialties, medical care would be more readily available. We must realize, however, that the “appetite of the public for medical care is insatiable,” and that many Americans are totally unrealistic in their expectations of the type and extent of care they want and believe they need. Having some doubt that distribution (both geographic and with respect to specialty) can be improved by manipulating training programs, what method might be utilized if we wished to encourage more doctors to undertake primary care practice? First, we should question our present medical school admission policies. Is the general lack of interest of today’s medical school graduates in primary care medicine a reflection of the type of student being admitted? Are we excluding many young men and 6

women who are qualified to prepare for primary care and who would enjoy and excel in a career which emphasized breadth of knowledge and interpersonal relationships? The high percentage of primary care practitioners among graduates of schools of osteopathy, many of whom do not meet the requirements for entrance to medical schools, suggests that our present admission criteria may be screening out those who are oriented toward primary care. Moreover, lack of training opportunities in the medical and surgical specialties for osteopathic school graduates may also be an important factor in their becoming primary care practitioners. One highly successful mechanism for increasing the number of family practitioners has been demonstrated in England where, although many young physicians would scoff at the notion that their idealistic goals could be modified by materialistic considerations, numerous new doctors have turned to family practice not only because the yearly income of the family practitioner has eclipsed that of the specialist but also because the family doctor can begin his practice years before his surgical colleague has completed his registrarship, thereby enabling the practitioner’s lifetime earnings to surpass those of his extensively trained colleague. Primary care physicians in America also earn satisfactory total incomes, but many of them work at a grueliing pace, with continuous patient responsibilities that are apt to exceed those of the consultant specialists. If the British experience is applicable in our country, adjusting the compensation of the doctor in practice is apt to be far more effective toward determining the type of practice than tampering with educational and training programs. If the Chinese have solved the problem of geographic distribution of physicians, they are probably the only country that has done so. Even in the most rigidly controlled societies elsewhere, an equitable distribution has never been achieved; as the environmentally concerned advertisement states, “There are no simple solutions-only intelligent choices.” Again, as we look about the world, the only action that has even approached solving the distribution dilemma when the quality of life differs widely among potentially open areas for practice has been achieved by governmental assignment of doctors to needy areas. On a very small, voluntary scale, such a system has been in operation in this country for some years, and recent legislation proposes to expand the program substantially on a voluntary basis. Hopefully, this will meet our most critical needs. If not, one solution that has worked in other countries and must be considered here is the establishment of a universal obligatory period of service. The American Journal of Surgery

Presidential

The cost of medical care is a major point of concern to physicians as well as to the public. It must be remembered that professional fees make up only approximately 10 per cent of the cost of such programs as Medicare and Medicaid. The bulk of expenditures under these programs go for hospital and nursing home care and drugs. Indeed, the cost of health care is a major problem in all countries of the western world. Hospital care no longer consists essentially of bed and board, attended by hospital personnel with minimal salaries and utilizing inexpensive, essentially symptomatic drugs as it did fifty years ago. The three basic factors involved in the marked cost increase are (1) proper salaries for highly trained and skilled personnel, (2) widespread use of expensive diagnostic and therapeutic tests and equipment, and (3) a remarkable increase in administrative staff to cope with governmental and private regulations, reports, and fiscal matters. Moreover, all of these items seem destined for further increases in the future. Society must eventually realize that it is financially impossible to supply any and all health care which present-day scientific medicine is capable of providing. Limitation must be made at both ends of the scale. Restrictions must be placed on care provided for the so-called “worried well” at one end of the scale, but an even tougher problem arises at the other end, when it becomes necessary to limit life support and maintenance in certain incurable disease conditions and situations. Such measures are among the important steps that need to be taken if we really wish to make a significant impact on the nation’s health bill. What, then, of the physician’s problems? Unfortunately, for the immediate future, one cannot see relief in sight. Medical care, which touches every citizen, provides an irresistable attraction to publicity-seeking politicians. An expose of any weakness in the health care system is news whether or not any constructive action results. The apparent affluent status of the profession is apt to provoke envy rather than sympathy and support for our point of view regarding the best methods of improving medical care. The median net income for 1971 of more than 5,000 surgeons responding to the SOSSUS survey was $46,100 [3], a comfortable but certainly not exorbitant income for such a highly trained and responsible segment of our society, and even a bit scanty when matched to comparable positions of responsibility in industry and in other professions. I believe that the present medical generation will continue to be frustrated, irritated, and bewildered by the voluminous forms, regulations, reports, audits, and evaluations that government and even private agencies thrust upon us. Sadly, I can foresee little Volume 133, January 1077

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respite from this harrassment in the offing, but it is my hope that the next generation of physicians reared in this milieu of reports and paperwork will somehow reach a state of tolerable symbiosis with the system. Finally, what of the physician’s need to cope with explosive expansions of scientific medical knowledge and technic, and how can he hope to practice effective and acceptable medicine? With respect to public acceptability, studies of malpractice litigation would seem to emphasize again the importance of factors other than purely scientific expertise in patient satisfaction. Studies by Nix and others have indicated that it is not necessarily the physician with inferior education and training who is sued, but frequently the highly trained specialist in a hospital setting seems to be the most vulnerable. It is probable that in the future, physicians will perform essentially two functions: (1) primary care, in which the physician’s forte is breadth of knowledge in diagnosis, treatment, referral sites, and the ability to direct his patients to the numerous health services that are available; and (2) increased specialization so the physician can comfortably assimilate the substantial amount of essential information (both new and old) in his field. Such specialists will tend to function as members of a team (either officially or unofficially) and to be mutually supportive in their work. Some of us can look back with satisfaction on the way we have been permitted to practice our profession, and we cannot help but view the current changes with apprehension. Maybe we have been fortunate to have participated in the golden period of American medicine, here at the end of the nation’s second hundred years. We also recognize how quickly similar prophecies have proved false in the past, and we must not merely accept the inevitable changes that will best serve society but proceed to explore with enthusiasm the exciting scientific opportunities that are ushering in the next hundred years of our nationhood, reassured with the knowledge that man has always sought and will continue to seek aid for his infirmities of body and mind, and that man has always been and will continue to be kind to those who can provide him with effective relief, sympathetic comfort, and sincere encouragement. References 1. Stevens R: American Medicine and the Public Interest. New Haven, Yale University Press, 197 1. 2. Stevens R: Dissenting comments, p 59. Physicians for the Future. Report of the Macy Commission. New York, Josiah Macy, Jr Foundation, 1976. 3. Surgery in the United States. A Summary Report of the Study on Surgical Services for the United States. The American College of Surgeons and the American Surgical Association, 1975.

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Presidential address: American surgery beyond the bicentennial.

William P. Longmire, Jr The American Journal of Surgery PRESIDENTIAL ADDRESS American Surgery beyond the Bicentennial William P. Longmire, Jr, MD,...
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