LESSONS IN LEADERSHIP AND LIFE
“The more you know about the past, the better prepared you are for the future.” Theodore Roosevelt.
Reminiscing about my time in medical school, I often try to remember what was more important than studying esoteric details of medical science. Certainly, it wasn’t politics or the business of medicine. To keep our heads above water, the first couple of years were spent writing copious notes in classroom lecture halls followed by cramming sessions on Fridays and exams on Saturdays.
By our third year, we became known as Scut Monkeys — performing mundane and undesirable tasks (scut) that resident and attending physicians didn’t want to do. And by the fourth year, we were pretty much left alone to do electives and look for residency spots after graduation.
I do recall that my favorite and most relaxing classes were those that pertained to the history of medicine, patient-physician dynamics, and how to perform physical diagnosis. I think this is where we began to learn the art of medicine.
All this reminiscence made me curious about how my colleagues viewed medicine then, and how they view it now. I was curious what different generations of doctors thought about our current state of medicine and what they liked or disliked about our profession.
EMERGENCE OF CONVERSATIONS
The catapulting medical events I’ve witnessed and experienced since I began my career in 1983 have had dizzying, mystifying, as well as awe-inspiring effects on our profession — from addressing patients’ and societal demands such as desire for gender affirming care, rapid weight loss strategies, and use of sexual dysfunctional drugs, to advances in pharmaceuticals, diagnostic and therapeutic innovations, and the complete overhaul of the business of medicine. It makes one want to stop — at least for a moment — to smell the roses.
To listen, reminisce, and learn from voices of the past, present, and future helps improve navigational skills required to lead and to be a good doctor.
I’ve assembled a list of interview questions tailored around some of my colleagues’ experiences and what good and bad things are happening or happened to our profession (in their opinion). This first article, focusing on “Conversations with the Past,” will be followed in subsequent issues by “Conversations with the Present” and “Conversations with the Future.”
PERSPECTIVES
My first conversation was with Dr. CHM, a graduate of the Ohio State University College of Medicine, Class of 1961. He is an internist, a former flight surgeon with the U.S. Air Force, and a long-time private practitioner. He spent the past 16 years dedicating his time and vast expertise to help poor and underserved populations. Along with many accolades, he was recently recognized locally as a 2024 Distinguished Physician. Dr. CHM is 89 years old at the time of this writing.
Question: What prompted you to get into medicine?
Dr. CHM: It was God who prompted me to seek a career in medicine, and I owe whatever success I have achieved to the wisdom He gave me to utilize properly what I learned in my multiple years of studies. I was literally born to become a primary care physician, and of that fact I have no doubt.
Question: How has the practice of medicine changed as it relates to patient care today?
Dr. CHM: When I began a determined course in life to become a physician, I was only eight years old (1944) and began observing a local general practitioner who saw patients in his home — in a small annex, as most family doctors did in those days. The office was never crowded since people used home remedies in those days rather than pay for an office call. I never went to a physician until I needed a college physical. I survived coughs with my dad’s magic tincture of honey, lemon juice, and whiskey.
The physician’s only diagnostic tools were his brain, eyes, ears, nose, hands, stethoscope, and a seldom-needed X-ray fluoroscope with which he could do many investigative things to unravel a difficult case. The brain, five senses, and hands were then and still should be a physician’s best method of arriving at a correct diagnosis by doing what is known as history and physical, often skipped in these days in favor of a CT scan and a pile of labs.
In 1944, a doctor using an office fluoroscope could observe real-time, moving X-ray images of a patient’s internal structures on a fluorescent screen, typically in a darkened room. While the image quality was low and radiation doses were high, it was a valuable tool for diagnosing, viewing motion, and guiding procedures. The doctor thus gained sight of four systems: digestive, cardiovascular, respiratory, skeletal, and orthopedic.
Because most illness or injury was managed by one physician in their office, who sutured lacerations, set fractures, and gave medications for coughs, colds, pain, or “intestinal flu,” office supplies and medical care was very inexpensive and efficient.
Question: Did you feel well-prepared to practice medicine after completing your medical school and residency training?
Dr. CHM: I felt very well-prepared after a one-year rotating internship, touching base in two-month segments with internal medicine, surgery, pediatrics, OB/GYN, and one-month electives in radiology and pathology. That gave me a broad-based underpinning and knowledge of medicine. I then practiced for two years in the Air Force before returning to a three-year internal medicine residency with special clinical training in endocrinology.
I passed both written and oral exams for my board certification, which I completed in 1968. However, feeling confident, not arrogant, I knew the urgency of keeping up through current literature and continuing medical education, and as a teacher of residents and medical students, I never stopped learning, and have not to this day done so, after 65 years in clinical medicine.
Question: How do you define the art of medicine?
Dr. CHM: The art begins when you first greet you patient, with a smile and an extended hand for a shake. If their hands are wet and cold, you immediately pick up a clue; your patient is nervous and it is time to reassure them. I learned to practice the art and science of medicine from my mentors at the Ohio State University College of Medicine.
The art of medicine, which is as firm as one’s skeletal anatomy, is practiced at the patient’s bedside as the putative father of internal medicine, the Canadian, knighted Sir William Osler, MD, taught at Johns Hopkins University from 1889 to 1905. That art is practiced in history-taking by knowing how to follow up the patient’s answers to your questions with the proper follow-up questions.
The science of medicine, unlike stable art, is ever changing with government-funded research and application. CT scans and MRIs supersede plain X-rays which surpassed fluoroscopy. Science has reduced hospital stays but not premiums. The surgeon receives as much for the lap as for the open procedure and he or she can do more in a day.
Total hips and knees have kept old folks on the move instead of living depressed, inactive, and becoming obese in a wheelchair in the last years of life. I hesitate to comment on what the science of medicine brings in another sixty-five years, other than to say it will result in exponential change.
Question: How has the practice of medicine changed as it relates to bureaucracy such as third-party payors, government payors?
Dr. CHM: Bureaucratic medicine changed everything from physician decision-making, crowding of a physician’s time, and particularly the cost of healthcare. The proverbial Neanderthal only practiced the house call. That was me! If you call your physician today after office hours or often even during their hours of operation you get this message before any other words are heard; “If this is an emergency go to the nearest hospital emergency room or call 911.”
Nursing homes now have their own full-time physicians and thus those visits are not made by PCPs. Hospital visits seldom occur for primary care doctors because of the lack of time, they do not get paid traveling to and from the hospital, and the “hospitalist,” a physician treating those of the PCP’s practice needing hospital care.
Specialists will address only problems they feel meet with their specialized training. They have tunnel vision and thus often miss the fact that the left shoulder pain for which the patient is seeing her orthopedist is a subphrenic abscess due to a ruptured colon diverticulum at the splenic flexure.
The crowding of offices and ERs resulted from the fact that the federal government offered to pay for most of the cost of a 65-year-old and up to death patient’s care. Medicare sent messages telling their customers to go for annual exams, complete with EKGs and laboratory tests. Suddenly the elderly arrived with complaints about gas, bloating, insomnia, constipation, muscle aches, and headaches that they had been treating themselves for years with home remedies.
The government set the cost of office visits so that competition of doctors for the same or better care at a more favorable cost was abolished.
Furthermore, eventually courtesy care was also eliminated between physicians and their families, or a patient who could only pay with a jar of homemade fruit jelly, a bottle of home-brewed wine, or a freshly butchered chicken, because equality of care was demanded by Medicare and audits would find those who did not comply. The result was to repay the government for all patients who paid the full price.
Medicaid eliminated the outpatient care of the indigent and with it a vital piece of education for hospital training of interns and residents in medicine, surgery, obstetrics, and pediatrics. Medicaid started paying physicians for their time and indigent care that many of us had used training house officers pro gratis.
Question: Do you believe electronic health records are an effective way to document information about your patients? Do you think it helps patients? Do you prefer paper charting?
Dr. CHM: EHRs serve several valuable purposes if used properly. They are legible to all who have a need to read them, unlike most physicians’ cursive, and are easily stored on a computer chip instead of rows of filing cabinets. A scribe assisting with the paperwork while the physician performs a proper history and physical exam and then assures later that the scribe’s report was identical with the physician’s history, physical, diagnostics, and impression, makes eye contact with the patient instead of a laptop more personal and professional.
Question: What do you think of the quality of patients today as compared to the past? Are they more knowledgeable? Are they more like partners with you for their healthcare management? Or are they more demanding and more of a nuisance? Do they possess errant information about medicine?
Dr. CHM: In the past, patients came to me because they wanted to know my opinion based upon my extensive training and board certification. We did not advertise because a satisfied patient is the best agent of referral to a PCP. They were full of questions, not their own opinions. Patients today are much more informed, and misinformed, because of social media, internet, and TV advertising. They often come in having made a diagnosis on themselves, pointing to a location.
Some patients appear deciding which specialist they want to be referred to. I then proceed as I said above, to ask how they came to that conclusion. The answers varied from “Aunt Bessie told me” to “I saw this ad on TV that talked about my problem and where to get it fixed.”
Question: What do you think of mid-level providers being part of the healthcare delivery system? Do you think they are well-trained to meet the tasks of healthcare management? What do you think their roles are or should be?
Dr. CHM: Being a collaborating physician in a patient-centered medical home facility for 16 years overseeing the practices of nursing practitioners and physician assistants, I have found that compared to physicians, they are sadly lacking in sufficient information to ever become private PCPs, unaccountable to anyone.
Granted, as with any healthcare professional, some are better than others, and their scores (GPA) on my quarterly peer reviews reflect that. Their training is far too brief and incomplete. They study gross anatomy from two-dimensional books, not three-dimensional cadavers, and their diagnostic acumen reflects that too.
Mid-level providers should be reviewed periodically by the physicians for whom they work. I have asked several who work for my personal physicians, PCP, and specialists, and found none who say that they ever need to submit to such reviews by their boss.
Question: Do you believe we are on the right track of where medicine is going these days?
Dr. CHM: Medicine got off track when physicians lost control of what was best for their patients beginning in 1965 under two executive administrations. Getting back on track would be harder than eliminating socialized medicine in Canada.
In some ways, one-stop shopping in our community, as offered by a local healthcare organization that is extremely well run, efficient, and availing patients of their choice in attending staff of highly acclaimed primary care physicians and specialists, appears a decent direction to go. Furthermore, federally qualified health centers offering care to underserved people in urban areas throughout the state is one of the lone advantages of the affordable care act.
Our clinic began as a dream of this article’s author, Dr. Dwinnells, in 1986. Due to his prescience and oft practiced vision, it was thus readily positioned to work into the 2010 law as I was soon to learn.
Question: Do you think doctors should be more involved in the political side of medicine to better influence policy and business?
Dr. CHM: Physicians today have no time to become politically active except through membership in the local medical society, which lobbies for them at the state level. They can write letters to editors, but otherwise they had better wait to retire to pontificate on politics if they are so inclined.
CONCLUSION
The past was a simpler time with less “clutter” and “noise.” The primary focus was on direct patient care and not so much about data collection and how it translates into reimbursement dollars. The increased scrutiny using business and management principles necessitated by increasing healthcare costs, placed the focus on population health outcomes with emphasis on data sets and analysis.
Let’s hope that the patient as a unique being does not become merely a statistic but someone who will be treated distinctly and receive complete attention by the physician.
Our next article, “Conversations with the Present,” will feature physicians in the “thick” of the business of medicine and its practice.
Disclaimer: The content does not reflect the opinion of AAPL nor the author of this article. Opinions and historical perspectives are entirely those of the interviewee.