Refer to: Moser RH: An anti-intellectual movement in medicine. West J Med 122:433-449, May 1975
Special Article
An Anti-Intellectual Movement in Medicine ROBERT H. MOSER, MD, Chicago
IT IS NOT NEWS that Western man is reentering a climate of anti-intellectualism-a new Dark Age wherein some fight fear with long since discarded devices. We have witnessed the return of mysticism as reflected in the reemergence of the black and white magic of the Tarot, the simplistic nonsense of astrology and a wave of perfervid religiosity. If these methods had ever worked, they would not have been reassumed and discarded myriad times in the history of civilizations. We are in a state of chaos, but it is nonsense to blame the mess on the clean, flourishing, logical and technical disciplines of science. Rather, it is, once again, the lagging of practical humanism reflected in failure of social and political systems to implement scientific knowledge that has created a gestalt inimical to the health of the individual person and, therefore, to the health of society. And I fear the wave of anti-intellectualism has begun to encroach upon the borders-if not the heart-of medicine. Let me explore this. One year ago I was battling the problems of providing patient care in an urban-rural community, with night calls, house calls and all the joys and agonies attendant thereto. And one cannot obliterate certain perspectives and attitudes simply by switching chairs: in this case, to one behind an editor's desk. So I would like to ruminate some things that had begun to worry me The author is Editor, The Journal of the American Medical Association, and Director, Division of Scientific Publications, The American Medical Association. Presented to the Calfornia Academy of Medicine, San Francisco,
September 28, 1974. Reprint requests to: R. H. Moser, MD, Editor, The Journal of the American Medical Association, 535 North Dearborn Street, Chicago, IL 60610.
before; and now that I have come to the big city and begun to wander about, and to take the pulse of American medicine, the fears have begun to crystallize.
First Signs of Change It is a little like watching animals react to a small fire in the forest. The whiffs of smoke were detected by sensitive creatures about five or ten years ago. You are all familiar with the tremors that were felt by the academic community. Some whispered that our research and educational establishments had become badly out of joint with the times. There were murmurings about excess fat in research budgets, escalating costs of medical care and maldistribution of professional talent-geographically and socioeconomically. But just as you and I had, the bright young graduates of the 60's continued to swarm the ivory towers and populate the specialties, while the vast mass of patients-those who were less-than-violently ill or less-than-interestingly ill-were all but forgotten in the academic scramble. And all of this had significant fallout. Patients obliged to wait several hours in offices, clinics and emergency rooms agreed most readily when they were told we were in the midst of a doctor shortage. And for many lower and middle income groups good medical care was scarce, if not unknown. The news media were replete with stories of dramatic progress in the science of medicine but little of this was perceptible, little filtered down to the vast mass of the less affluent sick. Words such as relevance and social responsibility began to creep into the conversations of our medical young. THE WESTERN JOURNAL OF MEDICINE
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Meanwhile, many medical schools, still basking in the warmth of their post-Flexner era bonanza, began to sense the distant smoke, and some reacted. Incoming classes were doubled and tripled; selection committees reached out for minority group students; curriculum committees sought new dimensions. Schools with unfamiliar names mushroomed throughout the land. Some clinical teachers became concerned about the capability of the existing, relatively finite pool of medical educators to accommodate the surge of new students, and still maintain traditions of excellence in classroom and clinic. But these fears were assuaged with assurances that the new mass media techniques would facilitate clinical teaching. Yet some of us were still worried about relegating these critical responsibilities to mechanical surrogates. But our concerns were only small eddies swirling against the mainstream.
More Doctors, Faster Produce more doctors and do it faster was the watch word. We were advised that we were 30,000 doctors short throughout the country-but few stopped to analyze this figure as it related to distribution and specialty. Yet on the basis of gross numbers alone the gates were thrown open to foreign-trained physicians, and they came in droves-to fill the need. This is not the time or place to discuss the merits or debits of this most complex situation. But the fact is that this relaxed policy of medical immigration did little to take the pressures off American medical schools. Thus, to accelerate the production of warm medical bodies, many medical schools condensed the curriculum by emasculating or deleting "irrelevant" departments (clinical pharmacology was an early, costly casualty); some merely eliminated vacation periods and began to churn out graduates in 36 months. Not much time for reflection, or emotional growth, or evolution of the other intangible elements that go to make up that elusive quality we call medical maturity. No one seemed to ask "What is the hurry?" Also no one paid much attention to where the warm bodies, foreign and domestic, gravitated. And there was no perceptible change in the pattern of physician distribution-geographically or by specialty. No one faced the problem of "How are you gonna keep 'em down on the farm-after they've seen Paree" or, to paraphrase, "How are you going to keep 'em down on the Indian reservation, or in the horizontal ghettoes of the delta, 444
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or the vertical ghettoes of Detroit after they've seen Massachusetts General or the National Institutes of Health or Scarsdale or San Francisco or Maui?" And what about the graduates of the late 50's and 60's? Some of us anachronistic curmudgeons-erstwhile bedside clinicians-could be heard to mutter darkly about the new breed of graduates and their tutors, mechanical and otherwise. Nasty phrases like laboratory-oriented myrmidons, molecular biology buffs, disease rather than patient-oriented, bereft of human virtues, assembly line products crept into our cloakroom conversations. Yet, the first significant militant protests against the educational grist mill came from the students. It was their forthright demands for relevance in curriculum and for meaningful medical experience that arose in response to their expanding social awareness. Students-not teachers-were the ones who scrutinized the academic tradition which had taught disdain of the local medical doctor, the LMD, and had extolled the virtues of the investigative-teaching career pattern. Students were the ones who studied this philosophy-and found it lacking, out of balance, out of synchrony with the times. While our generation focused mainly on individual patients, and accused our immediate successors of looking mainly at disease mechanism, indeed recent graduates were the ones who looked beyond both-at the need of society. There is a requirement that all three aspectspatient, mechanism and society-be kept in mind, and they are not mutually exclusive. But it is a difficult balance to strike. However, the point had been made. Admittedly, many perceptive educators had already began to suspect that perhaps the postFlexner momentum had crested, and that under their stewardship the thrust of medicine had carried beyond its cardinal purpose-the care of patients. They began to realize that concepts of patient care had become lost, sidetracked somewhere in the fascinating catacombs of scientific methodology. Educators began to realize that through their teaching, diseases had replaced patients in the priorities of education in medicine.
An Awesome Body of Knowledge But one must not forget; the smoke in the forest had originated in a most remarkable crucible. The golden years of research and postgraduate clinical
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training that began after World War II had produced an incredible cadre of talent and an awesome body of knowledge. New pathophysiologic mechanisms had been identified. Dramatic discoveries in molecular biology, immunology, cytogenetics, and enzyme and hormone chemistry had occurred. New diagnostic techniques and therapeutic tools were devised. All were products of these marvelous years. This was reflected in gigantic growth in capability for quality patient care. Admittedly, the distribution and availability of this care were far from optimal, however-as I said earlier-social and economic implementation always lags behind advancement in sciences. But the capability was there. (I sometimes suspect that in the grand scheme of life, there are times when such sudden spurts of genius and productivity must occur to maintain viability. But always, something else must be sacrificed.) Thus, despite this flush of success in science, some of us felt that during these grand years of progress in hard science, something had been lost along the way. Perhaps it was that bedside senses were being neglected and were becoming dulled. We thought that some training programs were out of balance; there was too much mechanization; too much stress on nuts and bolts-too little stress on people. In the passionate effort to master the vast new knowledge, students were being deprived of something vital and wonderful and satisfying in medicine: the joy of eyeball-to-eyeball, personal, one on one, longitudinal communication with patients. The humanity of medicine was all too often shunted aside in the headlong pursuit of hard science. There was more to be learned, and less time to learn it. Something had to be sacrificed, and we felt the choice, although it was perhaps inevitable, was unfortunate. In many cases the art of medicine was left on the curriculum cuttingroom floor. But the smoke in the wind became even more perceptible about three or four years ago. Things began to shift back toward the bedside. Preceptorships, neglected for 25 years, were being rediscovered. Most clinicians viewed this with cautious pleasure. A balance was being struck between bench and bedside. But in recent months, my delight has begun to fade. It has been replaced by something close to alarm. Let us look at what is happening. We are told by people who should know that despite the current overall physician shortage, if
present trends continue (the production of our medical schools plus the continued influx of foreign medical graduates), within 12 years the United States physician pool will number between 495,000 and 520,000. By 1985 we will have 220 doctors per 100,000 population as compared with 160 in 1970. If you believe this projection (and this numbers game has been the subject of great debate) we are facing a doctor surplus. Listen to the words of Dr. Charles C. Edwards at the Association of American Medical Colleges meeting in 1973, "I think that clearly we have moved beyond the point at which concern about a shortage of physicians was genuine if somewhat exaggerated. Even more significant is the possibility we may well be facing a doctor surplus in this country." Later he said "The task the medical schools now face is to work toward solution of problems that relate not to aggregate numbers of physicians, but to specialty and geographical maldistribution, physician productivity, and the underrepresentation of women and minorities among the health professions . . . "
The Government and Medical Education This can be translated into the fact that the government is taking a hard look at its philosophy of financing medical education. The holders of the federal purse strings are not satisfied with the current efforts by medical schools to meet the practical needs of the citizenry. Another example: There was a bill (S-3585, Kennedy-Javits) which was approved by the Senate Labor and Education Committee. In its original form it would have provided almost 2 billion dollars over a threeyear period in federal aid for medical and other health profession schools. This bill would have given the federal government power to allocate and limit postgraduate training for physicians. It included a provision designed to curb the reliance on foreign medical graduates and to increase the number of primary-care physicians. It would have required the Department of Health, Education and Welfare to limit the number of postgraduate training positions in hospitals to no more than 10 percent above the total of domestic medical and osteopathic school graduates of that year, and to assign the total number of physicians to various categories of specialty and subspecialty training. Among other provisions of this bill were those that would require all young physicians to serve for two years in a sort of domestic peace corps THE WESTERN JOURNAL OF MEDICINE
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program, whether or not they received federal loan or scholarship help. Also, within two years the Department of Health, Education and Welfare. would establish national standards for licensure of physicians and dentists. Under this bill, licensure renewal would occur at least every six years. A physician or dentist licensed to practice in any state would qualify in any other state in which the national standards are in effect. If a state had standards exceeding the national standards, a physician coming into that state would have to meet the additional requirements. Thus it was designed to require all recent medical graduates to serve in shortage areas, to limit the number and variety of postgraduate positions and to ensure the relicensing of all physicians. The final, much modified version-as amended by Beall of Maryland-was passed on September 24 by the Senate, 81 to 7. It would provide federal aid to medical and dental schools that agree to allocate 25 percent of their classroom spaces for students volunteering to serve in urban slums or rural areas short of medical care workers. In return for their service, the students would be entitled to government scholarships. The bill would require one year of service for each year of scholarship aid. To say the least, all of this is most provocative -and I will not speculate upon it at this time. Suffice to say that it is perhaps an indication of what is in the wind, a cardinal demonstration that the government is indeed concerned about problems of contemporary medicine in America at all levels. And I will not speak of the implications of Professional Standards Review Organizations, Health Maintenance Organizations or national health insurance on medicine overall. But let us return to the problem of medical education.
New Educational Directions In an effort to anticipate this need to qualify for such federal support of medical education, many schools have reevaluated their priorities in curriculum planning. One major thrust of all of this has been the creation of departments of family medicine-a welcome, long overdue development. The popularity of these programs is evident through the progressive increase in positions and applicants over the past three years. One estimate by the Division of Manpower Intelligence places the current shortage at 27,000 to 30,000 familycare physicians such as general practitioners, 446
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internists, pediatricians and obstetricians. So evidently there is a long way to go to meet the current need in numbers-as well as in
distribution. But in recent months have experienced a dim sense of uneasiness. I have detected a subtle antiintellectual, antispecialty, antiresearch movement developing at several levels, and it is expanding. Some might say that we had it coming-after years of pejorative comment about the LMD on our wards and in our clinics. Yet, while we all advocate more family physician training, I can see no useful or rational purpose in denigrating investigative or specialty medicine, while pursuing this new venture. I have heard such things as "students with good science grades do not necessarily make good doctors." This may apply to some few, but it is the implication of the statement that is disturbing. It has an anti-intellectual ring. No one can deny that there is a need in the selection process to seek out students who have qualities of compassion and human warmth. Also this aspect of personality must be nurtured and encouraged during the years of education in medicine, yet one must not ignore the seminal importance of a firm foundation in the sciences. Human compassion and academic excellence are not mutually exclusive virtues. Some of us are egotistical enough to think that we have come close to this ideal. And we are many. This is not a time for intemperate generalizations; these are indicators of panic and reaction. It is the time for balance-rational creative planning and the initiative should come within the profession. It is encouraging that many of our medical young are highly motivated to family practice. And we do need more of them. Yet we must continue to produce a proper proportion of specialists and investigators to complement the health care team. And I must express my concern that government through its fiscal power over medical education is seeking means to control the input into medical specialties. It is antithetical to traditional American freedom of choice for government to exercise control over one's selection of his lifework. Yet unless medicine itself can solve this problem of specialty growth and distribution, it may well become a function of government. As I look ahead 10 to 20 years, my crystal ball becomes distressingly cloudy.
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Improving Physician Distribution The problem of physician distribution is admittedly difficult, but I do not think it is insurmountable. There are several possible options. Federal subsidy of students with a mandatory two year pay-back time is one possible solution. But again the implication of univers!l compulsory service has ominous overtone. And, parenthetically, I might add that if indeed this comes to pass for medicine, why should we be singled out? Why not dentists and lawyers and teachers and perhaps even engineers, architects and plumbers? Certainly these services are also maldistributed throughout the country. But I am wandering; down this catacomb lies madness. Also regarding distribution, I am convinced that there are many physicians who can be induced to care for patients in less desirable geographical areas. This can be done by a reorientation of philosophy and priorities, by offering a rewarding lifestyle, by a team approach, with perhaps three or four family-oriented physicians working in a group each trained in a different discipline-internal medicine, obstetrics-gynecology, pediatrics. There must be professional recognition by colleagues and an end to the denigration of the LMD. There must be realistic financial compensation and rapid access to specialist backup. These physicians must also be provided a practical continuing medical education program, perhaps through periodic sabbaticals, while they are replaced by someone of comparable background and training. It is beyond the scope of this discussion to consider the role of physician assistants in this plan. But their potential contribution to patient care in remote areas and in other sections where physician distribution is a problem, is another distinct aspect to the solution of the distribution dilemma.
Changes in Investigative Medicine Now let us talk about what has happened in investigative medicine. It was about seven years ago that we began to hear new words such as targeted research and goal-oriented investigation -words sprung from the lexicon of the bureaucrat. It epitomized a pragmatic philosophy that seemed to say, "Trap the brightest investigators you can find; lock them in a laboratory with the finest equipment and limitless resources; feed, water and pet them occasionally. And if you keep
them there long enough, they will find cures for cancer, heart disease and stroke." Well, timetables may be applied to mathematical and physical sciences. And the pharmaceutical sciences have been successful in the creation of new molecules through a goal-directed orientation. Propylthiouricil and several synthetic antibiotics (most notably rifampin) have resulted. But biological arts do not work this way. In medical research there is, unfortunately, one variable that cannot be manipulated: the patient. The myopic bureaucratic philosophy that seems to say "If we can get to the moon in ten yearscertainly we can cure cancer in 15," was implemented through various mechanisms resulting in a significant constriction of research funds, most of which were diverted from "non-goal-oriented research." The alleged fat was trimmed mercilessly. Those who could not be enticed or coerced into "target-oriented" research began to drift away. It is probable that a significant portion of one or two generations of young investigators has already been lost. It is a tragedy of dimensions that may never be fully appreciated, since it cannot be measured. How do you evaluate something that was never discovered? Throughout the history of art and science there have been some free spirits that cannot be tethered. They must be recognized, cherished and given their heads. These have always been our most creative people; this is the nature of art and science. Alas, it is a concept alien to the bureaucratic psyche. And how much progress have we made in the war against heart disease, stroke and cancer? We are still a nation of slaves to cultural indolence; we are overindulgers in food, alcohol and cigarettes, and underindulgers in exercise, seat belts and self-restraint. No magic bullets have been forthcoming; no earthshaking breakthroughs from those locked into target-oriented research programs. There is statistical indication that there has been some reduction in the deaths from myocardial infarction over the past five years. And some have related this to a more rational diet among American men. But aside from this glimmer of light, there is little evidence of success in other areas. Too often, solutions of medical problems are inextricably interwoven with cultural, social and economic phenomena. As all of us know, quite often major discoveries are the result of serendipitous observations in disparate disciplinesTHE WESTERN JOURNAL OF MEDICINE
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seemingly unrelated-small discoveries made by bright, independent, non-goal-oriented people who just happen to meet and chat on boardwalks or in coffee shops.
Continued Support for Basic Research There is an urgent need for continued support of investigation in basic science and clinical research. Perhaps investigative medicine should not be as unstructured and insensitive to fiscal reality as in the past, but there must be a mechanism for recognizing and encouraging investigative virtuosity. This is the heart blood of medicine-the source of new knowledge. We must not overreact by a return to preFlexner attitudes-just as we must not continue an unrealistic spiral into superspecialties at the expense of primary care physicians. I will repeat -there is need for balance. I believe there will always be room in medicine for men and women of talent and dedication, and I think this essential freedom can be preserved without limitation of professional options as seems to have occurred in England and Sweden. And I repeat-I fear the incursion of government into this seminal aspect of medical education-as it fills a vacuum-a void left by the indolence and indifference of medicine. Human Investigation and Morality Finally, one other area deserves comment. The third direction of the anti-intellectual fire in the forest is human experimentation. This unfortunate expression seems to conjure up images of Buchenwald. I will confine these remarks to research on humans, the problems of abortus research, use of materials derived from human sources and animal investigation would carry us far into the night. But let us talk about human investigation. No rational person will deny the virtues of a sensitive but rational protocol review committee. And there have been lapses in our vigil to protect human individual rights. But I submit that most often these lapses have been caused by carelessness, or overwork, or overenthusiasm rather than by callousness. There are exceptions. No matter what semantic gambit one may wish to employ, we are all in the business of caring for human beings. Therefore, we must learn about human beings. And in the final analysis, I know of no other way to do this than to try procedures and therapies with human beings. To extrapolate 448
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to the absurd, each time we treat a patient with an approved drug or submit him to a well-tried
surgical procedure, it is indeed a miniature human experiment. We speak of a risk-benefit ratio-this is itself a euphemism for human experimentation. It is a truism that every significant advance throughout the history of medicine has been based on human experimentation. One wonders how Pasteur, Koch, Jenner, Reed, Florey and hundreds of others would have fared at the hands of some protocol review committees? And should they have been permitted to do such studies? Were they less moral, less sensitive? Was life worth less? It would seem that at some periods in history the rights of the individual person weigh more heavily than those of society. Then the pendulum will swing again. The dilemma is this: protection of the rights of the individual balanced against the good of mankind. Is there ever an occasion when the civil liberties and moral rights of an individual can be set aside to achieve a greater good? Answer that, and all other factors fade into insignificance. It is impossible to generalize. Must we begin to think in terms of lesser morality and greater morality? What is our moral obligation to women with breast cancer now, who might be tested with a drug that may arrest the tumor, but may have significant toxicity-as opposed to our moral obligation to untold future generations of women who we know will die of breast cancer? How does one measure the morality of present risk against future benefit? Clearly, it would be immoral to stop research in cancer, stroke and heart disease. And who are to be the volunteers who provide informed consent (that nightmare of social, economic, psychologic and legal entanglement which defies universal definition)? Should the volunteers be restricted to research scientists? (Well, surely in this group there could never be a question about full awareness of present risk or full cognizance of possible future benefit.) Are we ever justified in the use of children (How do you inform a child?); can a parent give consent for a child? How about prisoners (whose situation always might be construed as intrinsic coercion)? As an aside, after publication of a recent editorial in JAMA-an eloquent plea to protect prisoners-we received several letters from prisoners who expressed anger and frustrationat the possible restriction of their rights as human beings to volunteer for medical research projectsin an effort to square themselves with society or
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to indicate their desire to cooperate with society or even just to earn extra money and privilege. So there is never black and white-in any situation. And how about using the mentally retarded (who may certainly be incompetent to give informed consent)? Are we justified in using any of these groups of persons who are less likely to make a contribution to society than are research scientists? And who is to make such a judgment? I pose to you an insoluble dilemma. All one can ask is that each situation be studied with consummate circumspection and be approached rationally and compassionately. Again I am not convinced that ironclad guidelines, even etched in tablets from on high, will solve the problem. One might say that no person has the right to involve another person in an experiment that could maim or kill, regardless of the desire of the volunteer or the probable benefit to mankind. And this is a debatable point. It has more shades of gray than a charcoal drawing. Yet, we cannot let progress in medicine grind to a halt in a backlash of neurotic guilt and sanctimony. You know it has become almost fashionable-a herd instinct-for anonymous referees of medical manuscripts and rare, timorous journal editors to respond to papers that include the use of human volunteers (in almost any context) with pharisaic castigation-hurling thunderbolts
from Helsinki-to vilify the investigators. To me, this is destructive, purposeless sophistry. Thus, I submit, it is time to stop and take inventory.
The Three Cardinal Issues Some may say I have erected three men of straw-hobgoblins of my own nervous invention. I hope this is true. But in my opinion postdoctoral education, research in general and human experimentation are cardinal issues, at risk in the present and in the foreseeable future. I believe we stand at a major impasse. I see a vast swampland of intellectual impoverishment in medicine looming ahead. Yet scattered throughout I see tender saplings of what could become a magical forest destined to flourish and bring the bounteous blessings of an improvement in the quality of life to all of our people. So we must select our options with prudence and circumspection. If we do less, if we falter and despair, one day we may all awaken clutched in the doughy embrace of pervasive mediocrity. And so I say let us look to the forest. Let us approach the future with courage, born of the conviction that man is a most remarkable creature-capable of rising to the need of the hour, capable of inspiration to solve his problems with vision and tenacity and practical genius. These have been the hallmarks of our species.
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Special Article
An Anti-Intellectual Movement in Medicine ROBERT H. MOSER, MD, Chicago
IT IS NOT NEWS that Western man is reentering a climate of anti-intellectualism-a new Dark Age wherein some fight fear with long since discarded devices. We have witnessed the return of mysticism as reflected in the reemergence of the black and white magic of the Tarot, the simplistic nonsense of astrology and a wave of perfervid religiosity. If these methods had ever worked, they would not have been reassumed and discarded myriad times in the history of civilizations. We are in a state of chaos, but it is nonsense to blame the mess on the clean, flourishing, logical and technical disciplines of science. Rather, it is, once again, the lagging of practical humanism reflected in failure of social and political systems to implement scientific knowledge that has created a gestalt inimical to the health of the individual person and, therefore, to the health of society. And I fear the wave of anti-intellectualism has begun to encroach upon the borders-if not the heart-of medicine. Let me explore this. One year ago I was battling the problems of providing patient care in an urban-rural community, with night calls, house calls and all the joys and agonies attendant thereto. And one cannot obliterate certain perspectives and attitudes simply by switching chairs: in this case, to one behind an editor's desk. So I would like to ruminate some things that had begun to worry me The author is Editor, The Journal of the American Medical Association, and Director, Division of Scientific Publications, The American Medical Association. Presented to the Calfornia Academy of Medicine, San Francisco,
September 28, 1974. Reprint requests to: R. H. Moser, MD, Editor, The Journal of the American Medical Association, 535 North Dearborn Street, Chicago, IL 60610.
before; and now that I have come to the big city and begun to wander about, and to take the pulse of American medicine, the fears have begun to crystallize.
First Signs of Change It is a little like watching animals react to a small fire in the forest. The whiffs of smoke were detected by sensitive creatures about five or ten years ago. You are all familiar with the tremors that were felt by the academic community. Some whispered that our research and educational establishments had become badly out of joint with the times. There were murmurings about excess fat in research budgets, escalating costs of medical care and maldistribution of professional talent-geographically and socioeconomically. But just as you and I had, the bright young graduates of the 60's continued to swarm the ivory towers and populate the specialties, while the vast mass of patients-those who were less-than-violently ill or less-than-interestingly ill-were all but forgotten in the academic scramble. And all of this had significant fallout. Patients obliged to wait several hours in offices, clinics and emergency rooms agreed most readily when they were told we were in the midst of a doctor shortage. And for many lower and middle income groups good medical care was scarce, if not unknown. The news media were replete with stories of dramatic progress in the science of medicine but little of this was perceptible, little filtered down to the vast mass of the less affluent sick. Words such as relevance and social responsibility began to creep into the conversations of our medical young. THE WESTERN JOURNAL OF MEDICINE
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Meanwhile, many medical schools, still basking in the warmth of their post-Flexner era bonanza, began to sense the distant smoke, and some reacted. Incoming classes were doubled and tripled; selection committees reached out for minority group students; curriculum committees sought new dimensions. Schools with unfamiliar names mushroomed throughout the land. Some clinical teachers became concerned about the capability of the existing, relatively finite pool of medical educators to accommodate the surge of new students, and still maintain traditions of excellence in classroom and clinic. But these fears were assuaged with assurances that the new mass media techniques would facilitate clinical teaching. Yet some of us were still worried about relegating these critical responsibilities to mechanical surrogates. But our concerns were only small eddies swirling against the mainstream.
More Doctors, Faster Produce more doctors and do it faster was the watch word. We were advised that we were 30,000 doctors short throughout the country-but few stopped to analyze this figure as it related to distribution and specialty. Yet on the basis of gross numbers alone the gates were thrown open to foreign-trained physicians, and they came in droves-to fill the need. This is not the time or place to discuss the merits or debits of this most complex situation. But the fact is that this relaxed policy of medical immigration did little to take the pressures off American medical schools. Thus, to accelerate the production of warm medical bodies, many medical schools condensed the curriculum by emasculating or deleting "irrelevant" departments (clinical pharmacology was an early, costly casualty); some merely eliminated vacation periods and began to churn out graduates in 36 months. Not much time for reflection, or emotional growth, or evolution of the other intangible elements that go to make up that elusive quality we call medical maturity. No one seemed to ask "What is the hurry?" Also no one paid much attention to where the warm bodies, foreign and domestic, gravitated. And there was no perceptible change in the pattern of physician distribution-geographically or by specialty. No one faced the problem of "How are you gonna keep 'em down on the farm-after they've seen Paree" or, to paraphrase, "How are you going to keep 'em down on the Indian reservation, or in the horizontal ghettoes of the delta, 444
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or the vertical ghettoes of Detroit after they've seen Massachusetts General or the National Institutes of Health or Scarsdale or San Francisco or Maui?" And what about the graduates of the late 50's and 60's? Some of us anachronistic curmudgeons-erstwhile bedside clinicians-could be heard to mutter darkly about the new breed of graduates and their tutors, mechanical and otherwise. Nasty phrases like laboratory-oriented myrmidons, molecular biology buffs, disease rather than patient-oriented, bereft of human virtues, assembly line products crept into our cloakroom conversations. Yet, the first significant militant protests against the educational grist mill came from the students. It was their forthright demands for relevance in curriculum and for meaningful medical experience that arose in response to their expanding social awareness. Students-not teachers-were the ones who scrutinized the academic tradition which had taught disdain of the local medical doctor, the LMD, and had extolled the virtues of the investigative-teaching career pattern. Students were the ones who studied this philosophy-and found it lacking, out of balance, out of synchrony with the times. While our generation focused mainly on individual patients, and accused our immediate successors of looking mainly at disease mechanism, indeed recent graduates were the ones who looked beyond both-at the need of society. There is a requirement that all three aspectspatient, mechanism and society-be kept in mind, and they are not mutually exclusive. But it is a difficult balance to strike. However, the point had been made. Admittedly, many perceptive educators had already began to suspect that perhaps the postFlexner momentum had crested, and that under their stewardship the thrust of medicine had carried beyond its cardinal purpose-the care of patients. They began to realize that concepts of patient care had become lost, sidetracked somewhere in the fascinating catacombs of scientific methodology. Educators began to realize that through their teaching, diseases had replaced patients in the priorities of education in medicine.
An Awesome Body of Knowledge But one must not forget; the smoke in the forest had originated in a most remarkable crucible. The golden years of research and postgraduate clinical
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training that began after World War II had produced an incredible cadre of talent and an awesome body of knowledge. New pathophysiologic mechanisms had been identified. Dramatic discoveries in molecular biology, immunology, cytogenetics, and enzyme and hormone chemistry had occurred. New diagnostic techniques and therapeutic tools were devised. All were products of these marvelous years. This was reflected in gigantic growth in capability for quality patient care. Admittedly, the distribution and availability of this care were far from optimal, however-as I said earlier-social and economic implementation always lags behind advancement in sciences. But the capability was there. (I sometimes suspect that in the grand scheme of life, there are times when such sudden spurts of genius and productivity must occur to maintain viability. But always, something else must be sacrificed.) Thus, despite this flush of success in science, some of us felt that during these grand years of progress in hard science, something had been lost along the way. Perhaps it was that bedside senses were being neglected and were becoming dulled. We thought that some training programs were out of balance; there was too much mechanization; too much stress on nuts and bolts-too little stress on people. In the passionate effort to master the vast new knowledge, students were being deprived of something vital and wonderful and satisfying in medicine: the joy of eyeball-to-eyeball, personal, one on one, longitudinal communication with patients. The humanity of medicine was all too often shunted aside in the headlong pursuit of hard science. There was more to be learned, and less time to learn it. Something had to be sacrificed, and we felt the choice, although it was perhaps inevitable, was unfortunate. In many cases the art of medicine was left on the curriculum cuttingroom floor. But the smoke in the wind became even more perceptible about three or four years ago. Things began to shift back toward the bedside. Preceptorships, neglected for 25 years, were being rediscovered. Most clinicians viewed this with cautious pleasure. A balance was being struck between bench and bedside. But in recent months, my delight has begun to fade. It has been replaced by something close to alarm. Let us look at what is happening. We are told by people who should know that despite the current overall physician shortage, if
present trends continue (the production of our medical schools plus the continued influx of foreign medical graduates), within 12 years the United States physician pool will number between 495,000 and 520,000. By 1985 we will have 220 doctors per 100,000 population as compared with 160 in 1970. If you believe this projection (and this numbers game has been the subject of great debate) we are facing a doctor surplus. Listen to the words of Dr. Charles C. Edwards at the Association of American Medical Colleges meeting in 1973, "I think that clearly we have moved beyond the point at which concern about a shortage of physicians was genuine if somewhat exaggerated. Even more significant is the possibility we may well be facing a doctor surplus in this country." Later he said "The task the medical schools now face is to work toward solution of problems that relate not to aggregate numbers of physicians, but to specialty and geographical maldistribution, physician productivity, and the underrepresentation of women and minorities among the health professions . . . "
The Government and Medical Education This can be translated into the fact that the government is taking a hard look at its philosophy of financing medical education. The holders of the federal purse strings are not satisfied with the current efforts by medical schools to meet the practical needs of the citizenry. Another example: There was a bill (S-3585, Kennedy-Javits) which was approved by the Senate Labor and Education Committee. In its original form it would have provided almost 2 billion dollars over a threeyear period in federal aid for medical and other health profession schools. This bill would have given the federal government power to allocate and limit postgraduate training for physicians. It included a provision designed to curb the reliance on foreign medical graduates and to increase the number of primary-care physicians. It would have required the Department of Health, Education and Welfare to limit the number of postgraduate training positions in hospitals to no more than 10 percent above the total of domestic medical and osteopathic school graduates of that year, and to assign the total number of physicians to various categories of specialty and subspecialty training. Among other provisions of this bill were those that would require all young physicians to serve for two years in a sort of domestic peace corps THE WESTERN JOURNAL OF MEDICINE
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program, whether or not they received federal loan or scholarship help. Also, within two years the Department of Health, Education and Welfare. would establish national standards for licensure of physicians and dentists. Under this bill, licensure renewal would occur at least every six years. A physician or dentist licensed to practice in any state would qualify in any other state in which the national standards are in effect. If a state had standards exceeding the national standards, a physician coming into that state would have to meet the additional requirements. Thus it was designed to require all recent medical graduates to serve in shortage areas, to limit the number and variety of postgraduate positions and to ensure the relicensing of all physicians. The final, much modified version-as amended by Beall of Maryland-was passed on September 24 by the Senate, 81 to 7. It would provide federal aid to medical and dental schools that agree to allocate 25 percent of their classroom spaces for students volunteering to serve in urban slums or rural areas short of medical care workers. In return for their service, the students would be entitled to government scholarships. The bill would require one year of service for each year of scholarship aid. To say the least, all of this is most provocative -and I will not speculate upon it at this time. Suffice to say that it is perhaps an indication of what is in the wind, a cardinal demonstration that the government is indeed concerned about problems of contemporary medicine in America at all levels. And I will not speak of the implications of Professional Standards Review Organizations, Health Maintenance Organizations or national health insurance on medicine overall. But let us return to the problem of medical education.
New Educational Directions In an effort to anticipate this need to qualify for such federal support of medical education, many schools have reevaluated their priorities in curriculum planning. One major thrust of all of this has been the creation of departments of family medicine-a welcome, long overdue development. The popularity of these programs is evident through the progressive increase in positions and applicants over the past three years. One estimate by the Division of Manpower Intelligence places the current shortage at 27,000 to 30,000 familycare physicians such as general practitioners, 446
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internists, pediatricians and obstetricians. So evidently there is a long way to go to meet the current need in numbers-as well as in
distribution. But in recent months have experienced a dim sense of uneasiness. I have detected a subtle antiintellectual, antispecialty, antiresearch movement developing at several levels, and it is expanding. Some might say that we had it coming-after years of pejorative comment about the LMD on our wards and in our clinics. Yet, while we all advocate more family physician training, I can see no useful or rational purpose in denigrating investigative or specialty medicine, while pursuing this new venture. I have heard such things as "students with good science grades do not necessarily make good doctors." This may apply to some few, but it is the implication of the statement that is disturbing. It has an anti-intellectual ring. No one can deny that there is a need in the selection process to seek out students who have qualities of compassion and human warmth. Also this aspect of personality must be nurtured and encouraged during the years of education in medicine, yet one must not ignore the seminal importance of a firm foundation in the sciences. Human compassion and academic excellence are not mutually exclusive virtues. Some of us are egotistical enough to think that we have come close to this ideal. And we are many. This is not a time for intemperate generalizations; these are indicators of panic and reaction. It is the time for balance-rational creative planning and the initiative should come within the profession. It is encouraging that many of our medical young are highly motivated to family practice. And we do need more of them. Yet we must continue to produce a proper proportion of specialists and investigators to complement the health care team. And I must express my concern that government through its fiscal power over medical education is seeking means to control the input into medical specialties. It is antithetical to traditional American freedom of choice for government to exercise control over one's selection of his lifework. Yet unless medicine itself can solve this problem of specialty growth and distribution, it may well become a function of government. As I look ahead 10 to 20 years, my crystal ball becomes distressingly cloudy.
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Improving Physician Distribution The problem of physician distribution is admittedly difficult, but I do not think it is insurmountable. There are several possible options. Federal subsidy of students with a mandatory two year pay-back time is one possible solution. But again the implication of univers!l compulsory service has ominous overtone. And, parenthetically, I might add that if indeed this comes to pass for medicine, why should we be singled out? Why not dentists and lawyers and teachers and perhaps even engineers, architects and plumbers? Certainly these services are also maldistributed throughout the country. But I am wandering; down this catacomb lies madness. Also regarding distribution, I am convinced that there are many physicians who can be induced to care for patients in less desirable geographical areas. This can be done by a reorientation of philosophy and priorities, by offering a rewarding lifestyle, by a team approach, with perhaps three or four family-oriented physicians working in a group each trained in a different discipline-internal medicine, obstetrics-gynecology, pediatrics. There must be professional recognition by colleagues and an end to the denigration of the LMD. There must be realistic financial compensation and rapid access to specialist backup. These physicians must also be provided a practical continuing medical education program, perhaps through periodic sabbaticals, while they are replaced by someone of comparable background and training. It is beyond the scope of this discussion to consider the role of physician assistants in this plan. But their potential contribution to patient care in remote areas and in other sections where physician distribution is a problem, is another distinct aspect to the solution of the distribution dilemma.
Changes in Investigative Medicine Now let us talk about what has happened in investigative medicine. It was about seven years ago that we began to hear new words such as targeted research and goal-oriented investigation -words sprung from the lexicon of the bureaucrat. It epitomized a pragmatic philosophy that seemed to say, "Trap the brightest investigators you can find; lock them in a laboratory with the finest equipment and limitless resources; feed, water and pet them occasionally. And if you keep
them there long enough, they will find cures for cancer, heart disease and stroke." Well, timetables may be applied to mathematical and physical sciences. And the pharmaceutical sciences have been successful in the creation of new molecules through a goal-directed orientation. Propylthiouricil and several synthetic antibiotics (most notably rifampin) have resulted. But biological arts do not work this way. In medical research there is, unfortunately, one variable that cannot be manipulated: the patient. The myopic bureaucratic philosophy that seems to say "If we can get to the moon in ten yearscertainly we can cure cancer in 15," was implemented through various mechanisms resulting in a significant constriction of research funds, most of which were diverted from "non-goal-oriented research." The alleged fat was trimmed mercilessly. Those who could not be enticed or coerced into "target-oriented" research began to drift away. It is probable that a significant portion of one or two generations of young investigators has already been lost. It is a tragedy of dimensions that may never be fully appreciated, since it cannot be measured. How do you evaluate something that was never discovered? Throughout the history of art and science there have been some free spirits that cannot be tethered. They must be recognized, cherished and given their heads. These have always been our most creative people; this is the nature of art and science. Alas, it is a concept alien to the bureaucratic psyche. And how much progress have we made in the war against heart disease, stroke and cancer? We are still a nation of slaves to cultural indolence; we are overindulgers in food, alcohol and cigarettes, and underindulgers in exercise, seat belts and self-restraint. No magic bullets have been forthcoming; no earthshaking breakthroughs from those locked into target-oriented research programs. There is statistical indication that there has been some reduction in the deaths from myocardial infarction over the past five years. And some have related this to a more rational diet among American men. But aside from this glimmer of light, there is little evidence of success in other areas. Too often, solutions of medical problems are inextricably interwoven with cultural, social and economic phenomena. As all of us know, quite often major discoveries are the result of serendipitous observations in disparate disciplinesTHE WESTERN JOURNAL OF MEDICINE
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seemingly unrelated-small discoveries made by bright, independent, non-goal-oriented people who just happen to meet and chat on boardwalks or in coffee shops.
Continued Support for Basic Research There is an urgent need for continued support of investigation in basic science and clinical research. Perhaps investigative medicine should not be as unstructured and insensitive to fiscal reality as in the past, but there must be a mechanism for recognizing and encouraging investigative virtuosity. This is the heart blood of medicine-the source of new knowledge. We must not overreact by a return to preFlexner attitudes-just as we must not continue an unrealistic spiral into superspecialties at the expense of primary care physicians. I will repeat -there is need for balance. I believe there will always be room in medicine for men and women of talent and dedication, and I think this essential freedom can be preserved without limitation of professional options as seems to have occurred in England and Sweden. And I repeat-I fear the incursion of government into this seminal aspect of medical education-as it fills a vacuum-a void left by the indolence and indifference of medicine. Human Investigation and Morality Finally, one other area deserves comment. The third direction of the anti-intellectual fire in the forest is human experimentation. This unfortunate expression seems to conjure up images of Buchenwald. I will confine these remarks to research on humans, the problems of abortus research, use of materials derived from human sources and animal investigation would carry us far into the night. But let us talk about human investigation. No rational person will deny the virtues of a sensitive but rational protocol review committee. And there have been lapses in our vigil to protect human individual rights. But I submit that most often these lapses have been caused by carelessness, or overwork, or overenthusiasm rather than by callousness. There are exceptions. No matter what semantic gambit one may wish to employ, we are all in the business of caring for human beings. Therefore, we must learn about human beings. And in the final analysis, I know of no other way to do this than to try procedures and therapies with human beings. To extrapolate 448
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to the absurd, each time we treat a patient with an approved drug or submit him to a well-tried
surgical procedure, it is indeed a miniature human experiment. We speak of a risk-benefit ratio-this is itself a euphemism for human experimentation. It is a truism that every significant advance throughout the history of medicine has been based on human experimentation. One wonders how Pasteur, Koch, Jenner, Reed, Florey and hundreds of others would have fared at the hands of some protocol review committees? And should they have been permitted to do such studies? Were they less moral, less sensitive? Was life worth less? It would seem that at some periods in history the rights of the individual person weigh more heavily than those of society. Then the pendulum will swing again. The dilemma is this: protection of the rights of the individual balanced against the good of mankind. Is there ever an occasion when the civil liberties and moral rights of an individual can be set aside to achieve a greater good? Answer that, and all other factors fade into insignificance. It is impossible to generalize. Must we begin to think in terms of lesser morality and greater morality? What is our moral obligation to women with breast cancer now, who might be tested with a drug that may arrest the tumor, but may have significant toxicity-as opposed to our moral obligation to untold future generations of women who we know will die of breast cancer? How does one measure the morality of present risk against future benefit? Clearly, it would be immoral to stop research in cancer, stroke and heart disease. And who are to be the volunteers who provide informed consent (that nightmare of social, economic, psychologic and legal entanglement which defies universal definition)? Should the volunteers be restricted to research scientists? (Well, surely in this group there could never be a question about full awareness of present risk or full cognizance of possible future benefit.) Are we ever justified in the use of children (How do you inform a child?); can a parent give consent for a child? How about prisoners (whose situation always might be construed as intrinsic coercion)? As an aside, after publication of a recent editorial in JAMA-an eloquent plea to protect prisoners-we received several letters from prisoners who expressed anger and frustrationat the possible restriction of their rights as human beings to volunteer for medical research projectsin an effort to square themselves with society or
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to indicate their desire to cooperate with society or even just to earn extra money and privilege. So there is never black and white-in any situation. And how about using the mentally retarded (who may certainly be incompetent to give informed consent)? Are we justified in using any of these groups of persons who are less likely to make a contribution to society than are research scientists? And who is to make such a judgment? I pose to you an insoluble dilemma. All one can ask is that each situation be studied with consummate circumspection and be approached rationally and compassionately. Again I am not convinced that ironclad guidelines, even etched in tablets from on high, will solve the problem. One might say that no person has the right to involve another person in an experiment that could maim or kill, regardless of the desire of the volunteer or the probable benefit to mankind. And this is a debatable point. It has more shades of gray than a charcoal drawing. Yet, we cannot let progress in medicine grind to a halt in a backlash of neurotic guilt and sanctimony. You know it has become almost fashionable-a herd instinct-for anonymous referees of medical manuscripts and rare, timorous journal editors to respond to papers that include the use of human volunteers (in almost any context) with pharisaic castigation-hurling thunderbolts
from Helsinki-to vilify the investigators. To me, this is destructive, purposeless sophistry. Thus, I submit, it is time to stop and take inventory.
The Three Cardinal Issues Some may say I have erected three men of straw-hobgoblins of my own nervous invention. I hope this is true. But in my opinion postdoctoral education, research in general and human experimentation are cardinal issues, at risk in the present and in the foreseeable future. I believe we stand at a major impasse. I see a vast swampland of intellectual impoverishment in medicine looming ahead. Yet scattered throughout I see tender saplings of what could become a magical forest destined to flourish and bring the bounteous blessings of an improvement in the quality of life to all of our people. So we must select our options with prudence and circumspection. If we do less, if we falter and despair, one day we may all awaken clutched in the doughy embrace of pervasive mediocrity. And so I say let us look to the forest. Let us approach the future with courage, born of the conviction that man is a most remarkable creature-capable of rising to the need of the hour, capable of inspiration to solve his problems with vision and tenacity and practical genius. These have been the hallmarks of our species.
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