If this is an Emergency, Hang up and Dial 911

The Demise of American Medicine, Part I

What you will be reading in this article has no bearing on the present situation that our country is involved with, meaning the SARS-CoV-2 pandemic. My concerns regard medical care rendered to citizens as a whole and how it has changed over the past few decades. Again, it is not only a problem with physicians per se, but the entire system that is destroying medical care. Presently we have good numbers of physicians trying hard to give society their best, but they are handicapped by the system governing them.

“If this is an Emergency, Hang up and Dial 911.” You hear this message whenever you call a clinic or a doctor’s office, or any medical facility. What is an emergency? The dictionary describes it as “a combination of unforeseen circumstances requiring an immediate response.” It is as diverse as the individual callers are. To some, if they scratched their hand, it is a significant problem. To others, the chest pain and sign of an impending heart attack have no real consequences. Shouldn’t there be some limit to this vague and broad-meaning announcement? Shouldn’t someone listen to the callers before giving the drastic suggestion of calling 911? It places unnecessary burden on the ER personnel and increases the cost of the medical care to an unacceptable level, benefiting no one except the big companies.

This is one indication of what I believe is the demise of the United States’ medical system, once the best in the world but sadly now the quality of healthcare is deteriorating significantly as evidenced by healthcare spending for outcomes like life expectancy. 

What I will elaborate in the following pages does not necessarily encompass all circumstances. Neither will it apply to all members of the medical profession. There were, there are, and there always will be exceptions to the rules. Nevertheless, I reflect in this discussion on the characteristic of the majority of those involved as I can see them. 

Let us start with a question: have you recently called your doctor’s office? Were you successful in talking to your physician? It would be a miracle if you did. For me as a physician, it has been almost an impossibility, and I was never that lucky. You cannot even get hold of a nurse or physician assistant. If you are lucky enough to talk to a person, it will be the receptionist. 

The difficulty in simply speaking with one’s physician is emblematic of the state of affairs in the medical system of the US, and leads me to ask:

1. What is happening to American Medicine?
2. Is the United States losing its world leadership in medical care?
3. What are the causes of demise of what was once the world’s best medical care? 
4. Is this demise because doctors are benefitting financially and so have not taken steps to preserve the medical system? Greed – unappeasable greed – drives individuals who prioritize financial gain above all else
5. Has the nation become victim to runaway capitalism that adheres to no rules or regulations and has no integrity? Where are we as a  nation heading with such  runaway capitalism?  

Once the envy of the world, American medicine is being dismantled, leading a fast descent to its annihilation.  No scale can measure the scope of the astronomical disaster that hit this profession. Such descent will affect the safety of all citizens, young and old, rich and poor. Its secondary outcome may include, in a general way: poorly trained personnel in clinical medicine with compromised responsibility; incorporating unqualified individuals deprived of necessary education in a critical field. And, for those in charge, an insatiable appetite for wordily goods.  

What has happened to our medical field is bad enough that it could be ascribed to a nationwide conspiracy theory, if one opts to postulate such an idea. As an American-trained physician of yesteryear, it gives me extreme pain to observe the direction that our sacred profession has taken in recent years. I received my training in the old school, where our goal was to always put the patient first. We learned to observe the sanctity of our profession, which appears to be almost completely disregarded today.  

Society, as a whole,  has always respected its physicians. Most physicians did their best for their patients, which can be a significant element for a cohesive relationship. Both sides continued enjoying the reciprocity of such a relation.  To society, medicine was a revered profession combining science, business and spirituality. On many occasions, patients had much closer ties to their doctors than to their priests or rabbis. 

Given consideration, the fact remains that during the golden age of medicine in the United States, the financial gold mine of medical care was untapped. And the big capitalists, especially the hospital chains, needed to have their hands on the mines! Is this what in reality had transpired? In my observation over decades of practice, physicians typically are not good businessmen.  As such, they are sitting ducks for opportunists. To get the upper hand, institutions had to limit physicians’ hands in medical care, and using their hired physicians that would give them more financial benefit. In reality, this is what has taken place.  All the outcomes point to the direction: Physicians should have as little influence as possible in patients care. Did the businesses follow this line of thought? Let us discuss the matter a little more in-depth and see what the facts show.  Here are a few actions taken by businesses in recent years:

1. Diminish the role of the physicians in actual patient care by creating a substitute for the doctors
2. Remove the titles of doctors and physicians from the vocabulary
3. Replace that name with “Providers,” which can denote almost anyone 

It started in the early 1970s, when the Federal Government began to evaluate the “Physician Assistant Program,” ostensibly to address the shortage of physicians. They established significant grants for the medical schools around the country to study the program’s feasibility and its implementation and incorporation into the general medical practice.

In 1970, I moved back to the USA, with my family,  from my country of birth. I was working at the time at Baylor College of Medicine as an assistant professor. I received a note from the Chairman of the Department of Medicine, Dr. Herold Brown,  to participate in the conference to discuss whether Baylor should accept a grant to evaluate the Physician Assistant Program’s feasibility. 

It was a big meeting with representations of all departments in the school. Everyone in the room was in favor of the program, and I am sure they had absolutely no idea of what it meant to the long-term medical care of society. They were blinded mainly by the large government grant to study the subject, to publish their finding, and to solidify their standing among the faculty. 

I requested to speak and started with: “In 1960, I left the United States for my country of birth. I was to teach at the medical school and fulfill my position as an endocrinologist in the school and the main teaching hospital. Some years earlier, the country had adopted a “Physician-Aids” program. The Aids were high school graduates with two years of study in elementary medical care. They were  supposed to work under the supervision of the physicians, mainly in rural areas of the nation that did not possess adequate medical care.”  

“The program did not do well and did not meet the expectations. They took the matter on their hands and acted as full-fledged physicians, causing disastrous outcome.  The patients care deteriorated rapidly. By 1960, the government   abandoned the program and ordered those individuals that if they wish to continue their work as medical personnel, they have to go to medical school that would accept them in the second grade (the medical schools in that country had a six years course).”  

I ended my statement that this program is not a real solution for the shortage of physicians. For better medical care, we require a more comprehensive plan. However, at the end and after the votes were in, only one other physician agreed with me and voted against the proposal. 

Creation of Physician Substitutes: 

1. Physician Assistant (P.A.): 

The PA program in the U.S., however, began in 1965. Dr. Eugene A. Stead Jr., M.D. of the Duke University Medical Center, started this program on October 6, 1967. He based his action on the rapid healthcare training program of the WWII era when there was a great need for individuals with some degree of medical knowledge, sufficient for that sort of environment. 

A new idea came into being! Many interested institutions jumped on the bandwagon to benefit from what they could offer. Unfortunately, no one thought to consider that WWII was over, and what was right during the War may not be appropriate in peacetime.  It was a bad idea from the start and was not a reasonable solution to deal with the shortage of physicians.  On the whole, these individuals may be of help in the technical sections but not in the direct patient care that requires in-depth knowledge in the art of medicine. 

In their last meeting of May 23-26, 2021, their house of delegates voted to change the organization’s name from physician assistant to Physician Associates. What does this mean? The dictionary gives several meanings for this word, usually with differences in the professions. As a rule, grossly, it means a junior partner with practically the same degree of knowledge. For example, when I was in practice, I had an associate who covered me when I was off duty, but he was Board Certified Internist and Endocrinologist!  I don’t know how the physicians’ communities will respond to these name changes. I can’t imagine what the P.A. group had in mind when they approved the name change and what they strategically pursuing, which is in itself an intriguing question.

• Nurse Practitioners:

This group was also created in 1965 by Loretta Ford and Henry Silver at the University of Colorado. The idea was to substitute the lack of physicians by the nurses who have undergone some special training. Educational programs for nurse practitioners started in some prominent universities, such as Boston College. This college was one of the earliest to bestow master’s degrees to these individuals. There are hundreds of thousands of nurse practitioners working in hospitals around the country, providing care to the patients. Was the idea a good one? Did the creators get what they wanted? We shall talk about that later.

I do not argue that some of these individuals are giving the society services of value. However, the question remains: are they, in reality, qualified to engage effectively as physicians? 

• Other meaningful steps to diminish the authority of the physicians were taken by the hospitals. Among those we can name the followings: 

• Purchasing physicians’ offices:

As those steps mentioned above were not enough, the Hospitals pressured their physicians to sell their practice to them. By opting for such action, they would run the ensemble of the outpatients and the inpatients. In the big cities, i.e., Houston that I lived and practiced for decades, I witnessed the pressure exerted by the hospitals to the physician’s groups to sell their practice. This type of behavior, at the start, was mainly against the groups who had some business relationships with the institutions, such as supervising their cardiac lab, gastroenterology units, pulmonary sections, renal section, and more. They wanted control over those offices. They sought the power to dismiss the doctors they felt were not beneficial to the system and replace them with younger and inexperienced ones with lower salaries.  

I know of a group of physicians who resisted and did not sell. The hospital got their revenge by not renewing their leases once the time reached.  

• Hiring Physicians called Hospitalists, to care for inpatients:

It was the rule that a physician would care for his/her patients if they were admitted to hospital. One of the first steps taken by the hospital was to eliminate this service and for the hired hospitalist to take over the patients while they were in hospital. This action completely disrupted the continuity of care. The hospitalists were totally unaware of patients prior medical history, often creating problems in their care.

The majority of patients admitted have no idea who their doctors are and why they can’t see their own physicians. At the beginning of this program, the general opinion of financial analysts was that this program would help curb the expenses of inpatients by shortening their hospital stay. However, in the long term, it cost a lot more because of poorly-handled cases and the need for readmitting the patients for the same problems. 

Much research published during the past decades all point vividly to this fact. New England Journal of Medicine, August 8, 2011, discussed a study sponsored by the National Institute of Aging in conjunction with the National Cancer Institute, which studied over 58000 Medicare patients from 2001 -2006 at 454 US hospitals. The length of stay was shorter in the hospitalist group by 0.64 days. And, the mean cost 282 dollars lower. However, mean Medicare costs 30 days after discharge were 332 dollars higher for the hospitalists group. Their patients experienced more subsequent E.R. visits and readmissions. 

To be continued.