Perspectives in Biology and Medicine

THE CHANGING MEDICAL SCENE (1929-1985): A PERSONAL PERSPECTIVE JOSEPH B. KIRSNER* I begin once more my daily work. Be Thou with me, Almighty Father ofMercy, in all my efforts to heal the sick. . . . Grant that I may be filled with love for my art andfor my fellow-men. May the thirstfor gain and the desireforfame befarfrom my heart. . . . Grant that I may be able to devote myself, body and soul to Thy children who sufferfrom pain. Preserve my strength, that I may be able to restore the strength of the rich and the poor, the good and the bad, thefriend and thefoe. Let me see in the sufferer the man alone. . . . Let me be intent upon one thing, O Father ofMercy, to be always merciful to Thy suffering children. May there never rise in me the notion that I know enough, but give me strength and leisure and zeal to enlarge my knowledge. Our work is great, and the mind of man pressesforwardforever. . . . Guide me in thL· immense work so that I may be of avail.—Maimonides (1 135— 1204), Daily Prayer of a Physician before Visiting a Sick Man. Introduction Medicine has undergone profound changes since 1929 when I began the study of medicine. Economic forces and societal pressures, especially after World War II, created a favorable milieu for the expansion of medical manpower, hospitals, and medical centers. Specialization and biomedical research flourished as never before, with unprecedented advances in medicine; including the virtual eradication of smallpox, diphtheria, scarlet fever, rheumatic fever, and poliomyelitis; the development of the human insulins, BJ2 for pernicious anemia, antibiotics, psychotropic drugs, beta blockers, H2 blockers, kidney dialysis, and vaccines ; the development of computerized scanners, ultrasonography, positron emission tomography, nuclear magnetic resonance, endoscopy, This paper was presented in part as the Alpha Omega Alpha lecture, Bowman Gray School of Medicine, Winston-Salem, North Carolina, April 10, 1985. *Professor, Department of Medicine, University of Chicago.©1986 by The University of Chicago. AU rights reserved. 003 1-5982/86/2902-0475$0 1 .00 Perspectives in Biology and Medicine, 29, 2 · Winter 1986 | 227 radioimmunoassays, kidney, liver, and heart transplantations, coronary by-pass grafts, laser therapy, limb reimplants, artificial organs, dissolution of gallstones, artificial fertilization and genetic engineering; offering diagnostic resources and therapeutic options in the 1980s unimaginable in the 1930s [1, 2]. The remarkable advances in medicine also have significantly modified the nature of medical practice. The independent physician rapidly is being replaced by group practices, emergicenters, urgi-care, and surgicenters . Health care today is increasingly delivered through a variety of contractual arrangements, involving health maintenance and preferred provider organizations and home health-care programs. There are more medical schools today than in the 1930s (127 vs. less than 50); many more medical students (over 67,000); and countless numbers of medical societies and paramedical groups. Clinical and research programs have so multiplied as to provide educational update opportunities in all aspects of medicine at all times. Medicine during this time also has changed in less desirable ways: the rising costs of health care, weakening of the doctor-patient relationship, the negative image of some physicians as avaricious and less caring, declining physician sovereignty, hospital TV self-advertising, the increasing purchases of university teaching hospitals by profit-oriented corporations, and the prospect of corporate dominance of health care in the United States, building interest in "trade unionism for doctors" [3], escalating malpractice suits, the "industrialization of medicine" (A. ReIman ) [4], the "monetarization of medical care" (Eli Ginzburg) [5], the possibility of overspecialization, and public concern whether the benefits of medical care are commensurate with its high costs [6]. Such publications as "Medicine on the Brink," Dilemma of a Learned Profession [7], "The 'Excellence' Deception in Medicine" [8], "The Academic Medical Center—A Stressed American Institution" [9], "Are Medical Schools Obsolete" [10], "The Young Physician—Living with Uncertainty" [11], "What's Happening to Clinical Teaching" [12], "The Deterioration of Clinical Medicine" [13], "Where Have All the Doctors Gone" [14], and "Can Hospitals Survive?" [15] have raised disturbing questions about the worthiness and the direction of American medicine today. And, so, paradoxically, when the understanding of human illness is attaining remarkable heights, when technological developments approach...