A New Type of Doctor Emerges

U.S. medicine, the nation's most conservative profession, is being shaken up. Many medical students and young doctors are determined to change its rules and traditions. Old totems like the one-to-one doctor-patient relationship and the direct fee for service are losing respect. The American Medical Association, traditional foe of any system hinting of collectivism, is losing membership.* Interns and junior residents, who once were to senior staff what braceros are to farmers, are talking back and dreaming of new, more egalitarian forms of practice. The line in the Hippocratic oath that pledges the neophyte to "hold him who has taught me this art as equal to my parents" is little more than a charming bit of irony for many of tomorrow's doctors.

Yet resistance to change is strong, and no speedy revolution of U.S. medicine is in sight. What is happening amounts to a slow, often painful evolution that is shaping a new kind of doctor. He still represents only a vocal minority, but his attitudes are significant: - >He is more like his grandfather than his father, preferring the model of the old general practitioner to that of the specialist or researcher. The modish catch phrases and aspirations are "community medicine, " "family medicine," "household medicine." He recognizes the inadequacies of the old G.P., but thinks that better training can overcome them. He acknowledges the need for specialists, but envisions them as part of a team. "Specialists take one organ and ig nore everything else," says Jeffrey Beckwith, 26, an intern at Bronson Meth odist Hospital in Kalamazoo, Mich. "I want to get it all together." Harvard Medical School Junior Jerry Avorn, 23, rejects what he calls the "academic and elitist approach" of medical researchers because it places no premium on the delivery of health care.

>He is less interested in solo practice and a big income. None of the new doctors expect to starve, of course, and some interns are even demanding and getting salaries in excess of $10,000 a year. But a growing number of young physicians are seeking partnerships or jobs in which they will work standard hours for salary and share with their colleagues the responsibility of responding to after-hours emergency calls. Says Harold Jaffe, 25, an intern at U.C.L.A.

Hospital: "In a group I can practice good medicine without being on call 24 hours a day. I like reading something besides a medical journal, I like going some place besides a medical convention, and I like talking to somebody other than a doctor about something other than medicine."

>He is willing to accept Government participation in medicine and new types of health insurance schemes. Though only a radical few favor socialization, most see health care as a citizen's right rather than a privilege. They also realize that the money necessary to assure that right for all--and some degree of supervision over its spending --will have to come from some level of government.

> He is increasingly willing to accept paraprofessional assistance. Unlike older physicians, who often refuse to delegate responsibility, younger doctors are eager for all the help they can get. "A corpsman can set a bone or give a shot," says David Campisi, 25, a fourth-year student at U.C.L.A. School of Medicine. "If doctors would lose a part of their enormous ego, they could easily get the help they say they need."

The Fourth Era. American medicine has undergone three major cycles since Abraham Flexner published his comprehensive critical report on medical education in 1910. The first period emphasized the general practitioner, who had broad--but rarely deep--training in the science and clinical techniques of his day. This gave way in the 1940s to a trend toward specialization as doctors realized that no physician could possibly be competent in all areas of medicine. During the post-Sputnik '50s and '60s, scientific research was assigned high priority and prestige, along with generous financing. The fourth era, if the most reform-minded of the students and young physicians have their way, will stress wholesale availability of good clinical care.

Harvard Psychiatrist Daniel Funkenstein, who has studied the goals and attitudes of 2,000 medical students since 1958, has plotted the change statistically. When Funkenstein began his inquiries, practically none of the students with whom he talked planned careers in "community health." By 1969, however, 30% expressed an interest in practicing this type of medicine.

The biggest impact so far has been felt on the campuses, which are booming. Five new medical schools opened this fall, bringing the U.S. total to 108, with a total enrollment of 43,000 and a freshman class of 11,858, the highest ever. But the nation needs an estimated 50,000 additional doctors, and the increase in trainees will only nibble at the deficit. It was faculty members, acting out their own brand of idealism, who put research on the pedestal in the late '50s. Now some professors are following the students' lead in seeking to make training more appropriate to the practice of community medicine. Class hours devoted to pure science are being reduced in favor of earlier and more intense clinical work and less technical studies.

Lost Composure. Students at New York's Albert Einstein College of Medicine follow pregnant women through delivery, providing pre-and postnatal care for them and their babies. M.D. candidates entering the University of Missouri's new medical school in Kansas City this fall made hospital rounds on their first day of classes. Visiting the overcrowded wards of Kansas City General Hospital, the 36 students timidly felt a swollen abdomen, saw a diabetic amputee, and stood in stunned silence around the bed of a patient who died as they were on their way to his room. The school's provost, Dr. E. Grey Dimond, told the students: "It will be Christmas before you find your composure again."

Twenty-five schools have attempted to hasten the new doctor's debut by lopping up to a year off the traditional four-year program. A number of other schools are considering that basic change, which both offsets the rising costs of medical education and allows schools to accommodate more trainees over a period of years. Postgraduate training programs are also changing. New York's Montefiore Hospital has initiated a four-year residency in social medicine that requires participants to involve themselves in neighborhood activities. Resident Steven McCloy, 27, who spends half his time working at a federally funded local health center, has taken advantage of the opportunity by starting a sex education program in the area's elementary and junior high schools.

Nor have changes at the medical centers been confined to curriculum. Students at the University of Chicago's Pritzker School of Medicine are forcing a reorganization of the lying-in clinic system at the university's Billings Hospital. Patients at the clinic are now segregated according to their ability to pay, leaving one wing white and the other black. The school is planning to integrate them. Northwestern University is initiating a two-year program to prepare members of minority groups for entrance to medical school. Conducted in Chicago's South Side ghetto rather than the leafy Evanston campus, the program gives qualified students preliminary scientific training and exposure to patients. It also seeks to encourage them to practice in doctor-short ghettos.

Change Opposed. Significant as these developments are, their effect on the general practice of medicine across the country has been modest so far. Medical schools could play a still larger role in the movement for change than they now do, but most are firmly controlled by the profession's elders. The great majority of doctors with established practices have personal stakes in the present system. Opportunities for a medical education and incentives to experiment in new types of fee arrangements, though expanding faster than previously, are still scarce.

Some opponents of rapid reform make telling points. They warn that the trend toward group medicine will prevent rather than encourage a re-establishment of warm doctor-patient relationships. The growing tendency in some schools to stress the humanistic aspects of medicine at the expense of scientific studies worries many of the profession's leaders. "This attitude goes beyond anti-science," cautions Glen Leymaster, director of undergraduate education for the A.M.A. "It surfaces in the form of anti-intellectualism. Medical schools today need more science, not less." U.C.L.A.'s Dr. William Longmire Jr. shares that concern. Says he: "There comes a time when a doctor has to decide whether the dose of digitalis is five point zero or zero point five. He cannot be a judge then. He has to be a scientist."

There is also anxiety that the current antipathy toward laboratory work may slow the process of the basic research that has produced so many of the advances in modern medicine. Asks one Manhattan physician: "Where will we find the next generation's Albert Sabin if no one goes into research?"

The medical establishment, however, is not the only obstacle to community practice. Many idealistic young doctors who yearn to establish practices in rural areas fear being cut off from the advanced brand of medicine common to urban teaching hospitals. Others continue to cluster in the cities because there are few opportunities elsewhere. Of the 700 internships available annually in Illinois, fully 650 are in Chicago.

A kind of culture shock and a feeling of helplessness also afflicts some young middle-class doctors when they do get the opportunity to serve the poor. John Curd, 26, decided against community medicine after a two-month stint at Boston City Hospital. "To work there would just drive me nuts," he says. "The patient population depressed me to the point that I thought the earth was about to blow up and turn into fire. It really bothers me to take care of people who are just totally degenerate about their lives." Says Paul Simpson, 29, a resident at Massachusetts General Hospital: "In reality, you're not doing anything for people. They need social and psychological rehabilitation just as much as they need medical care."

The greatest cause of frustration is money. There are not enough public clinics or privately sponsored group practices to hire all those interested in this type of medicine. Nor have federal funds been forthcoming to support private group practice. Some idealistic doctors emerge from medical schools with heavy debts and cannot afford to take jobs that offer only modest incomes. As a result, says Harvard's Funkenstein, the trend toward community medicine has already peaked for the time being. Many young doctors, unable to break out of the system, have settled into conformity.

Financial Obstacles. Few appreciate the situation better than Michael Palmer, 29, a resident at Boston City Hospital. More interested in treating a variety of wounds and ailments than in research or specialization, Palmer helped set up the Cincinnati Free Clinic while serving a two-year hitch with the U.S. Public Health Service. Eventually he would like to participate in a prepaid group practice in the inner city, though he realizes that financial obstacles may well force him to shelve his ambition and settle in the suburbs. "Nothing in this area is going to be ready for me by the time I have to make my decision in a year or two," he says.

Palmer may be wrong. Public demand for a more efficient health care system is greater than ever, and politicians have begun to recognize this. House committee hearings on national health insurance legislation are under way in Washington and may run for months. Though Republicans and Democrats are still far from agreement on the major points of their bills, they do see eye to eye on one thing: the importance of group practice. Both parties would have the Government help begin to finance the group approach. Nothing would delight many new M.D.s more. "The image is not what we're here for." says Boston City Hospital Resident Richard Dellapenna, 30. "We're here to deliver health care."

*In 1963, 73.9% of the nation's eligible physicians belonged to the organization; only 69% currently hold membership. Because medical societies in California and New York have just dropped requirements that members also belong to the A.M.A., the association expects membership to fall even more this year.

This file is automatically generated by a robot program, so reader's discretion is required.