Education
THE CHANGING FACE OF MEDICINE ADOLPH ROSTENBERC, JR., M.D.
, I am pleased, as one who is on the verge of leaving medicine, to talk to you who are entering it. 1 graduated from medical school almost 45 years ago. It was a different world, and the practice of medicine, as a part of the changing world, has become vastly modified. I shall not talk about the tremendous intellectual and technological advances since I graduated, but about the place of medicine in contemporary society and the relationship of the individual physician to his patients.
From the Department of Dermatology, The Abraham Lincoln School of Medicine, University of Illinois, Chicago, Illinois
The Ethic
When 1 graduated from medical school, the prevailing ethic in our society was labeled the Protestant ethic; but at about that time, this attitude of society slowly began to change, and today has metamorphosed into what is labeled the Bureaucratic ethic. The basic difference between the Protestant and the Bureaucratic ethics is that the former emphasizes the rights of the individual and asserts that these transcend that of the society in which the individual dwells; the latter emphasizes the rights of society and holds that the individual is subservient to the whole. The one glorifies rugged individualism; the other praises belongingness. Presented at the Honors Day Program, University of Illinois, May 8, 1974. Address for reprints: Adolph Rostenberg, Jr., M.D., Department of Dermatology, Abraham Lincoln School of Medicine, Chicago, IL 60612.
41
Modern medicine developed under the spirit of the Protestant ethic. The individual physician was lauded for the rugged individualism he displayed. Today, he is a lonely island of individualism in a sea of bureaucratic controls and, just as the sea continuously and inexorably eats away land, so too our society is eroding and destroying the ability of the individual to be an individual. I am not passing any judgments on this, nor do I believe that the words "right" or "wrong" apply. What I am saying is that these are facts and that the medical community, as a relatively small segment of the overall society, cannot behave in a fashion different from the society of which it is a part. In the 197O's Professional Standards Review Organizations or PSRO's became the law of the land, and we hear more and more about peer review. It has interested me to speculate as to why at this time the public is clamoring for peer review of physicians. Why does the public have less trust and confidence in physicians than it formerly had? I think there are four main reasons for this: (1) the increasing bureaucratization of society, (2) the vastly increased cost of medical care, (3) third party payments, and (4) the weakening of the patient-doctor relationship.
42
INTERNATIONAL JOURNAL OF DERMATOLOCY Jan./Feb. 1975
' I will not have time to discuss these individual factors in any detail. I have already touched on the first reason, which is the changing attitude of society. Reasons 2 and 3, namely, the increased cost of medical care and the effect of third party payers, are more or less self-explanatory, and I shall not discuss them further. The Patient-Doctor Relationship
I would like to say a few words about the fourth reason, namely, the weakening of the patient-doctor relationship. Unfortunately, this seems to be an inevitable concomitant of medical progress. The vast increase in knowledge has promoted an extreme degree of specialization. Consequently, a patient is now treated by many physicians, and it is much more difficult for him to develop rapport with any given one. He feels, and with some justice, that he is treated as a hospital number or as a medical problem, but not as a human being. In a sense, all of this was adumbrated thousands of years ago. In the Book of Ecclesiastes it says, "For in much wisdom is much grief and he that increaseth knowledge increases sorrow." I have no simple solution for this problem, but I am convinced that the physician will never regain the position or role he had in our society until he is able to coat his knowledge and skills with humanity so that the patient feels he is being treated as an individual human being. Finally, I want to discuss another aspect of the physician-patient relationship that is going to have to change. In the past the physician has been in the position of a benevolent despot. He examined the patient, he assessed the nature of the trouble and then determined the course of action, or in other words, the therapy. In general, the patient was not consulted, but rather was told what he
Vol. 14
was to do. This means that the physi-l cian played a dual role, namely, as information provider and decision maker. For many reasons I am becoming increasingly convinced that the physician is going to have to abrogate the role of decision maker. Time will not permit me to go into all the reasons, but one of the main ones is the development of drugs which have an inherent toxicity and the increase in their use for relatively benign conditions. Let me give an example from my own specialty. Consider the use of a drug such as methotrexate for a disease such as psoriasis. Here, one has the combination of a relatively dangerous drug for a disease that is rarely fatal. The problem is how and when a physician should use such a drug for such a condition. :} Let me put the problem more dramatically, even at the risk of oversimplifying and overstating it. Divide all diseases into two categories, namely, life-threatening and nonlife-threatening and similarly divide all drugs into life-threatening and nonlife-threatening. We then have a four-cell table. With three of the cells there is no problem. Only one cell, the use of life-threatening drugs for nonlife threatening diseases, gives us concern. How shall we handle such drugs in such situations? Let me be quite clear about the difference between what I have labeled lifethreatening drugs and the conventional drugs we have used. Obviously, with drugs such as morphine or digitalis, or for that matter almost any drug one would care to name, fatalities could result, but these would be due either to gross negligence on the part of the physician, or to unpredictable allergic reactions which on occasion were fatal. In general, with an appropriate dose of a given medication, there was no particular reason to believe that any untoward con-
No. 1
CHANCINC FACE OF MEDICINE • Rostenberg
sequences would develop. On the other hand, with drugs such as methotrexate and new ones that surely will be synthesized, we have agents that affect some of the fundamental processes of the body, such as DNA replication. While these drugs are administered to affect certain rapidly producing cells, they nevertheless affect all cells to some degree. Consequently, there is an inherent, unavoidable danger in their use. When these are used for conditions such as acute leukemia or choriocarcinoma, they are being used in desperate situations, and no one worries too much about the possible hazards of the drug itself. However, when they are used for relatively benign conditions, it is necessary to reevaluate under what circumstances they should be used.
Possible Solutions There are various possible solutions, but before discussing these I should like to state that I have had much to do with drug development and safety both from the point of view of the government and that of pharmaceutical houses. I mention this because 1 want you to know that my views are not purely theoretical but based on a considerable personal experience. The first possibility is that so-called life-threatening drugs not be used for nonlife-threatening conditions. 1 think this possibility is both incorrect and unrealistic. First, it is unrealistic, for if a drug exists for treating some condition— say, methotrexate for acute leukemia— and physicians believe it will help in psoriasis, they will use it. 1 believe this solution is also wrong because if a drug is valuable for a given condition and needed, the patient is entitled to have an opportunity to be benefited by that drug.
43
The second possibility is that physicians prescribe these drugs in the same fashion as they do the older, more conventional ones; that is, just order the drug for the patient as they would any other drug. If a reaction develops, that is unfortunate, but that's the way the ball bounces. Such an attitude would lead to disastrous results, both for the public and the physician. First of all, if drugs of this kind were used promiscuously, so many reactions would develop that malpractice insurance rates would become so enormous that most physicians would not be able to afford it or, more likely, companies would not underwrite malpractice insurance at ail. The second consequence would be that the image of the physician, which, as 1 stated earlier, is being eroded, would be more seriously undermined. The public would have little confidence in and much fear concerning the safety of anything that was prescribed for them. Finally, 1 am convinced that if such drugs were to be handled in this way, the Food and Drug Administration would step in as therapeutic dictators and decree which drugs could be used for which conditions. As a consequence, the only way a physician could legally prescribe such drugs would be via a set of rules elaborated in Washington, D. C. Needless to say, this would be a dreary and inefficient way to practice medicine. This then brings me to what I am convinced is the only possible solution, namely, the patient is going to have to make the decision. Before such drugs are prescribed, the physician will have to spell out what benefits might accrue from their use and what the hazards are. This will have to be spelled out in plain, simple, ambiguous language, so that there is no doubt that the patient understands it. It will then be the patient's decision whether he wishes the drug
44
INTERNATIONAL JOURNAL OF DERMATOLOCY Jan./Feb. 1975
used or not. In the final analysis it is his disease, his body and his life, and it will have to be his decision. To many of you the changes that I have described will seem quite normal and possibly laudable. To one such as I there is a nostalgia for the past, but I worry about nostalgia, as it had been defined as "the rose-scented goose grease on the toboggan slide to senility." On the other hand, today's attitude has
Vol. 14
much to commend it. This was beautifully expressed by John Donne five or six hundred years ago when he said: "No man is an island entire of itself. Every man is a piece ot the continent, a part of the main; if a clod be washed away by the sea Europe is the less as well as if a promontory were, as well as if a manor of thy friends or thine own were. Any man's death diminishes me because / am involved in mankind; and therefore never send to know for whom the bell tolls—it tolls for thee."
SELF-ASSESSMENT MINI-PROGRAM LAMAR S. OSMENT, M.D. From tbe Division ol Dermatology, Medical College of the University of Alabama, Birmingham, Alabatria
On admission to the hospital, a 20year-old woman said that for 2 weeks she had experienced daily fever and chills. Her left wrist had become very tender, warm and swollen. Aching muscles, headache and malaise were associated complaints. Pulmonary, abdominal, and genitourinary complaints were denied. The day before admission, tender skin lesions appeared predominantly on the face and extremities. Physical examination revealed a less than acutely ill patient with a temperature of 102.5° F. (39.2° C). Sparse small pustules were noted on the forearms and legs. The palms, toes, and fingers were the sites of purpuric macules undergoing early mild ulceration. The white blood cell count was 11,800/cu. cm. with 65% neutrophils. The packed cell volume was 39%. The C-reactive protein test was positive. Normal lab reports included: urinalysis. blood urea nitrogen, alkaline phospha-
tase, fasting and 2-hour post-prandial blood glucose, latex fixation, antinuclear antibodies, bilirubin, serum protein elec-
THE CHANGING FACE OF MEDICINE ADOLPH ROSTENBERC, JR., M.D.
, I am pleased, as one who is on the verge of leaving medicine, to talk to you who are entering it. 1 graduated from medical school almost 45 years ago. It was a different world, and the practice of medicine, as a part of the changing world, has become vastly modified. I shall not talk about the tremendous intellectual and technological advances since I graduated, but about the place of medicine in contemporary society and the relationship of the individual physician to his patients.
From the Department of Dermatology, The Abraham Lincoln School of Medicine, University of Illinois, Chicago, Illinois
The Ethic
When 1 graduated from medical school, the prevailing ethic in our society was labeled the Protestant ethic; but at about that time, this attitude of society slowly began to change, and today has metamorphosed into what is labeled the Bureaucratic ethic. The basic difference between the Protestant and the Bureaucratic ethics is that the former emphasizes the rights of the individual and asserts that these transcend that of the society in which the individual dwells; the latter emphasizes the rights of society and holds that the individual is subservient to the whole. The one glorifies rugged individualism; the other praises belongingness. Presented at the Honors Day Program, University of Illinois, May 8, 1974. Address for reprints: Adolph Rostenberg, Jr., M.D., Department of Dermatology, Abraham Lincoln School of Medicine, Chicago, IL 60612.
41
Modern medicine developed under the spirit of the Protestant ethic. The individual physician was lauded for the rugged individualism he displayed. Today, he is a lonely island of individualism in a sea of bureaucratic controls and, just as the sea continuously and inexorably eats away land, so too our society is eroding and destroying the ability of the individual to be an individual. I am not passing any judgments on this, nor do I believe that the words "right" or "wrong" apply. What I am saying is that these are facts and that the medical community, as a relatively small segment of the overall society, cannot behave in a fashion different from the society of which it is a part. In the 197O's Professional Standards Review Organizations or PSRO's became the law of the land, and we hear more and more about peer review. It has interested me to speculate as to why at this time the public is clamoring for peer review of physicians. Why does the public have less trust and confidence in physicians than it formerly had? I think there are four main reasons for this: (1) the increasing bureaucratization of society, (2) the vastly increased cost of medical care, (3) third party payments, and (4) the weakening of the patient-doctor relationship.
42
INTERNATIONAL JOURNAL OF DERMATOLOCY Jan./Feb. 1975
' I will not have time to discuss these individual factors in any detail. I have already touched on the first reason, which is the changing attitude of society. Reasons 2 and 3, namely, the increased cost of medical care and the effect of third party payers, are more or less self-explanatory, and I shall not discuss them further. The Patient-Doctor Relationship
I would like to say a few words about the fourth reason, namely, the weakening of the patient-doctor relationship. Unfortunately, this seems to be an inevitable concomitant of medical progress. The vast increase in knowledge has promoted an extreme degree of specialization. Consequently, a patient is now treated by many physicians, and it is much more difficult for him to develop rapport with any given one. He feels, and with some justice, that he is treated as a hospital number or as a medical problem, but not as a human being. In a sense, all of this was adumbrated thousands of years ago. In the Book of Ecclesiastes it says, "For in much wisdom is much grief and he that increaseth knowledge increases sorrow." I have no simple solution for this problem, but I am convinced that the physician will never regain the position or role he had in our society until he is able to coat his knowledge and skills with humanity so that the patient feels he is being treated as an individual human being. Finally, I want to discuss another aspect of the physician-patient relationship that is going to have to change. In the past the physician has been in the position of a benevolent despot. He examined the patient, he assessed the nature of the trouble and then determined the course of action, or in other words, the therapy. In general, the patient was not consulted, but rather was told what he
Vol. 14
was to do. This means that the physi-l cian played a dual role, namely, as information provider and decision maker. For many reasons I am becoming increasingly convinced that the physician is going to have to abrogate the role of decision maker. Time will not permit me to go into all the reasons, but one of the main ones is the development of drugs which have an inherent toxicity and the increase in their use for relatively benign conditions. Let me give an example from my own specialty. Consider the use of a drug such as methotrexate for a disease such as psoriasis. Here, one has the combination of a relatively dangerous drug for a disease that is rarely fatal. The problem is how and when a physician should use such a drug for such a condition. :} Let me put the problem more dramatically, even at the risk of oversimplifying and overstating it. Divide all diseases into two categories, namely, life-threatening and nonlife-threatening and similarly divide all drugs into life-threatening and nonlife-threatening. We then have a four-cell table. With three of the cells there is no problem. Only one cell, the use of life-threatening drugs for nonlife threatening diseases, gives us concern. How shall we handle such drugs in such situations? Let me be quite clear about the difference between what I have labeled lifethreatening drugs and the conventional drugs we have used. Obviously, with drugs such as morphine or digitalis, or for that matter almost any drug one would care to name, fatalities could result, but these would be due either to gross negligence on the part of the physician, or to unpredictable allergic reactions which on occasion were fatal. In general, with an appropriate dose of a given medication, there was no particular reason to believe that any untoward con-
No. 1
CHANCINC FACE OF MEDICINE • Rostenberg
sequences would develop. On the other hand, with drugs such as methotrexate and new ones that surely will be synthesized, we have agents that affect some of the fundamental processes of the body, such as DNA replication. While these drugs are administered to affect certain rapidly producing cells, they nevertheless affect all cells to some degree. Consequently, there is an inherent, unavoidable danger in their use. When these are used for conditions such as acute leukemia or choriocarcinoma, they are being used in desperate situations, and no one worries too much about the possible hazards of the drug itself. However, when they are used for relatively benign conditions, it is necessary to reevaluate under what circumstances they should be used.
Possible Solutions There are various possible solutions, but before discussing these I should like to state that I have had much to do with drug development and safety both from the point of view of the government and that of pharmaceutical houses. I mention this because 1 want you to know that my views are not purely theoretical but based on a considerable personal experience. The first possibility is that so-called life-threatening drugs not be used for nonlife-threatening conditions. 1 think this possibility is both incorrect and unrealistic. First, it is unrealistic, for if a drug exists for treating some condition— say, methotrexate for acute leukemia— and physicians believe it will help in psoriasis, they will use it. 1 believe this solution is also wrong because if a drug is valuable for a given condition and needed, the patient is entitled to have an opportunity to be benefited by that drug.
43
The second possibility is that physicians prescribe these drugs in the same fashion as they do the older, more conventional ones; that is, just order the drug for the patient as they would any other drug. If a reaction develops, that is unfortunate, but that's the way the ball bounces. Such an attitude would lead to disastrous results, both for the public and the physician. First of all, if drugs of this kind were used promiscuously, so many reactions would develop that malpractice insurance rates would become so enormous that most physicians would not be able to afford it or, more likely, companies would not underwrite malpractice insurance at ail. The second consequence would be that the image of the physician, which, as 1 stated earlier, is being eroded, would be more seriously undermined. The public would have little confidence in and much fear concerning the safety of anything that was prescribed for them. Finally, 1 am convinced that if such drugs were to be handled in this way, the Food and Drug Administration would step in as therapeutic dictators and decree which drugs could be used for which conditions. As a consequence, the only way a physician could legally prescribe such drugs would be via a set of rules elaborated in Washington, D. C. Needless to say, this would be a dreary and inefficient way to practice medicine. This then brings me to what I am convinced is the only possible solution, namely, the patient is going to have to make the decision. Before such drugs are prescribed, the physician will have to spell out what benefits might accrue from their use and what the hazards are. This will have to be spelled out in plain, simple, ambiguous language, so that there is no doubt that the patient understands it. It will then be the patient's decision whether he wishes the drug
44
INTERNATIONAL JOURNAL OF DERMATOLOCY Jan./Feb. 1975
used or not. In the final analysis it is his disease, his body and his life, and it will have to be his decision. To many of you the changes that I have described will seem quite normal and possibly laudable. To one such as I there is a nostalgia for the past, but I worry about nostalgia, as it had been defined as "the rose-scented goose grease on the toboggan slide to senility." On the other hand, today's attitude has
Vol. 14
much to commend it. This was beautifully expressed by John Donne five or six hundred years ago when he said: "No man is an island entire of itself. Every man is a piece ot the continent, a part of the main; if a clod be washed away by the sea Europe is the less as well as if a promontory were, as well as if a manor of thy friends or thine own were. Any man's death diminishes me because / am involved in mankind; and therefore never send to know for whom the bell tolls—it tolls for thee."
SELF-ASSESSMENT MINI-PROGRAM LAMAR S. OSMENT, M.D. From tbe Division ol Dermatology, Medical College of the University of Alabama, Birmingham, Alabatria
On admission to the hospital, a 20year-old woman said that for 2 weeks she had experienced daily fever and chills. Her left wrist had become very tender, warm and swollen. Aching muscles, headache and malaise were associated complaints. Pulmonary, abdominal, and genitourinary complaints were denied. The day before admission, tender skin lesions appeared predominantly on the face and extremities. Physical examination revealed a less than acutely ill patient with a temperature of 102.5° F. (39.2° C). Sparse small pustules were noted on the forearms and legs. The palms, toes, and fingers were the sites of purpuric macules undergoing early mild ulceration. The white blood cell count was 11,800/cu. cm. with 65% neutrophils. The packed cell volume was 39%. The C-reactive protein test was positive. Normal lab reports included: urinalysis. blood urea nitrogen, alkaline phospha-
tase, fasting and 2-hour post-prandial blood glucose, latex fixation, antinuclear antibodies, bilirubin, serum protein elec-
