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Reflections on 50 years as a doctor

July 27, 2010

I just got this essay written by Dr. Joseph Chazan- a specialist in kidney care, but also a long time supporter of the local art scene.  He has an incredible art collection and supports AS220 in many ways- my favorite is the fact he buys wine for the dinners following their Action Speaks series (which we used to host on WRNI.)

Dr. Chazan said he’d send this to me only AFTER the Projo got it. But I’m putting his words here too.  I’d like to hear what you think about this article.  Has medicine changed for the better?  How do we balance saving people’s lives with cost control?

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50 Years a Physician by Dr. Joseph Chazan

Recently, I returned to the University of Buffalo to celebrate the fiftieth year since my graduation from its medical school.  This occasion prompted me to reflect not only on my professional life but also on changes in my profession during these many years.  Like society in general, the practice of medicine has changed dramatically over this half century.

When I graduated in 1960, medicine was literally an art. Advancements in science that could be applied to the practice of medicine were, by today’s standards, remarkably few.  Taking a patient’s history and performing the physical examination in such a way as to discover clues to the problem was the “art.”  The “science” was in choosing from the few tests available to inform diagnoses and then selecting from a very limited armamentarium of medications and treatments the ones most likely to alleviate, though frequently not solve, the problem.  When I was interning at the Boston City Hospital, my Chief of Medicine told me, “taking the history will tell us what to look for in a physical examination, and then we will decide which, if any, tests to order to confirm our suspicions.”  Simplistic as it sounds, given our limited diagnostic and therapeutic options, it was efficient and effective.

The scope of changes in medicine over the past 50 years can be illustrated with a few examples:

▪ During an entire year of practice in 1960, I saw only one patient over the age of 80.  This well-muscled, tanned gentleman, who swam every day in the Boston Harbor, entered with a bleeding ulcer. Fifty years ago, to see an elderly patient with a chronic disease was exceptional.  People typically died at earlier ages from untreatable complications of infection, heart disease, diabetes, or high blood pressure.  Today, seeing patients well over the age of 80 is common.  They are frequently sustained by the myriad medications and treatments available to them since the 1966 introduction of Medicare provided universal insurance to those older than sixty-five, leading many to seek care they may not have sought or received previously.

▪ Risk factors for heart disease had not yet been identified, and it was not even possible to measure blood cholesterol levels accurately. Patients with heart attacks were kept at complete bed rest for weeks, with convalescence and rehabilitation prolonged over weeks and months.  Today, patients are diagnosed and treated within hours and days and are promptly discharged to full activity and rehabilitation in a matter of weeks.

▪ There were no oral medications to treat diabetes.  All diabetic patients were put on insulin.  Complications, especially blindness, were frequent, and death at an early age was common.  Today, we have a range of oral medicines that lower blood sugar, and a host of insulins that can control blood sugar effectively, markedly reducing complications and extending healthy life.

▪ Smoking was rampant throughout our society, romanticized in movies and on television.  That tobacco smoking might actually cause lung cancer was still being debated.  Over the years, the impact of smoking has been well recognized.   Once common in hospitals– my colleagues and I often smoked pipes while making hospital rounds–smoking is no longer allowed in most public places and is discouraged by society in general.

▪ In 1960, few hospitals offered any form of dialysis treatment for patients with kidney disease.  While training to become a specialist in kidney disease, I performed the first acute hemodialysis for patients at two Boston hospitals.  When I came to Providence in 1967 to begin practicing nephrology, there was not one facility offering dialysis in the state.  Patients needing chronic dialysis had no choice but to travel to Boston three times each week.   In 1970, we began providing dialysis at Rhode Island Hospital.  In 1973, I opened the first free-standing dialysis facility in East Providence. Thirty-seven years later, dialysis is available from a number of providers at fifteen sites throughout the State.  Virtually all patients with kidney failure can now be treated in a location convenient for them.

Other tools, common today, were not available. Screening tests, such as for cancer of the colon and prostate, did not exist.  There were no pace makers, CAT scanners, MRIs, angiography.  Penicillin and sulfa drugs were virtually the only available antibiotics.

Despite these many limitations, the patient-doctor relationship fifty years ago was typically strong, and physicians were regarded by their patients as counselors and even friends.  Technological and pharmacological advances have enhanced the practice of medicine.  But as was true in 1960, direct personal contact, with sufficient time allowed to evaluate nuance, remains essential for successful diagnosis and treatment.  That is compromised today, with the involvement of third party payers and ever-increasing pressure on medical professionals to see more patients in less time.

Fifty years ago, the health insurance industry was in its infancy, and the costs of medical care were rarely discussed.  Today, opportunities to do tests and procedures are endless, and they all cost money. To maximize the use of these advances, we must collectively manage expectations and accept reality.  The notion of using trained, clinical judgment and the “art” of medicine has tremendous potential for cost reduction but is possible only with malpractice reforms that free physicians from practicing defensively, ordering tests and performing procedures “just in case. “  And pursuit of outcomes at any cost, in the hope that all injuries, degenerative diseases and complicated lifetime illnesses can be cured and reversed, reverting 80-year olds to 50 year-olds, is both unrealistic and enormously costly.

With the advent of the new healthcare legislation, more people will have greater access to the healthcare system.  To control the costs of increased utilization, patients and doctors must work closely together with mutual trust and responsibility, as they did in the era before technology, tests, and treatments depersonalized these relationships.  While doctors couple available advanced science with the “art” of practicing medicine, patients must accept that information gleaned from the internet cannot replace years of study and decades of diagnostic and therapeutic experience.

For me, the relationships I have had with my patients form the remarkably rewarding and continuous thread running through my half century in medicine.  As a physician, I have always felt the awesome responsibility of attending to and helping another human being who, when seeing me, is both vulnerable and in need of ministration, whether for a minor problem or a life-threatening event.  That is one thing about medicine that has not, and, for me, will not change.

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