G. Gayle Stephens, MD
University of Alabama, Birmingham
The First G. Gayle Stephens Lecture
Second National Conference on Primary Health Care Access
Hyatt Regency Beaver Creek
April 14, 1991
This address hasn’t been peer-reviewed. As a matter of fact, if it had, I might have gotten an answer somewhat like the poet who complained to Oscar Wilde about why he couldn’t get published. He said, “There seems to be a conspiracy of silence against me. What should I do?” And Oscar Wilde said, “I believe you should join it!” There was also a tale that a nephew of a prominent composer had written a march in honor of his uncle’s death and had asked Rossini to review it. Rossini, after careful reflection, said, “Well, it’s a fine march but I think it would have been better if you had died and your uncle had written the march!”
What does that all have to do with what I have heard us saying here?: that the U.S. has enormous problems with its medical care system, problems that resist and defy all attempts to solve them even though demonstrably effective solutions are known and available in varying stages of development in varying sizes and shapes. What is frustrating about all this and dismaying is the intransigent and implacable nature of the powers and forces that control and drive the medical care system, despite the palpable failures to live up to its own claims and promises. I have also heard us say in various ways that we have blunted our own swords in the battles to reform the system, that our optimism about the larger outcome is thinner than it was (mine is certainly thinner than it was 25 years ago), and that perhaps our optimism is sometimes even overtaken by cynicism and despair.
We have won some battles here and there, but we are no where close to winning the war. The fog of battle depletes our energy and dims our vision. But we are not ready to surrender even though we are perplexed. Like ancient Homeric heroes, we have encountered a Hydra-headed monster that has the genetic capacity to grow new heads as fast as they’re cut off — a ravenous beast that also transforms itself into a thousand disguises.
A riddle I learned in childhood comes to mind. Upon the hill there is a big red bull. He eats and eats and never gets full. Well, the first answer that I learned to this riddle (which will betray my age and rural background) was that the bull was a threshing machine. It huffs and puffs and clatters away and consumes all the shocks of wheat that a gang of laborers can gather and stuff into its mysterious innards. The latter answer — perhaps more broadly applicable – is that the big red bull is a fire raging out of control. It may be a forest fire. It may be a tall building ablaze.
These military, mythological, and obsolete agricultural images might be too dramatic, but they capture some of my feelings about having been involved in medical reform during the past 25 years. I rather like the metaphor of the big red bull who eats and eats and never gets full, because it fits my imagination about the medical care system. In some ways it is a magnificent beast with enormous power — a prize winning creature, coddled and nurtured since birth, and capable of unimaginable fertility. It’s a syndicated bull owned by rich investors who expect an exorbitant return.
He is no mere goose that lays a few golden eggs for an otherwise impecunious and ordinary farmer, but the master of his breed who can populate thousands of farms with his offspring. Everyone who sees him marvels at his perfection and dreams of owning one of his progeny. It would be unthinkable to butcher him. But he is amoral in his animal perfection. He has no conscience about what he inseminates, brooks no rivals in the pasture, and cares not a wit about the expenses of his upkeep or the price of the grain that goes into his insatiable mouth. He exists for himself alone, uncaringly unaware that his demands are outrageous.
Moreover, he is cranky, ill-tempered, and intimidating. One would never think of petting him. He needs no affection. One swipe of his gigantic horns would disembowel an unwary intruder and his hooves would crush a score of victims if he stampeded. He is untouchable. His small army of caretakers and owners control him from a distance. They build higher and stronger fences, more palatial barns, and keep an endless supply of greener pastures. They lure him to move in the company of hordes of cows in estrus. In his world, he is the king of beasts.
This bull’s registered name is “Hi-Tech Medicine;” his dame, “Undisciplined Empiricism,” and his sire, “Experimental Method.” His remote ancestors included “Belief,” “Nurture”, “Traditional Wisdom,” “Keratose,” and “Placebo.” But his recent breeding has selected for quantification, instrumentation, somatification, classification, chemicalization, and secularization. The dominance and penetrance of these newer gene pools have produced big, beautiful, powerful animals that are impossible to domesticate. They rush headlong through ordinary fences and crash through flimsy barns, devastating the neighbors’ farms. They can only be corralled in huge, new feedlots where they consume extraordinary amounts of costly feed. Their flesh is delicate and delicious, but can be afforded only by the rich. Their milk is scant and poor in nutrition, unsuitable for the children of the poor.
The owners of “High-Tech Medicine” and his herds became rich and powerful and insisted upon their dominance even though they were insufficient to feed all the people. They consumed disproportionate amounts of resources to maintain the herds and produce multitudes of similar genetic variance of the breed. When poor people complained that they hadn’t enough to eat and that their children lacked milk, the owners spoke of rationing and generously provided food stamps which ensured that the poor would never have enough. The outcome was that in a rich land of plenty, capable of feeding all its citizens, herds of big red bulls that ate and ate and never got full became the dominant breed, despite their failures to support the masses.
Reformers arose among the hungry and disenfranchised who attempted in out of the way places to correct these deficiencies. They produced another breed of bull in small numbers that was more suitable for their needs. Their name was “Low-Tech Medicine.” He nurtured the people in life and in death. They made small gains against the dominant breed, but they could not replace him. It remained for a great famine in the land, a cataclysm of destruction that killed all the bulls before the survivors could raise up a new breed that nurtured everybody. The big red bulls were protected to the end, but eventually they all died at the hands of their owners who ate their delicate meat until they all starved.
I see us here in this meeting and in other meetings dancing around the mainstream and trying to get a few nips of victory here and there when we really ought to attack the damn thing. The mainstream is not good. The medical care of the entire population is inappropriate. It’s not just the poor who lack appropriate medical care. The rich also lack appropriate medical care. You can’t buy appropriate medical care no matter how much money you have any more than an Egyptian pharaoh could have bought a shot of penicillin. It isn’t there!
I talked to a man recently — the only person I’ve ever known who was “on disability” because of migraine headaches!. He is a 43-year old engineer who is a very bright person who has gone every place, and seen everybody, and has done everything that has been recommended for his headaches. He went to Chicago and I don’t mind mentioning a name — to the Clinic of Seymour Diamond — who writes more on headache than anyone else in the world. He had an appointment at 8:00 a.m. on a Monday. He went to Chicago and got a hotel room. With great expectancy he goes to meet his appointment and there are 300 other people in the waiting room with the same appointment. He finally saw the great Dr. Diamond for his 15 minutes on Thursday. Later I talked with him for a half an hour or in Birmingham, where he’s now getting his three shots of Demerol a week in another physician’s office. He was almost obsequious in saying how grateful he was that I had spent more time with him than any doctor he has ever seen.
I am saying that the system is rotten. And the system is inappropriate. It is applicable only to a small fraction of the problems that beset us. And the biggest amount of waste and fat in the system is the inappropriate care given to ordinary people who pay for it. So, therefore, I do think we have a problem of maldistribution. We have a problem of distributive injustice, but if all we distribute to the poor is what the rest of us are getting, it will be rotten too. And what is missing from the high tech system is low tech care. It is the care in which one human being encounters another human in dialogue, in conversation. It is a labor-intensive, non-procedural exercise in morality. That is what is missing.
As a matter of fact, I don’t think the poor lack high-tech care in this country. They don’t in Birmingham! Now they have to go through hell to get it, but they get it. The poor people eventually end up in the emergency room. When things are bad enough, the poor get high-tech care.
I recently worked in an office where there was a high rise building for retired working class women — such as waitresses and food service workers. It is called the Bankhead Towers. They’re all in their 60′s, some may be in their lower 70′s. It occurred to me as I talked to some of those people that they are the first generation in the U.S. who have had high-tech medicine available to them throughout their lifetimes — say beginning in the 1940s. And they know how to press “911.” They get the ambulance all the time! They go to this emergency room and that emergency room. They get tuned up a bit here, and tuned up a bit there. But nobody knows these people! And when they run out of their welcome at Care-Away, they can go to St. Vincent’s, or they can go to Baptist Princeton. They get high-tech care! But nobody talks to them about their health. There is no low-tech care in the system.
So my message, I guess if I have a message and it’s not nearly as elegant as what David Sundwall has said, is that we have not only got to work around the periphery of this big red bull who will kill us if we’re not careful. ( I am sure that all of us who have gone into that pasture have some scars and certainly bull excrement) But that part of the system which contains the single specialty clinics is where the fat is. What is more ridiculous than a headache clinic run by one doctor?. I talked to a woman who goes to the headache clinic. She spends $2,000. She gets her prescription for Cafergot and Propanerol, and she has a thermograph of her head. These are not consulting clinics, and we’ve got them all over. We’ve got the high-tech guys and gals directly available to the public for the disease that they want to focus on. They inevitably attract a lot of people who don’t have that disease, but who all get processed in the same manner at exorbitant costs. These are not experts. These are not consultations. These are exploitations! These are over-sells! They’re rotten! And they ought to be stopped. And we’ve got to do something about that part of the system as well as to contort ourselves to find a little toehold here and there where we can do an honest job of medicine.
So I think that despite the convincing successes that high-tech medicine has had (and I really don’t want to butcher the bull yet, although when it comes times to butcher him I might like to be there) but despite the convincing successes, medicine has developed serious mismatches between its splendid veterinarism and its broader public mission, between what scientific medicine is good for and the range of problems over which it has now extended its hegemony, between what doctors know best and what patients need most. Curative therapy and primary prevention are available only for a fraction of diseases. Non-curative therapy and secondary or tertiary prevention are available for more, but the largest fraction can only be palliated. We have no cures for predatory and self-destructive behaviors. None for finitude and ultimate mortality. It is a paradox that no matter how much death rates for specific diseases improve and life expectancy lengthens, body counts are destined to increase in our growing and aging population. We, our generation, and the generation to follow me is going to deal with more deaths than I ever dealt with no matter how bad a doctor I might have been.
Whitehorn observed more than 30 years ago that even if scientific medicine had perfect knowledge and perfect treatment for all known diseases, physicians would still be busy trying to manage a broad range of clinical problems that arise from the ways we conduct our lives and live together in groups. I need mention only habits and accidents and violence and abuse and stress to illustrate the genre of problems that demand redirection of scientific attention towards human behavior, towards living in community, and therapeutic leadership styles towards nurture which I owe to Charles Odegaard as well as nature.
Moreover, scientific medicine does not come with a package insert directing the uses to which it should be put any more than nuclear physics came with one saying, “Make the bomb,” or “Drop two in 1945.” Even when we know what to do medically there are problems in applying medical knowledge to individuals and in distributing medical care equitably among the population. We know a lot more about the health risk of groups and populations than about the risks of individuals. There is a mismatch — a gap — between epidemiological knowledge and the knowledge of persons. There is a mismatch between the demography of doctors and patients. Baby boomer doctors are destined to preside over the deaths of their grandparents and parents. White physicians are destined to provide most of the medical care for racial minorities. Middle and upper class physicians must treat the poor. We have a young, white, rich medical profession and a population that is aging, increasingly diverse ethnically and, by most estimates, contains 35,000,000-40,000,000 people who are poor enough to be uninsured. This demographic mismatch promises that more doctor/patient encounters in the future will be “cross-cultural” and that age, race, and social class will have to be dealt with if medicine is to be personal rather than merely technological.
We have no basis for hoping that the experience of being sick can ever be separated from the meaning of being sick. Science deals in information and significance but not meaning which is cultural and personal. W. R. Houseton said in the 1930′s that doctors and patients do not believe the same things about illness, their causes and cures. There is a growing literacy gap between state-of-the-art medicine and the medical knowledge of the public. Contradictory as it seems, medicine has again taken on the aura of magic. Many people I talk to have not the slightest idea of what happened to them in the hospital. Not only do they not know the names of their doctors or think that it matters, but they don’t even know what tests were done, let alone the results. (Forgive me those of you who are not physicians here — I wrote this at a time when I was thinking about doctors — but I know there are other people besides physician) Doctors can never look forward to a time when it will be easy to separate the organic from functional complaints, because the mind/body split was never the truth about us. At most, it was a temporarily useful, intellectual distinction that rapidly lost its explanatory power. Pain will never be the same as suffering.
Because of these mismatches, low-tech medicine, what I choose to call “personal” medicine, becomes a clinical imperative — not merely what a few physicians practice because they lack a proper grasp of scientific medicine. Personal medicine, or low-tech medicine, facilitates the practice of scientific medicine, but more than that it goes where science cannot go. It is not heretical to recognize and criticize the limitations of science or to appropriate in modern form what physicians have always done for their patients while waiting for science to catch up. T. F. Fox, the late editor of The Lancet, gave the clearest defense of personal medicine in 1961. He said it is the care of a person by a person, by someone who accepts real responsibility for looking after his patient in sickness and health.
When this simple and profound idea is acted out, something remarkable happens. Both patient and doctor cease to be ordinary to the other. Fox put it this way, “If the physician is so good a doctor as not to be put off by weakness, folly, grief, or bad manners, if he places himself at the patient’s side, if he puts the patient’s interests before his own, the relationship can be something valuable.” Is this hopelessly sentimental and obsolete? Has anything happened to us — to me — in the last 20 years that makes me no longer desire such relationships with patients, afraid of intimacy, or incapable of sustaining continuity of care?
It’s true! The circumstances of medical practice have changed a great deal, but circumstances have never been good. There never was a golden age in which personal medicine was easy. The safe, non-exploitative, intimate encounter between doctors and patients has always been an achievement over and against circumstances.
Well, what are the consequences of practicing low-tech medicine? We know too well the consequences of not doing it — increasing alienation, adversaries, complaints and litigation, what the media publicizes. But what about the benefits? Well, the first benefit to patients, no matter what their condition, status, or role, is support — that is, acceptance without blame. They receive personal recognition, respect for their dignity and autonomy, and appreciation for whatever is normal about them. Many come with unspoken or unspeakable agendas. They are unhappy, worried, suspicious, conflicted, isolated, trapped, and, but they speak of headaches, and pains, and spells, and indigestion, and sleepless nights, and chronic fatigue. They mention allergies, and vitamins, and wonder about rare and mysterious diseases. The need support and encouragement to tell their stories without fear of being ignored, rebuffed, disbelieved, or humiliated. It is a fearful thing to be a patient! Support engenders hope which begins by putting symptoms into the perspective of common human experience. No matter how bad the problems, something can always be offered.
What can be hoped for? Always the best as that is mutually defined. It may be a cure. It may be a treatment. It may be partial recovery. It may be preservation of a function, participation in an important event, relief from suffering, courage to face the unknown, even a good death. There is always something that can be hoped for if it can be defined. When the doctor hopes as well as works, the patient can hope too. Houston wrote that faith heals more by contagion than by argument. Support and hope can lead to reconciliation. Overtone’s life has regrets, hurts, failures, conflicts, broken relationships and promises. Illnesses tend to bring these into bold relief. A personal relationship with a physician that is open, honest, safe, and trustworthy can be an example, a training ground for other relationships that also have possibilities for reconciliation. It is a rare experience of illness that does not offer the benefit of rearranging one’s priorities and reassessing one’s style of being with others. Reconciliation has remarkable power to heal.
Well these three — support, and hope, and reconciliation — sometimes create surprise which is the appearance of unexpected benefit. Norman Cousins and Bern Seagull have made careers out of encouraging patients to believe in surprise — a miracle, if one is not put off by that word. One cannot take a surprise by storm, by demanding it. But one can create the conditions in which surprise is possible. But even when surprise is not forthcoming, nothing has been lost by creating the conditions for it.
On the doctor’s side, the benefits of low-tech medicine go far beyond getting paid for services. They validate the humanity of the role and gratify the instincts that enticed us into medicine. They confirm our calling and connect us to the longest tradition in medicine — the works of mercy that antedated the modern era by 1500 years, the time when medicine earned the capital of public trust upon which we all still draw interest. Who would not want to be the sort of doctor described by Harvey Cussing who said in an address to a graduating class in 1925 and I quote, “The time an experienced and sensible doctor who can alleviate, if not cure, his particular ailments — be they physical or mental. And the kind of sagacity and resourcefulness he will expect and need is less laboratory-borne than bred of long and sympathetic familiarity with the anxieties and complaints of ailing, damaged, and worn out human beings.”
Almost by chance, it seems to me now, family practice came along at a propitious moment in medical history. If fell our lot to straddle the fence between a burgeoning medical technology and the human services that most patients need most of the time. And this awkward posture of straddling is hard to maintain. As we struggle to direct our own evolution, let us not be intimidated or enticed to give up our most indispensable ideal which is personal medicine. The need for it will never become passé although we must continue to learn what it means and how to do it.
John E. Midtling, MD, MS Medical College of Wisconsin: That was tremendous, Gayle. Once again, some very provocative comments. I think you got the peer review process. If I had known you were going to use the red bull analogy, I would have invited a couple of my veterinary friends. I think it’s a very appropriate analogy. We have some time for comments from the audience.
John Payne, MD, Stanislaus Medical Center, Modesto, California: I believe many of us are, at this point, ready to be bullfighters. We are, however, specialists in personal medicine which by nature makes us sort of peace loving individuals who don’t have the aggressive swagger that it appears to take to take on the big red bull’s keepers. Have you any suggestions for us timid sorts?
Stephens: I think as far as family practice is concerned, which is the pasture that I have been tending most of the last 25 years, I think we have been entirely too preoccupied with legitimacy, with what that big red bull thinks. And we have projected a lot of thoughts into that big red bull. We think the bull is dangerous. The bull thinks we are paranoid, that we’re hard to get along with.
My dean tells me that the family practice faculty are the most contentious and difficult faculty he has to deal with. But I think we can give up a little bit now of this obsessive need for legitimacy. We have proved that we can enter the doors of academia, that we can teach. We have demonstrated that with what opportunities we have had.
And I would like to see us relax a little bit about making ourselves always agreeable and acceptable to the medical school, which is the worst part of this big red bull. If you want to know the worst part of the medical school, it’s the basic science departments. That’s where the bull is really bad.
These are protected, silent opponents and perpetuators of high-tech medicine operating very effectively and unobserved in those two pre-clinical years where they set the tone of what is truth, and what counts as knowledge, and what the students believe, and what makes them contemptuous of low-tech medicine because the basic scientists are contemptuous of low-tech medicine.
They don’t know anything about it! But they are the gyroscope, they are the ballast that makes the medical school incapable of changing. And so one of the thoughts that I am having is how can we loosen up a little bit our frantic clutching of the medical school for legitimacy. Can we not get some legitimacy from doing our work?
I know there is some reality here in doing what the school says you have to do to get promoted and all of that. But I am ready to quit doing seven somersaults every time the Dean says to do two. So I would like to see us loosen up and relax in that particular part of bullfighting. I think that’s where a lot of the action takes place.
There are some very real battles within organized medicine. For instance, there are more than a hundred self-designated specialties that have nothing to do with the American Board of Medical Specialties. More than a hundred self-designated specialties, which means that fragmentation is out of control. It has been out of control but it’s even more out of control. Each of those self-designated specialties probably holds us in contempt in one way or another unless we provide them with a number of patients.
I’m not going to send my patients to this headache specialist. I don’t think headaches is a specialty, self-designated or not. I guess maybe it’s a change of attitude on my part that 25 years ago I couldn’t wait to get into the medical school. I screwed up my whole life in order to be a faculty member and I wish I hadn’t. It wasn’t worth it.
Gene (Rusty) Kallenberg, M.D., Washington, D.C.: I thought your quite extraordinary comments and parable linked well with Dave Sundwall’s suggestion. It seems to me that the chief source of our credibility is the other half of the doctor/patient relationship and has been for the past 30 years, and was in my father’s generation when he was a GP. It seems to me that in the rush to get into the medical school, that we have, in a sense, turned away from a political base of support.
It’s going to take very strong people to attack the bull. I find that in our medical center it’s the clinical subspecialists that are even more malevolent than the basic scientists because they have giant incomes to protect. And the basic scientists are more like the lay patient in the sense that when they need medical help, they don’t know what the hell they’re doing, just like a patient doesn’t frequently.
My question is — would it not be appropriate to create larger political alliances in three directions: 1) with the nursing profession and the other people who are committed to taking care of patients and have been for 30 or 40 years or hundreds of years; 2) with other primary care physicians without sacrificing our principles and understanding that we probably do it best and better than any of the other so-called “primary care” clinicians; 3) with the poor people — the people in the rural zones of the country out of which family medicine grew on literally through state legislatures in the late 60′s and 70′s. Now we have a whole new urban population of equally underserved folks. It seems to me that it would be a terrific political alliance that would just wipe out the bull.
Stephens: I couldn’t agree with you more. I am going to have the opportunity to say that to the American Academy of Family Physicians next Friday because I have a chance to speak to the state officers’ convention. I am going to address this issue of numbers and alliances. I think without doubt the 41,000 members of the American Academy of Family Physicians are a pretty impotent lot for the task at hand.
We should ally ourselves with a number of groups. We started off — as the membership of the Society of Teachers of Family Medicine would suggest — with allying ourselves with non-physicians, with other health professions. I think we’ve taken a step back away from that. We started off with ambitions about family nurse practitioners and other nurse specialists. More recently there has been the thought that we should ally ourselves with primary care internists and pediatricians. I know Dr. Odegaard is working hard on that but that still is an upward mobility for us.
I would like for us to look at the 30,000 doctors of osteopathy, the 30,000 osteopaths with whom we might come together in some coalitions for political purposes. I think it’s very unlikely that the AAFP is going to give me two seconds on this. But I am going to say it, that there is no hope by the year 2000. By my best estimates, the AAFP will have about 50,000 members.
If we keep recruiting first year residents at a 65% rate, it’s going to be a hell of a lot less than that. That may be the largest last man’s club left in the world unless something is done. Because the way they count their membership, you would get the impression that there are 65,000. But it’s not. They’re closer to 41,000 and many of them are like me — they’re old and lame and fat. But there is a problem and I think politically you’re right on target — that we need to find ways of allying ourselves with other groups, at least for the promotion of the primary care agenda — what I consider the low-tech agenda.
Thomas Brown, Ph.D., Long Beach, California: You mentioned possible, and I think it’s the probable or being proven, co-opting of family practice by the medical schools in terms of its leadership and its direction. I have watched this for 23 years and it does seem to be quite interesting how that’s all occurred. The values of the medical schools and the systems that the medical school does demonstrate has definitely influenced, to a tremendous extent, the training of medical students and of residents, and I think, by this time, certainly the way they practice medicine out in the field. I don’t think that family medicine is ever going to get the power-base within the medical school to pay much attention.
However, the real power that I think family medicine can have is by really looking at its membership out in practice, understanding from them how they control the health care delivery system on behalf of their patients — the kind of rapport they establish with patients, the kind of referral systems that they use, and the way they manipulate the whole system in behalf of their patients as patient advocates, recognizing that that’s an extremely powerful base — those patients — in part of the coalition building that you’re talking about. I wonder if you might comment on that.
Stephens: I certainly agree that the patients were a part of the reforms of the 1960′s that got us a place at the federal trough. I think, though, the patients are confused now about the doctors and they don’t know whether we’re family physicians, or whether we’re family planners, or what we are. What the public had in mind as a doctor close to them and accessible was not exactly what we produced. Ed Pellegrino has written very persuasively about this, that we had an agenda that he calls “a mutation.” We were trying to move away from the general practice model.
We have in our presence a person who served on the Millis Commission and a man who also has had personal conversations with Abraham Flexner, Charles Odegaard, who’s got a lot of medical education history in his head and who has given a good portion of his life, as far as I know, to try to help us help the public.
When the Millis report said “primary physician,” and that’s where the word came from, they had in mind something a little bit different than what we started producing. Is that not right, Charles? We went a little overboard. We promised a little too much. We did what was interesting to us in the academic setting.
It’s quite disheartening if you call most family practice departments at 4:00 p.m. on any afternoon, they’re closed. They’re gone! There may still be some people there working, but they’re like the bank. They shut their phones off at 5:00 p.m. while they’re finishing up the load in the clinic. I think we’ve expended some of our moral high ground that we had 25 years ago.
I don’t know whether the people give a damn whether we survive or not. That may be a harsh thing to say. The people want somebody to survive, but I don’t know whether they care whether it’s us or not. It might be somebody else who plays that role. I am finding that when family physicians take on the airs of the academic institution, they are no more to be admired than any other. I lose my interest in them almost immediately.
Patricia Chase, California Office of Statewide Health Planning and Development, Sacramento: I want to thank Dr. Stephens particularly for his statement that all of us are underserved. I think politically this is something that all of you should also utilize and that is to recognize that some very powerful groups, including business, including insurers, as well as including the well-insured middle class, are feeling underserved and would be very supportive if they were informed and had a clearer understanding of what primary care and family practice are all about.
I think it is terribly important that you as a group and as a specialty, if you choose to call it that, utilize this and talk about service for people other than the poor and the traditionally underserved.
Stephens: We need a preference for the poor.
Charles Odegaard, University of Washington, Seattle: First, I should make it very evident to everybody here, it they don’t know it, that I am an alien breed outside the law. I don’t belong to any of these guilds that we’re discussing this morning. I come in from the outside as a citizen who became a member of what was called “The Citizens Commission on Graduate Medical Education.”
I think sometimes the origins of the Millis Commission are not fully understood. We had been through a period of years of production in the medical schools of biologically specialized physicians following World War II. By the early 60′s when the Millis Commission was appointed, there was a real fissure developing within the membership of the American Medical Association.
So this Millis Commission was actually appointed by the AMA because of an internal fight which had developed between the many specialized biomedically oriented physicians produced by the medical schools in the post-World War II period and the old GP’s.
Now even to this day, I think if you go to a meeting of STFM and to a meeting of SGIM, you will notice a difference in the distribution of gray heads. There’s an older generation in family medicine and a younger generation. There is no older generation to speak of among the general internists. They are a product of much more recent developments in the medical schools, the original heretics.
As a medieval historian by background, I really do think it appropriate to use that word, “heretic” and “orthodox” in regard to medicine because it is as though we have a conflict in two religious systems. There are mindsets here. Their gray matter has to be dislodged. It’s not just bad habits that you see in what they do. You got to figure out what’s going on up here if you’re going to effect changes in the way medicine operates in this nation in the near future.
So the Millis Commission chose the word “primary physician” because GP had become a dirty word to the more entrenched elements of specialized medicine then. To get out from under this, we picked up the word “primary physician” simply not to have an argument over words and to get onto the substance.
As an outsider, I would like to say that I think you should be careful in assessing where you are in this process. I can testify from the fact that I have reasons for watching this from 1963 on that there really is a shifting going on. There is a heretical group within the “House of Medicine.” The reason you can’t ignore the medical schools is that the future generation is born there. So it’s all right to say you’ll stay outside it if you’re in the “old guard.” You’re not going to be in the “new guard.”
But if you’re going to get into the new guard, you got to get inside the medical school, so you have to take on the big beast itself in order to finally win this battle for the American people in terms of having a more appropriate distribution of right kinds of health care providers. I do think that one thing you can do is to infiltrate that castle.
One of the ways of getting there, I think, is by affiliation with the other primary care oriented groups — the general internists, the pediatricians. I do know that some internists, maybe some pediatricians, were invited to come here. I know of one in particular, Tom Inui, my recent colleague in some of these ventures, was very eager to come here. He is a former president of STIM but he was not able to come to this meeting because of a prior commitment.
I do think that in the next meeting it would be helpful if you had with you here — I’m not talking about merger — I’m talking about collaboration with some other allies that I think would be helpful. I’m sorry that there aren’t general internists and pediatricians here in larger numbers because I think this has been an extraordinarily informative meeting about good things that are going on that have a potential for the future.
So I would hope that in your next meeting you would accept the fact that you need all the allies you can find in order to beat the great beast. Some recent experiences have demonstrated that internists have developed some very real respect for aspects of primary care which could be learned by going to some of your specialized meetings. I am thinking particularly of the Amelia Island experience.
I’ve gone to each of these meetings on some threat of giving me continued medical education. But I have been honest enough to say that I’m not allowed to use it. I do urge, as you look for your allies wherever you can find them because you got a big problem to beat. I must say that it’s a great pleasure for me to be here. I’m here, I think, through the invitation that came from Gayle. It was a great personal pleasure for me to hear Gayle, but I wasn’t surprised by it because I heard him before in doing such a brilliant job.
Midtling: Thank you, Charles. With that I think we will break off the discussion because some people have to make it to the airport. I’ll just offer a few comments. Unfortunately, I don’t think the change will come from the owners and the handlers of the big red bull. The change will come from those who purchase services from the big red bull. I hate to be cynical about the house of medicine but I think much of what Gayle has said is true and that the change will have to be external. I am struck by the fact that two weeks ago I gave the keynote address at ADFM, the department chairs meeting, in Florida.
Following me on the podium was the president of the American Farm Bureau and following him was Tom Tocke, who is a congressman from rural Iowa who founded the Rural Health Caucus. Both of them said, “You show us the way. We know there has to be change. You need to link up with us and we need to build a coalition of forced change in America.
I think that’s one thing that I would like to see come out of this meeting. To some extent, and I think this ties into what you were saying Charles, we’re preaching to the choir and we’re preaching to the converted. I really think we do need to link up with general internal medicine. I would like to see several leaders of general internal medicine come to this meeting because they tell me that they view us as being more similar to them than many of their subspecialty colleagues. I think that for general pediatrics the same could be said.
But I think there are other coalitions. Phyllis Kritek identified nursing. I think there are coalitions outside of the health professions that we should be linking up with us — the Tom Tockes of the world, the American Farm Bureau people, and others — and as we move into future conferences, I would like to invite them.
I am struck by the success stories that were presented here the past three days. It gives me a greater sense of hope than after last year’s meeting when I went home somewhat depressed, actually. I think we’ve seen some phenomenal success stories at the local level, at the state level, at the federal level. I think, hopefully, the proceedings can be a vehicle by which some of these local success stories or demonstration projects can be disseminated throughout the country so that others can see what has worked at a regional level and maybe implement that. Then maybe we can move toward a national system.
I really think we’re dealing with a system that is probably going to make incremental change. I think we need a few successes like the Oregon model, perhaps — maybe some of the things that Dave Sundwall was talking about which are really incremental piecemeal. I think if we can develop some model demonstration projects, perhaps then we can show that these work and begin to move toward a more revolutionary change in the system.