MEDICINE, SCIENCE AND SOCIETY
Wealth Impact of the Physician
WALSH
MCDERMOTT, M.D.
Princeton, New Jersey
From the Robert Wood Johnson Foundation, Princeton, New Jersey. Requests for reprints should be addressed to Dr. Walsh McDermott, Ths Robert Wood Johnson Foundation, Post Dffice Box 2316, Princeton, New Jersey 06540. Manuscript accepted June 23, 1976.
For most current public policy issues, and for all that are sciencerelated, we must form our judgments from hearing an argument between those whose comprehension of the subject may be grossly warped because they do not know it from the inside, and those whose perceptions may be grossly warped because they do know it from the inside. A lively topic in public policy today is whether the doctor-figures we have known since childhood-the physicians and surgeons who make up the personal encounter physician system-merit continued major social investment or whether a different approach based largely on acquiring good “health habits” would not serve us better in the long run. The latter concept, which can be roughly labeled “self-care,” enjoys support not only from popular authors like Ivan lllich or Rick Carlson, but also from some hardheaded economic planners. In actuality, compared with many peoples, Americans do assume considerable individual responsibilities for their health; the idea that we should do more, provided it be done rationally, is only to be applauded. But what is it that is to be endorsed? Current proposals take many forms, but one frequently stated is that there is a known set of health habits which, if learned, taught and practiced by us, would result in significantly longer and healthier lives. This is to say it is postulated that the group, as a group, would have longer and healthier lives. To what extent this would improve the lot of the individual person cannot be stated. What should be stated emphatically, however, is that, except for the long-known obvious excesses, there is really no solid evidence that permits identification of one way of living as significantly different from another in terms of health. Indeed, such evidence would be very hard to come by, for it would involve careful, lifelong epidemiologic studies of people whose life habits could be periodically observed and recorded. Retrospective studies, as pointed out by the authors of a frequently cited study [ 11, can at best be only suggestive. Policy decisions on interventions, therefore, except for those having to do with the long-recognized excesses, notably of alcohol or tobacco, will have to be based largely on what in the nature of things can be no more than the conventional wisdom. Such a base, if carefully anallyzed, might well provide reasonable arguments for what in the trade has acquired the title “alternative strategies for health.” But this does not seem to be happening. Instead, many of today’s spokesmen seeking to forward such self-care choose as the foundation of their argument an asserted failure of the personal physician system. We are told that very little of our past major health achievements has come from personal
October 1979
The American Journal of Medicine
Volume 65
569
HEALTH IMPACT OF THE PHYSICIAN-MCDERMOTT
physicians; the gains have come largely from the way of living permitted by our economy or at times from our programs in public health. As for the future, so goes the argument, the major unconquered diseases are life-style related and multifactoral in origin-characteristics that make them relatively immune to change unless there is a fairly widespread change in our way of life [ 21. Neither of these assertions stands up to critical analysis [3]. With respect to the first assertion-the past and present lack of influence on the health of our society exerted by the encounter system-it is essential to realize that what are termed “the usual indices of health status” cannot possibly be used to measure the effectiveness of that system. Thus, when health planners contend, as some are now doing, “You say personal physicians do wonderful things, but there is no evidence of it in the indices of our nation’s health,” it reveals a lack of understanding of what it is those indices reflect. These indices or indicators, developed through the years, have been traditionally used to measure the effectiveness of the public health system. They reveal the gross outline of a society’s disease pattern by enumerating births, deaths and their causes, and ages at death. They have to do with a whole population. What the personal encounter physician does is to perform an act or series of acts for an individual person. One might ask, “Would not these persons add up so that over time they could form a large enough group to show up in the public health indicators?” This does happen, but only as a rare historic event, for it requires a very special set of circumstances: Specifically, it is necessary to have the wide-scale introduction of a powerful new cure or preventive measure administered through the encounter physician system and effective against some very frequently occurring disease or disease grouping. This has occurred at least twice in the past half-century. On both occasions-the introduction of sulfonamide and of tuberculosis chemotherapy-effects were measurable by changes in mortality. Tuberculosis mortality, which had been steadily declining since the 19th century, fell precipitously-70 per cent-in the seven years after the start of the general use of drug therapy in 1947 [3]. Except for such rare events, however, what the personal encounter physician does cannot be reflected by the usual health indicators. What might be viewed as his failures-deaths-show up on the public health scoreboard; but his successes virtually never do. What the physician does falls into four categories: samaritanism, i.e., perceptive human support; the appropriate use of the technology to control disease; the sciencebased modulation of deranged physiology to prolong effective life; and the technology-based capability to rule out the presence of feared conditions and hence
570
October 1979
The American Journal of Medicine
help to maintain peace of mind [3,4]. We have devised no indicators to measure the effectiveness of these four categories of professional activity on the health status of a society. The fact that this is so is something that is not understood. These four functions are not to be written off with the faint praise that they are mainly compassionate human support. This is certainly there, but there is also a very large component of the discriminating application of science and technology for the great benefit of an individual person. Death from serious heart disease cannot be indefinitely prevented. But with good physician care involving much sciencebased physiologic management, useful life, including full employability, may be extended for two or three or more years. With hundreds of thousands of deaths from heart disease each year in the U.S.; however, deaths postponed from one period to another (say 1971 to 1974) cannot be distinguished from those occurring in the first year of the diagnosis. This great achievement of today’s personal-encounter physician-the ability to modulate the deranged physiology of ultimately fatal chronic disease-is something for which we lack measures. Thus, there is no.way such physician “successes” can be detected in the box score of the public good. Today’s oft repeated statement that what the physician does has relatively little influence on health is more correctly stated that what the physician does has relatively little influence on those indicators of health that are largely irrelevant to what he does. Because the usual health indices bear only a remote relation to what it is a physician does, the influence of the encounter system on the over-all health of our society can neither be affirmed nor denied. For the individual person, however, the situation is quite the opposite and the capability of the system to fulfill its critically important functions can be clearly demonstrated. The second assertion has to do with life-style and our major diseases, and the unlikelihood of change:That our current major diseases are stubborn because of their embedment in our life-style seemed indeed to be the case throughout the 1960’s, but this perception has now been overtaken by events. Culture-linked as our current diseases may be, they are yielding to something. Indeed the pattern has shown remarkable change. Since the early 1970s there have been highly significant reductions in infant mortality in the U.S. and in the death rates from such major killers as heart disease and stroke [3]. Significant falls, but of a lesser extent, have occurred in virtually all major causes of deaths. With cancer, the death rate for those over 55 years of age has increased, but in the younger age groups it has shown some decrease. These exciting results cannot be attributed directly to any one of the three major health
Volume 65
HEALTH IMPACT OF THE PHYSICIAN--MCDERMOTT
forces (the encounter system; public health including health education; or the material culture). It seems probable that all three have contributed. But clearly the results provide no support at all for the idea that the nature of today’s diseases is such that unless we drastically change our approaches things are doomed to remain at a standstill.
If our long traditional physician system becomes downgraded by our society, it is not apt to come because the system is not highly effective, but because it is either organized in such a way that it is not uniformly accessible, or its expense has become unbearable. These are the two issues that demand our immediate attention.
REFERENCES 1. 2.
3.
ElellocNB, Breslow L: Relationship of physical health status and health practices. Prev Med 1: 409, 1972. McKeown T: Historical perspective on science and health. Presented at annual meeting of Institutes of Medicine, National Academy of Science, Washington, DC, October 1976. McDermott W: Medicine: the public good and one’s own. Per-
4.
5.
October 1976
spect Biol Med (in press). McDermott W: General medical care. identification and analysis of alternative approaches. The Johns Hopkins Med J 135: 292, 1974. McDermott W: Evaluating the physician and his technology. Daedalus, Winter 1977.
The American Journal of Medicine
Volume 65
571
Wealth Impact of the Physician
WALSH
MCDERMOTT, M.D.
Princeton, New Jersey
From the Robert Wood Johnson Foundation, Princeton, New Jersey. Requests for reprints should be addressed to Dr. Walsh McDermott, Ths Robert Wood Johnson Foundation, Post Dffice Box 2316, Princeton, New Jersey 06540. Manuscript accepted June 23, 1976.
For most current public policy issues, and for all that are sciencerelated, we must form our judgments from hearing an argument between those whose comprehension of the subject may be grossly warped because they do not know it from the inside, and those whose perceptions may be grossly warped because they do know it from the inside. A lively topic in public policy today is whether the doctor-figures we have known since childhood-the physicians and surgeons who make up the personal encounter physician system-merit continued major social investment or whether a different approach based largely on acquiring good “health habits” would not serve us better in the long run. The latter concept, which can be roughly labeled “self-care,” enjoys support not only from popular authors like Ivan lllich or Rick Carlson, but also from some hardheaded economic planners. In actuality, compared with many peoples, Americans do assume considerable individual responsibilities for their health; the idea that we should do more, provided it be done rationally, is only to be applauded. But what is it that is to be endorsed? Current proposals take many forms, but one frequently stated is that there is a known set of health habits which, if learned, taught and practiced by us, would result in significantly longer and healthier lives. This is to say it is postulated that the group, as a group, would have longer and healthier lives. To what extent this would improve the lot of the individual person cannot be stated. What should be stated emphatically, however, is that, except for the long-known obvious excesses, there is really no solid evidence that permits identification of one way of living as significantly different from another in terms of health. Indeed, such evidence would be very hard to come by, for it would involve careful, lifelong epidemiologic studies of people whose life habits could be periodically observed and recorded. Retrospective studies, as pointed out by the authors of a frequently cited study [ 11, can at best be only suggestive. Policy decisions on interventions, therefore, except for those having to do with the long-recognized excesses, notably of alcohol or tobacco, will have to be based largely on what in the nature of things can be no more than the conventional wisdom. Such a base, if carefully anallyzed, might well provide reasonable arguments for what in the trade has acquired the title “alternative strategies for health.” But this does not seem to be happening. Instead, many of today’s spokesmen seeking to forward such self-care choose as the foundation of their argument an asserted failure of the personal physician system. We are told that very little of our past major health achievements has come from personal
October 1979
The American Journal of Medicine
Volume 65
569
HEALTH IMPACT OF THE PHYSICIAN-MCDERMOTT
physicians; the gains have come largely from the way of living permitted by our economy or at times from our programs in public health. As for the future, so goes the argument, the major unconquered diseases are life-style related and multifactoral in origin-characteristics that make them relatively immune to change unless there is a fairly widespread change in our way of life [ 21. Neither of these assertions stands up to critical analysis [3]. With respect to the first assertion-the past and present lack of influence on the health of our society exerted by the encounter system-it is essential to realize that what are termed “the usual indices of health status” cannot possibly be used to measure the effectiveness of that system. Thus, when health planners contend, as some are now doing, “You say personal physicians do wonderful things, but there is no evidence of it in the indices of our nation’s health,” it reveals a lack of understanding of what it is those indices reflect. These indices or indicators, developed through the years, have been traditionally used to measure the effectiveness of the public health system. They reveal the gross outline of a society’s disease pattern by enumerating births, deaths and their causes, and ages at death. They have to do with a whole population. What the personal encounter physician does is to perform an act or series of acts for an individual person. One might ask, “Would not these persons add up so that over time they could form a large enough group to show up in the public health indicators?” This does happen, but only as a rare historic event, for it requires a very special set of circumstances: Specifically, it is necessary to have the wide-scale introduction of a powerful new cure or preventive measure administered through the encounter physician system and effective against some very frequently occurring disease or disease grouping. This has occurred at least twice in the past half-century. On both occasions-the introduction of sulfonamide and of tuberculosis chemotherapy-effects were measurable by changes in mortality. Tuberculosis mortality, which had been steadily declining since the 19th century, fell precipitously-70 per cent-in the seven years after the start of the general use of drug therapy in 1947 [3]. Except for such rare events, however, what the personal encounter physician does cannot be reflected by the usual health indicators. What might be viewed as his failures-deaths-show up on the public health scoreboard; but his successes virtually never do. What the physician does falls into four categories: samaritanism, i.e., perceptive human support; the appropriate use of the technology to control disease; the sciencebased modulation of deranged physiology to prolong effective life; and the technology-based capability to rule out the presence of feared conditions and hence
570
October 1979
The American Journal of Medicine
help to maintain peace of mind [3,4]. We have devised no indicators to measure the effectiveness of these four categories of professional activity on the health status of a society. The fact that this is so is something that is not understood. These four functions are not to be written off with the faint praise that they are mainly compassionate human support. This is certainly there, but there is also a very large component of the discriminating application of science and technology for the great benefit of an individual person. Death from serious heart disease cannot be indefinitely prevented. But with good physician care involving much sciencebased physiologic management, useful life, including full employability, may be extended for two or three or more years. With hundreds of thousands of deaths from heart disease each year in the U.S.; however, deaths postponed from one period to another (say 1971 to 1974) cannot be distinguished from those occurring in the first year of the diagnosis. This great achievement of today’s personal-encounter physician-the ability to modulate the deranged physiology of ultimately fatal chronic disease-is something for which we lack measures. Thus, there is no.way such physician “successes” can be detected in the box score of the public good. Today’s oft repeated statement that what the physician does has relatively little influence on health is more correctly stated that what the physician does has relatively little influence on those indicators of health that are largely irrelevant to what he does. Because the usual health indices bear only a remote relation to what it is a physician does, the influence of the encounter system on the over-all health of our society can neither be affirmed nor denied. For the individual person, however, the situation is quite the opposite and the capability of the system to fulfill its critically important functions can be clearly demonstrated. The second assertion has to do with life-style and our major diseases, and the unlikelihood of change:That our current major diseases are stubborn because of their embedment in our life-style seemed indeed to be the case throughout the 1960’s, but this perception has now been overtaken by events. Culture-linked as our current diseases may be, they are yielding to something. Indeed the pattern has shown remarkable change. Since the early 1970s there have been highly significant reductions in infant mortality in the U.S. and in the death rates from such major killers as heart disease and stroke [3]. Significant falls, but of a lesser extent, have occurred in virtually all major causes of deaths. With cancer, the death rate for those over 55 years of age has increased, but in the younger age groups it has shown some decrease. These exciting results cannot be attributed directly to any one of the three major health
Volume 65
HEALTH IMPACT OF THE PHYSICIAN--MCDERMOTT
forces (the encounter system; public health including health education; or the material culture). It seems probable that all three have contributed. But clearly the results provide no support at all for the idea that the nature of today’s diseases is such that unless we drastically change our approaches things are doomed to remain at a standstill.
If our long traditional physician system becomes downgraded by our society, it is not apt to come because the system is not highly effective, but because it is either organized in such a way that it is not uniformly accessible, or its expense has become unbearable. These are the two issues that demand our immediate attention.
REFERENCES 1. 2.
3.
ElellocNB, Breslow L: Relationship of physical health status and health practices. Prev Med 1: 409, 1972. McKeown T: Historical perspective on science and health. Presented at annual meeting of Institutes of Medicine, National Academy of Science, Washington, DC, October 1976. McDermott W: Medicine: the public good and one’s own. Per-
4.
5.
October 1976
spect Biol Med (in press). McDermott W: General medical care. identification and analysis of alternative approaches. The Johns Hopkins Med J 135: 292, 1974. McDermott W: Evaluating the physician and his technology. Daedalus, Winter 1977.
The American Journal of Medicine
Volume 65
571
