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MORNING PANEL DISCUSSION* HARRY M. ZIMMERMAN, M. D., Moderator Consultant, Department of Pathology Montefiore Hospital Medical Center Bronx, N.Y.
EDWARD B. HARVEY, Ph.D., ROBERT J. WEISS, M.D., CHARLES M. PLOTZ, M.D., AND HERBERT BERGER, M.D. DR. HARRY M. ZIMMERMAN. I shall start off this discussion by asking the panelists in turn for any comments they may have; then I shall ask for questions from the audience. Dr. Harvey, you have been challenged in part by Dr. Weiss. Do you want to respond to the statement he made? The question that I am especially interested in having you respond to, one Dr. Weiss raised, was whether the experience in Canada is totally applicable to the problems we face in the United States. DR. EDWARD B. HARVEY. That is a difficult question to answer. Some aspects would be more applicable than others. I believe that rational planning to meet manpower requirements is one effective way to get a handle on the complexities and uncertainties we now face. I would like to ask Dr. Weiss to reformulate his contention so that we might enter into dialogue about the specific substantive differences as opposed to more formal differences. DR. ROBERT J. WEISS. I do not have the data at hand, but my last recollections in relation to the Canadian data did not show the clear exodus out of the cities, both the urban centers and inner cities, experienced in the United States. This country faces a special kind of problem in relation to the inner cities, their characteristics, and the exodus from practice. I do not believe this is true of Canada to the same degree; I believe that Canadian practice and the distribution of physicians in the inner cities differs from what we have in the United States. This is not a point of disagreement, but rather of explication. Unless Dr. Harvey disagrees with me, I do not think we would find the same numbers *Presented as part of a Symposium on the Medical School and Its Surrounding Community held by the Committee on Medical Education of the New York Academy of Medicine October 14, 1976.
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in the juxtaposition that he offered with regard to people in community practice in the United States. DR. HARVEY. I believe you are right. One has to bear in mind that the situation in the inner cities of Canada is somewhat different; in fact, it is the reverse of the United States in many instances. Our inner-city areas often are regarded as highly desirable places to live. Hence, the kind of outward migration from the cities you talk about does not happen. Our problems are getting adequate medical services to small communities, particularly in the northern and remote areas. Another problem we are beginning to face is that some larger communities, such as those with between 50,000 and 80,000 residents, are beginning to encounter shortages as physicians move out of these communities to the more heavily populated centers. I attribute this in some measure to medical school policies and priorities which I think distort in some degree what our priorities should really be. More emphasis must be placed upon accessibility and continuity of primary care. The manpower movement that I refer to is serious, but it is not specifically the kind of migration from inner cities that Dr. Weiss mentions. I strongly agree with Dr. Weiss' well-taken points about the difficulty of trying to deliver continuous horizontal care in vertical structures. It behooves us to look more critically and imaginatively at our organizations, to see whether we could do a better job, to see if, by putting more of medical education into a broader range of settings, we could not begin to lessen the division between the educator and the practitioner which all three of us have been discussing in different ways. DR. CHARLES M. PLOTZ. Dr. Harvey said that they are training more doctors than they probably need in Canada. I wonder if, as opportunities for doctors in the urban areas become financially less attractive, simply because there is more competition, whether physicians will be attracted to more remote areas where they would have a better chance to make a living. It has been my experience, at least in our area of New York, which is certainly special, that people are reluctant to accept anything less than a fully trained physician to provide their medical care. DR. HARVEY. One of my chief concerns is the issue of time lag. If a community has not had a physician for the last five years, I prefer a somewhat more humane approach to those problems than waiting for the laws of economics ultimately to rearrange the system. We should do something in the community that will start to meet the needs of that Vol. 53, No. 5, June 1977
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community. I believe that the nurse-practitioner program, although certainly not a total answer, is one step in that direction. I also think that there is an increasing role for the medically trained social worker. In addition, I wonder whether physicians who are forced for economic reasons into areas where they do not wish to practice are going to give their best service or whether the service may be delivered grudgingly. I am aware that economic principles are important as carrots and sticks, but I am concerned when our policy uses sticks only. On the question of public acceptance, I must reemphasize that in some communities where there has been a paucity of service the people would be delighted to have almost anyone who could help them with their medical and associated problems. DR. WEISS. I would like to reinforce Dr. Harvey's point about the position of the nurse-practitioner in a community which has not had a physician. I do not know how many of you know of Dr. Robert O'Season's experiment in New Mexico. This experiment took place in a community some 45 miles from Albuquerque, N.M., which had had a physician for many years. In that community the physician brought up his family. His son became an obstetrician and gynecologist and wanted to practice in Albuquerque. For many years the community was without a physician. It used funds from the Sears Roebuck Foundation to attract a physician who left after a year because his wife did not like the community (the most usual reason physicians give for leaving small communities). The community then went for many years with a facility but without a physician. Finally, Dr. O'Season-who is now in Canada at McGill University and who was then at the University of New Mexico as chairman of the Department of Community Medicine-decided to train a nurse-practitioner as a primary-care provider for that community. The community was asked to select the person to be trained. A mother of five children who had been a nurse for many years prior to moving to this community was selected. Dr. O' Season enrolled the nurse at the University of New Mexico School of Medicine for training. But the faculty was very upset about what she was going to do. Dr. O'Season asked the surgeons to train her to do simple sutures on simple lacerations-a very common problem with children in the country. They said something like "My God no! That's a job for a surgeon!" Dr. O'Season asked what they thought she should be trained to do. Bull. N.Y. Acad. Med.
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They said they would like her to be able to diagnose an acute abdomen. Dr. O'Season pointed out that that is one of the most complicated diagnoses to make. It requires years of experience to know what to do about an acute abdomen. Dr. O'Season noted that this woman probably had sewn more stitches-having made the clothes for all her children-than any of the surgeons had in a lifetime, and said he was sure that she could learn to suture. Finally, they agreed to train her to suture simple lacerations. Then he went to the obstetricians and gynecologists and asked them to train her to do simple pelvic examinations and Pap smears. Goodness no, they said, they could not permit a nurse-practitioner to make a pelvic examination. Asked what they wanted to train her to do, they replied that she could do family planning. He then asked how she would be able to do family planning if she were not able to fit a diaphragm and insert an IUD (intrauterine device)? They then agreed that maybe she could be trained to do a pelvic examination, and she was so trained. To make a long story short, she is still practicing in this small community. She is backed up by telephone by an internist and pediatrician and by physicians who come to see some of her patients in consultation where it is appropriate. She sends her acute emergencies to Albuquerque 40 miles away. This supports Dr. Harvey's view that in many rural communities which have no physicians nonmedical people have been accepted and have done rather well. However, I also believe that much of what Dr. Plotz said in terms of family practice has more relevance to rural and small-town problems than to problems of the urban center and the city. Perhaps family practitioners who are in solo practice and distant from specialist backup should have more training rather than less, simply because they are faced with many more complicated situations. One of my first educational programs with general practitioners and family practitioners was in New Hampshire, where we established a closed-circuit, two-way television consultation service with the department of psychiatry of a hospital. This enabled the family practitioners or general practitioners (as they were known back in 1967 and 1968) to handle their own psychiatric patients. They would sit in an adjacent room to watch the interview, which was done at their request by a psychiatrist. We felt quite comfortable in their being able to care for those patients. In Portland, Me., which is not far from rural centers and is not a large city, the Vol. 53, No. 5, June 1977
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departments of family practice in its hospitals are having great difficulty in getting patients to care for. Thus, even in the smaller cities such as Portland, family practitioners are running into a kind of resistance and difficulty that is not unusual. I think this is much less likely in the smaller towns-those with 15,000 population and less. It is a real problem, and I do not think it can be solved quickly. I am not deciding whether these departments should or should not get patients. I am merely pointing out the existing situation, which makes for complications. That is why I posed a different model for the urban setting. DR. PLOTZ. I wish to point out that Dr. Weiss' experience has been mainly in medical schools which lack departments of family practice. Dr. Weiss mentioned that family doctors in Portland are having difficulty finding patients. I have not found that to be a problem throughout the United States, and I probably have met more family doctors and know more about what is going on in the nation from their point of view than perhaps anyone here-with the possible exception of Dr. Endicott. Family doctors are begging for help. Hardly a day goes by that I do not get a dozen requests from groups throughout the country asking for my residents because they need help. I really do not believe that family doctors need more patients. One of the problems in this country is not too few doctors, but too many patients. DR. ZIMMERMAN. Dr. Plotz, what is your definition of family practice? DR. PLOTZ. The questions "What is family practice?" "What is primary care?" "What is family medicine?" all mean different things to different people. I have not prepared a concise definition but I consider family practice to be horizontal, longitudinal care which starts with primary care, but also is concerned with the patient's entire family, his place in the family, and the role of the family in his illness. DR. ZIMMERMAN. Dr. Plotz, another question asks: "What are the inpatient services on which the family-practice residents are trained? Are there any data as to whether any of the residents in family practice secure forgiveness for loans obtained as undergraduates?" DR. PLOTZ. I shall deal with the second half of that question first. I am sure that Dr. Endicott will discuss that topic later in terms of the law which President Ford signed, which has vast implications for the future in regard to this issue. I can answer the first part only as far as our own family-practice residencies are concerned, since each program is slightly different. Ours is Bull. N.Y. Acad. Med.
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a three-year program. In the first year the residents spend seven months on medicine, three months on pediatrics, and one month in the Emergency Room (they get a month's vacation). During this time they spend one afternoon a week in the outpatient family-practice center developing their skills with our patients. In the second year they spend four months on medicine, two months on liaison psychiatry, three months on pediatrics, and two months on either surgery or obstetrics and gynecology, as they choose. At this time they spend two afternoons a week in the family-practice center. The third year they deal entirely with outpatients; their time is divided between the medical, surgical, obstetrics and gynecology, and pediatric departments, plus two months of elective time. During this time they also spend three or more half days a week in the family-practice center. DR. ZIMMERMAN. Dr. Plotz, now that it is fashionable to emphasize primary care, will the medical schools, particularly the departments of medicine, again take over the role of teaching primary care at the expense of the family-practice departments? DR. PLOTZ. I think I implied an answer to that. I hate to say it, but the dollars are in primary care right now, and where the dollars are, there you will find the emphases of academic departments-family practice, medicine, and everything else. Since the money is now going into primary care, you would expect departments of medicine to be going after it, and they are. I do not know how this will affect family practice. My guess is that it will be all to the better. As far as family practice is concerned, we welcome the internists and pediatricians to our ranks. DR. ZIMMERMAN. Dr. Weiss, what strategies or change would you suggest in medical education to bridge the gap between existing group practices in the community and the medical schools? DR. WEISS. I think the major strategy in relation to existing group practices and medical schools will result from the pressure that the hospitals and the urban medical centers are beginning to feel with regard to occupancy rates and filling their beds. I think the second major factor which is going to play a role is the issue of on-site training for residents in ambulatory care if we begin to move out of the hospital. The strategy resulting from these factors would be a quid pro quo arrangement in which group practices begin to offer opportunities to train residents in a special setting. This is not going to be easy to arrange. The zealous guarding of the special prerogatives of departments of internal Vol. 53, No. 5, June 1977
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medicine and, less so, of pediatrics are not easy to breach. It is difficult for the hospitals to begin to see their roles vis-a-vis outside groups, but this is becoming easier. New York has an opportunity which, if seized, could make it the leader in this area of medicine. The adversity in which the city finds itself could be used to push political forces into action. Hospitals are beginning to feel the pressure for such action, and the judicious application of political pressure might prove fruitful. DR. ZIMMERMAN. Dr. Weiss, you have partly answered the next question in what you have said. How will community-health and ambulatory care centers provide important medical education? Will those who work in the centers be trained as teachers, or do you propose apprenticeship training? DR. WEISS. For many years the major burden of clinical teaching was carried by practicing physicians in most major medical schools. Indeed, even today it is unusual not to have a large amount of teaching done by people who live nearby and work full time or who are in private practice within the medical center. This is a false issue to me; I do not see it as a major problem. Medical education is expensive, and I am not sure how that cost will be borne for medical students studying community medicine. If you look at the medical school course contents, the common aspects of primary care are taught in almost all specialty departments. It is rare that the department of obstetrics and gynecology does not deal with vaginitis. Just the importance they give it, the way they treat the patient, and the way they view the patient make it different. The same material will be taught, but it is difficult and expensive to have medical students in this setting. Let me give you one example of the use of health centers for education and the support of physicians. (I am sure that Dr. Endicott is familiar with this example.) In Seattle the Group Health Cooperative of Puget Sound, a prepaid plan, has decentralized a great deal, in terms of limiting its centers to a maximum of 15,000 people and using smaller groups of physicians. They tend to use primary practitioners in many of these outlying centers. They started a family-practice residency-a cooperative in which a medical group negotiates the capitation with the cooperative, which is run by a board. The physicians operate their own practice, and the cooperative operates the plan. It is a rapidly growing, very successful prepaid practice. The system for the payment of residents in family practice provided that in the first year Bull. N.Y. Acad. Med.
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the cooperative paid the total stipend for the resident; in the second year the medical group and the cooperative split the stipend; and in the third year the medical group pays the entire stipend because the residents by that time had increased their productivity to the point of earning it. There has been some talk about the financing of postgraduate medical education on the basis of physicians paying some portion of the cost. The Mayo Clinic has supported postgraduate medical education in that manner for a long time. In Hanover, N.H., the Hitchcock Clinic has paid its residents stipends all the way along. This practicing multispecialty group in Seattle has paid the resident's stipend. The federal government and the Congress have had some questions about the financing of postgraduate medical education. It is a very complicated problem. I do not have all the answers, and I do not think that what is applicable in the Mayo and Hitchcock clinics is necessarily applicable here. But I believe that arrangements can be worked out to provide this kind of education in primary care. DR. PLOTZ. As Dr. Zimmerman knows, two years ago I had a World Health Organization fellowship to examine a new medical school in Israel that is basing its entire curriculum on primary care, namely, Soroka Medical Center in Beersheba. Dr. Prywes, the dean, has tried hard to emphasize primary care in medical education. The results of that experiment are going to be watched with great interest by many people. DR. ZIMMERMAN. Dr. Harvey, in your endorsement of the nursepractitioner, physician assistant, and so forth how do you overcome consumer sensitivity to the issue of malpractice? DR. HARVEY. In Canada malpractice suits simply are not as significant as they are in the United States. Physicians in Canada do not feel that they have to protect themselves at every point against potential malpractice suits. I do not want to imply that Canadians have lower expectations about the standards of health care. I believe, rather, that they are less prone to litigate over it. In communities where adequate health care simply is not available I believe the chief concern in people's minds would be attaining accessibility to someone who could help them with their problems. That would be the primary consideration. If worries over malpractice were present at all, they would be secondary and of much less importance. DR. ZIMMERMAN. Dr. Harvey, do your studies include any educators who spend most of their time and derive most of their income from patient Vol. 53, No. 5, June 1977
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care? And if so, how do they differ from nonaffiliated practitioners or full-time educators in the attitudes you were examining? DR. HARVEY. Canadian medical schools do have a certain proportion of educators who are engaged in practice as well as teaching. Again, I would like to emphasize the great importance we attach to a medical school appointment. It makes one a member of the inner fraternity. It provides opportunities to become engaged in research, to secure research funding, to be consulted by the government, to be involved directly in the policy and planning process. This is far less true for the physician who does not have a medical school appointment. The degree of involvement in a medical school is not as important a question as whether one is involved at all. That is the critical consideration. In our statistical studies we have not yet gone into a detailed analysis of full-time medical educators versus those who also practice in the community to some degree. But it is my impression that the differences among medical educators are far less profound than the differences between medical educators and community practitioners. DR. ZIMMERMAN. Dr. Weiss, is there any economic reason why neighborhood health centers flourish in Boston and not in New York City? DR. WEISS. I suggested that physicians are not motivated wholly by economics. That does not mean that everyone does not like to have a salary and to earn an adequate income. But I can hire physicians in Boston to work in primary care for a good deal less money than in New York, partly because of what they see there as other than financial benefits. Boston is a preferred community, where they enjoy living. New York has attained a reputation in terms of people coming to the city to practice, which I do not think is based on economics. As a matter of fact, physicians are exploited in Boston's neighborhood health centers, badly exploited. They are paid an hourly wage for which we could not employ a physician in New York. They have no fringe benefits or long-term security. They do it because they are dedicated, but most physicians stay only a short time. In Boston I tried to get the physicians in the neighborhood health centers to incorporate themselves into a group to get some bargaining power. This was primarily related to obtaining admitting privileges to care for their patients in the city hospital. When Boston City Hospital was taken over by Boston University, and Tufts University and Harvard University were pushed out to make it more economical for the hospital (it did not do so, Bull. N.Y. Acad. Med.
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but it was supposed to), there was one service, and Boston University had that service. I met with the health-center physicians and urged them to incorporate so that they could bargain more effectively with the chief of the service at Boston City Hospital, but they refused. Boston University refused them admitting privileges because the chief of the service used the fees to pay full-time faculty members; thus, he was keeping neighborhood health center physicians from caring for their own patients. It is a complex situation. I do not think it is basically a matter of economics. DR. ZIMMERMAN. Dr. Plotz, are there any data available about the tendency for family-practice graduates to move later into the specialties or
superspecialties? DR. PLOTZ. There are not enough data yet to draw a conclusion about such things. I expect that most physicians have known an occasional graduate of a family-practice residency program to become entranced with one or another specialty. We had one who went into ophthalmology, and he will make a wonderful ophthalmologist. I believe that the drop-out rate is low thus far. Only the next 10 years or so will tell whether it will be significant, but I am inclined to doubt that it will. As the graduates get into family practice, they become attached to their patients and communities. I once asked the ambassador of a developing Asian nation how they solve the problem of getting doctors into the rural areas. He said it was very simple. Doctors are taken into the army for five years after finishing their training. They are assigned to various rural areas where their army duties occupy them from 9 to 12 in the morning; afternoons they are free to moonlight. They all set up practices in the communities because they are paid little. After five years, he told me, you would be amazed at how many of them stay. That is how that country solved its problem. DR. HERBERT BERGER. The title of this program was The Medical School and Its Surrounding Community, but the three panelists-whom I found interesting-have discussed this subject rather circumferentially. It has been usual for us to look upon the medical school as a threelegged stool-one leg being the training of physicians, the second, community service or patient care, and the third, research. I believe that this is an erroneous concept. The primary purpose of a medical school is to train physicians. The rest of its functions are secondary. Dr. Weiss pointed out that only one third of patients with symptoms applied for medical care. As Vol. 53, No. 5, June 1977
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a member of the Royal Society of Health in England, I have had the opportunity to observe there that where medical care is completely free similar figures obtain. It is not only an economic problem that keeps people from going to doctors. This situation is particularly characteristic of underprivileged areas such as Lime House and the dock areas in Liverpool. It is interesting to note that in England, when the British United Provident Association (a Blue Cross/Blue Shield type of organization) was established, this group enrolled two million people in the first year. This indicates that access to free care is not necessarily desired by the population as a whole. Those two million people were already paying dearly for medical care through taxes. Dr. Weiss has rightly indicated that there is inadequate care of patients with functional complaints in our medical-care system. This is particularly true because we have failed to cover these illnesses in our insurance plans. Some years ago I surveyed 1,000 consecutive consultations in internal medicine and, as I recall, I reported in the medical literature that 762 of them were for completely functional complaints. I have been called to task by the Medicare authorities in this city for caring for such people, since they must be seen at frequent intervals to manage their problems. Medicare claims that this really is not the practice of internal medicine. Someone must take the government to task, because the kind of thing we are accused of most-not giving our hearts, souls, compassion, and generosity to patients-is exactly what this care provides. The government, on one hand, tells us that we do not do this properly and, on the other hand, refuses to pay for this very time-consuming activity. Dr. Harvey mentioned the use of the nurse-practitioner or various paramedicals. Like Dr. Plotz, I have had the opportunity to study medical care in a large part of the world. Twice I visited Siberia and Mongolia, where they have the feldsher-a sort of nurse-practitioner. This is not a good source of treatment, primarily because the best skills should be available at the front line. I do not believe we should place individuals in rural areas who are not the most highly trained persons we have. We ought to be training our very best people, as Dr. Plotz is trying to do, to work where the first diagnosis must be made. Dr. Plotz already has been asked, "What happens to residents in family practice over the years? Do they stay in family practice?" If this program
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is supposed to provide medical care for the community in Brooklyn, I understand that it probably has not done so. Dr. Plotz, I have heard that only a few of your residents actually have stayed in Brooklyn, and that most of them have moved to other pastures. Is this correct? DR. PLOTZ. My residency-training program so far has graduated three residents, two of whom are in Brooklyn. DR. BERGER. I am glad to hear that. Since I have been complaining, perhaps I should suggest some remedies. Most physicians my age were trained by clinical teachers who practiced medicine. I think that the medical art, which has been mentioned several times by Dr. Harvey and Dr. Weiss, can best be taught by an actual practitioner rather than by a full-time academic person. With regard to insurance, it is imperative that we cover treatment costs of all kinds of illness, including the neurotic ones, with insurance-keeping in mind that there is a neurotic component to every illness. I cannot emphasize this too strongly. The man who has had a myocardial infarction certainly has an organic illness, but, more important, now he also has the threat of imminent death hanging over him for the rest of his life. This needs to be treated with the greatest skill; I assure you that it requires much more skill than simply giving him some anticoagulants in an intensive care unit. As an answer to the entire problem of providing community care, we need to reestablish compulsory rotating internships. When this is done, and when the boards and the various specialties demand that such training include some years in family practice, preceeding preparation for a specialty (a suggestion which is never greeted with any enthusiasm, but which I am sure has value), we would accomplish two things. First, it would teach our young physicians how to treat patients rather than diseases. We have to emphasize this repeatedly; this is really our job. Second, these physicians would get opportunities to determine their aptitudes and interests. Having made a mistake in this area myself, I am keenly aware of this need. I come from a family of surgeons, and was originally trained in surgery. After eight years of a sort of combination of general and surgical practice, I decided to become an internist and had to be retrained. My experience was not a bad one; it was very useful to me. With this type of program we shall eventually train much better specialists. For example, Dr. Plotz said that one of his students is going into ophthalmology. He will be a much better ophthamologist because he will
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know how to treat the whole person. The vast majority of people trained in this fashion probably will recognize the enormous challenge of family practice and probably will respond to it and stay in family practice. DR. ZIMMERMAN. Dr. Harvey, would you like to respond to any of Dr. Berger's statements? DR. HARVEY. I am certainly not unsympathetic to the point made by Dr. Berger, that it is desirable to try to put our best people on the front line. But what if we cannot do so? The weight of empirical evidence, at least in Canada, indicates that we are so far from realizing that aspiration that we had best explore vigorously effective interim measures. I am not convinced from my research that the feldsher program in other countries and the nurse-practitioner program developed in Canada are precisely comparable. There are ways of reinforcing the diagnostic capabilities of the nursepractitioner or, for that matter, the family practitioner who serves in a remote area without adequate backup facilities. I am thinking of methods that, perhaps, sound futuristic, such as computer-diagnosis linkups, but nonetheless these methods are becoming more feasible with advances in telecommunications. Many people I have talked with who are involved in health-delivery policy and planning seem to think that this is increasingly coming within the realm of reality. I would also note that academic family physicians are not necessarily regarded as the best people within the academic community. We have found that, despite the development of family-physician programs within our medical schools, the medical schools still remain very segmented. There is a good deal of invidious comparison among and between specialties. Dr. Plotz indicated that there was little or no danger of attrition from family practice. In Canada one of the underlying considerations in the development of family-practice programs was to provide a primary practitioner who would be knowledgeable about a wide range of health problems in a broad social and family context. It also was felt that by providing a more viable career line through family practice it would prove possible to stem some of the very serious attrition from general practice that we were witnessing in Canada. I am sorry to say that the results are somewhat disappointing. In some interviews with family practitioners we found complaints about income, conditions of practice, feelings of exclusion, being low man on the totem pole, and so on. I do not know why some of the matters I have commented on today should seem to differ from the experience in the United States. Perhaps it Bull. N.Y. Acad. Med.
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is because Canada is a more elitist society. Physicians are an elite within an elitist society and therefore may be particularly conscious of these distinctions. Also, our society may be difficult to decentralize for a number of reasons. Away from the narrow, urbanized strip along the American border, a physician finds that he has to do without a great many things, both as a scientist and as a person with urban tastes. As long as we cultivate certain values and expectations of a personal, social, and scientific character within the setting of the medical school, it will remain difficult indeed to realize the goal (laudable as it is) of putting our best people on the front line. DR. WEISS. I have to agree with Dr. Berger. I have always believed that the place for the most skilled and most experienced physician was where the first judgment has to be made. Once diagnosis and a management scheme have been made, the treatment for most conditions can be given by a lesser physician. We have never followed that plan; in most of our hospitals we put our interns in the emergency rooms. During 10 years at Dartmouth Medical School as chairman of the Department of Psychiatry, which grew quite large, I always insisted that a senior staff member be on call, and that no resident could make a disposition of hospitalization or send a patient out without the staff member on call seeing the patient. I kept myself on call during those 10 years, and came in to see patients at 2 and 4 in the morning. I found it one of the most rewarding and exciting times to teach. It is a little bit easier to do this in New Hampshire than in New York. I also agree with Dr. Berger that the role of the medical school is to train physicians. Medical school faculties do not believe this in general. Harvard Medical School turns 85% of its graduates into practice when they leave; I asked its faculty the question: "If you really are training research scientists, what's wrong? Either you are picking the wrong people or you are doing a bad job, because you are only successful with 15% out of the whole class." In reality, medical schools are not training medical scientists; they are training physicians. Some of the graduates happen to choose to become medical scientists. Indeed, unless the faculty recognizes that they are training physicians and that most of their students will end up in medical practice, they cannot do a very good job. It really concerns me that very bad medicine can be practiced by the best institutions, as you can see if you walk into the clinics. This does not mean that they are graduating bad Vol. 53, No. 5, June 1977
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doctors, but their whole ambience, atmosphere, and value system are contrary to what we see as the ultimate role of the practice of medicine. We have to reestablish a rightful place in the medical school structure for the people who do practice. They have a role to play, a great deal to teach, and a great deal to learn. Another thing bothers me terribly. The structure of medical schools and medical centers has tended to keep our best graduates within the institution for more training. Those that do not make it to the highest level are pushed further and further out of the educational system. The people who need more training most are pushed furthest out; we ought to make the greatest effort to pull them back. We have failed in this responsibility abysmally, almost as badly as France has failed in its system of training by setting up examinations as barriers to moving on to the next level of training. For example, graduates from the Sorbonne take an examination; those who score well receive an internship. After internship another examination is given and those who score best go on to residency. The ones who do the worst on graduation enter practice immediately. Our segregation and pushing people from the medical schools, medical centers, and teaching programs, instead of pulling them in-with graded responsibility if necessary-produces the same result. If we do not assume responsibility for those who do the worst, we have failed as medical educators in a
medically responsible community. DR. PLOTZ. I want to thank Dr. Weiss for so eloquently stating the case for family practice. And I agree with Dr. Harvey that family practitioners should have more of what the godfather calls respect. I think they are getting it. It may be some consolation to him, although it is a source of dismay to me, that of the four schools of the State University of New York which established departments of family practice, two of them-at Buffalo and Stony Brook-imported family practitioners from Canada to head their departments.
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MORNING PANEL DISCUSSION* HARRY M. ZIMMERMAN, M. D., Moderator Consultant, Department of Pathology Montefiore Hospital Medical Center Bronx, N.Y.
EDWARD B. HARVEY, Ph.D., ROBERT J. WEISS, M.D., CHARLES M. PLOTZ, M.D., AND HERBERT BERGER, M.D. DR. HARRY M. ZIMMERMAN. I shall start off this discussion by asking the panelists in turn for any comments they may have; then I shall ask for questions from the audience. Dr. Harvey, you have been challenged in part by Dr. Weiss. Do you want to respond to the statement he made? The question that I am especially interested in having you respond to, one Dr. Weiss raised, was whether the experience in Canada is totally applicable to the problems we face in the United States. DR. EDWARD B. HARVEY. That is a difficult question to answer. Some aspects would be more applicable than others. I believe that rational planning to meet manpower requirements is one effective way to get a handle on the complexities and uncertainties we now face. I would like to ask Dr. Weiss to reformulate his contention so that we might enter into dialogue about the specific substantive differences as opposed to more formal differences. DR. ROBERT J. WEISS. I do not have the data at hand, but my last recollections in relation to the Canadian data did not show the clear exodus out of the cities, both the urban centers and inner cities, experienced in the United States. This country faces a special kind of problem in relation to the inner cities, their characteristics, and the exodus from practice. I do not believe this is true of Canada to the same degree; I believe that Canadian practice and the distribution of physicians in the inner cities differs from what we have in the United States. This is not a point of disagreement, but rather of explication. Unless Dr. Harvey disagrees with me, I do not think we would find the same numbers *Presented as part of a Symposium on the Medical School and Its Surrounding Community held by the Committee on Medical Education of the New York Academy of Medicine October 14, 1976.
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in the juxtaposition that he offered with regard to people in community practice in the United States. DR. HARVEY. I believe you are right. One has to bear in mind that the situation in the inner cities of Canada is somewhat different; in fact, it is the reverse of the United States in many instances. Our inner-city areas often are regarded as highly desirable places to live. Hence, the kind of outward migration from the cities you talk about does not happen. Our problems are getting adequate medical services to small communities, particularly in the northern and remote areas. Another problem we are beginning to face is that some larger communities, such as those with between 50,000 and 80,000 residents, are beginning to encounter shortages as physicians move out of these communities to the more heavily populated centers. I attribute this in some measure to medical school policies and priorities which I think distort in some degree what our priorities should really be. More emphasis must be placed upon accessibility and continuity of primary care. The manpower movement that I refer to is serious, but it is not specifically the kind of migration from inner cities that Dr. Weiss mentions. I strongly agree with Dr. Weiss' well-taken points about the difficulty of trying to deliver continuous horizontal care in vertical structures. It behooves us to look more critically and imaginatively at our organizations, to see whether we could do a better job, to see if, by putting more of medical education into a broader range of settings, we could not begin to lessen the division between the educator and the practitioner which all three of us have been discussing in different ways. DR. CHARLES M. PLOTZ. Dr. Harvey said that they are training more doctors than they probably need in Canada. I wonder if, as opportunities for doctors in the urban areas become financially less attractive, simply because there is more competition, whether physicians will be attracted to more remote areas where they would have a better chance to make a living. It has been my experience, at least in our area of New York, which is certainly special, that people are reluctant to accept anything less than a fully trained physician to provide their medical care. DR. HARVEY. One of my chief concerns is the issue of time lag. If a community has not had a physician for the last five years, I prefer a somewhat more humane approach to those problems than waiting for the laws of economics ultimately to rearrange the system. We should do something in the community that will start to meet the needs of that Vol. 53, No. 5, June 1977
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community. I believe that the nurse-practitioner program, although certainly not a total answer, is one step in that direction. I also think that there is an increasing role for the medically trained social worker. In addition, I wonder whether physicians who are forced for economic reasons into areas where they do not wish to practice are going to give their best service or whether the service may be delivered grudgingly. I am aware that economic principles are important as carrots and sticks, but I am concerned when our policy uses sticks only. On the question of public acceptance, I must reemphasize that in some communities where there has been a paucity of service the people would be delighted to have almost anyone who could help them with their medical and associated problems. DR. WEISS. I would like to reinforce Dr. Harvey's point about the position of the nurse-practitioner in a community which has not had a physician. I do not know how many of you know of Dr. Robert O'Season's experiment in New Mexico. This experiment took place in a community some 45 miles from Albuquerque, N.M., which had had a physician for many years. In that community the physician brought up his family. His son became an obstetrician and gynecologist and wanted to practice in Albuquerque. For many years the community was without a physician. It used funds from the Sears Roebuck Foundation to attract a physician who left after a year because his wife did not like the community (the most usual reason physicians give for leaving small communities). The community then went for many years with a facility but without a physician. Finally, Dr. O'Season-who is now in Canada at McGill University and who was then at the University of New Mexico as chairman of the Department of Community Medicine-decided to train a nurse-practitioner as a primary-care provider for that community. The community was asked to select the person to be trained. A mother of five children who had been a nurse for many years prior to moving to this community was selected. Dr. O' Season enrolled the nurse at the University of New Mexico School of Medicine for training. But the faculty was very upset about what she was going to do. Dr. O'Season asked the surgeons to train her to do simple sutures on simple lacerations-a very common problem with children in the country. They said something like "My God no! That's a job for a surgeon!" Dr. O'Season asked what they thought she should be trained to do. Bull. N.Y. Acad. Med.
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They said they would like her to be able to diagnose an acute abdomen. Dr. O'Season pointed out that that is one of the most complicated diagnoses to make. It requires years of experience to know what to do about an acute abdomen. Dr. O'Season noted that this woman probably had sewn more stitches-having made the clothes for all her children-than any of the surgeons had in a lifetime, and said he was sure that she could learn to suture. Finally, they agreed to train her to suture simple lacerations. Then he went to the obstetricians and gynecologists and asked them to train her to do simple pelvic examinations and Pap smears. Goodness no, they said, they could not permit a nurse-practitioner to make a pelvic examination. Asked what they wanted to train her to do, they replied that she could do family planning. He then asked how she would be able to do family planning if she were not able to fit a diaphragm and insert an IUD (intrauterine device)? They then agreed that maybe she could be trained to do a pelvic examination, and she was so trained. To make a long story short, she is still practicing in this small community. She is backed up by telephone by an internist and pediatrician and by physicians who come to see some of her patients in consultation where it is appropriate. She sends her acute emergencies to Albuquerque 40 miles away. This supports Dr. Harvey's view that in many rural communities which have no physicians nonmedical people have been accepted and have done rather well. However, I also believe that much of what Dr. Plotz said in terms of family practice has more relevance to rural and small-town problems than to problems of the urban center and the city. Perhaps family practitioners who are in solo practice and distant from specialist backup should have more training rather than less, simply because they are faced with many more complicated situations. One of my first educational programs with general practitioners and family practitioners was in New Hampshire, where we established a closed-circuit, two-way television consultation service with the department of psychiatry of a hospital. This enabled the family practitioners or general practitioners (as they were known back in 1967 and 1968) to handle their own psychiatric patients. They would sit in an adjacent room to watch the interview, which was done at their request by a psychiatrist. We felt quite comfortable in their being able to care for those patients. In Portland, Me., which is not far from rural centers and is not a large city, the Vol. 53, No. 5, June 1977
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departments of family practice in its hospitals are having great difficulty in getting patients to care for. Thus, even in the smaller cities such as Portland, family practitioners are running into a kind of resistance and difficulty that is not unusual. I think this is much less likely in the smaller towns-those with 15,000 population and less. It is a real problem, and I do not think it can be solved quickly. I am not deciding whether these departments should or should not get patients. I am merely pointing out the existing situation, which makes for complications. That is why I posed a different model for the urban setting. DR. PLOTZ. I wish to point out that Dr. Weiss' experience has been mainly in medical schools which lack departments of family practice. Dr. Weiss mentioned that family doctors in Portland are having difficulty finding patients. I have not found that to be a problem throughout the United States, and I probably have met more family doctors and know more about what is going on in the nation from their point of view than perhaps anyone here-with the possible exception of Dr. Endicott. Family doctors are begging for help. Hardly a day goes by that I do not get a dozen requests from groups throughout the country asking for my residents because they need help. I really do not believe that family doctors need more patients. One of the problems in this country is not too few doctors, but too many patients. DR. ZIMMERMAN. Dr. Plotz, what is your definition of family practice? DR. PLOTZ. The questions "What is family practice?" "What is primary care?" "What is family medicine?" all mean different things to different people. I have not prepared a concise definition but I consider family practice to be horizontal, longitudinal care which starts with primary care, but also is concerned with the patient's entire family, his place in the family, and the role of the family in his illness. DR. ZIMMERMAN. Dr. Plotz, another question asks: "What are the inpatient services on which the family-practice residents are trained? Are there any data as to whether any of the residents in family practice secure forgiveness for loans obtained as undergraduates?" DR. PLOTZ. I shall deal with the second half of that question first. I am sure that Dr. Endicott will discuss that topic later in terms of the law which President Ford signed, which has vast implications for the future in regard to this issue. I can answer the first part only as far as our own family-practice residencies are concerned, since each program is slightly different. Ours is Bull. N.Y. Acad. Med.
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a three-year program. In the first year the residents spend seven months on medicine, three months on pediatrics, and one month in the Emergency Room (they get a month's vacation). During this time they spend one afternoon a week in the outpatient family-practice center developing their skills with our patients. In the second year they spend four months on medicine, two months on liaison psychiatry, three months on pediatrics, and two months on either surgery or obstetrics and gynecology, as they choose. At this time they spend two afternoons a week in the family-practice center. The third year they deal entirely with outpatients; their time is divided between the medical, surgical, obstetrics and gynecology, and pediatric departments, plus two months of elective time. During this time they also spend three or more half days a week in the family-practice center. DR. ZIMMERMAN. Dr. Plotz, now that it is fashionable to emphasize primary care, will the medical schools, particularly the departments of medicine, again take over the role of teaching primary care at the expense of the family-practice departments? DR. PLOTZ. I think I implied an answer to that. I hate to say it, but the dollars are in primary care right now, and where the dollars are, there you will find the emphases of academic departments-family practice, medicine, and everything else. Since the money is now going into primary care, you would expect departments of medicine to be going after it, and they are. I do not know how this will affect family practice. My guess is that it will be all to the better. As far as family practice is concerned, we welcome the internists and pediatricians to our ranks. DR. ZIMMERMAN. Dr. Weiss, what strategies or change would you suggest in medical education to bridge the gap between existing group practices in the community and the medical schools? DR. WEISS. I think the major strategy in relation to existing group practices and medical schools will result from the pressure that the hospitals and the urban medical centers are beginning to feel with regard to occupancy rates and filling their beds. I think the second major factor which is going to play a role is the issue of on-site training for residents in ambulatory care if we begin to move out of the hospital. The strategy resulting from these factors would be a quid pro quo arrangement in which group practices begin to offer opportunities to train residents in a special setting. This is not going to be easy to arrange. The zealous guarding of the special prerogatives of departments of internal Vol. 53, No. 5, June 1977
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medicine and, less so, of pediatrics are not easy to breach. It is difficult for the hospitals to begin to see their roles vis-a-vis outside groups, but this is becoming easier. New York has an opportunity which, if seized, could make it the leader in this area of medicine. The adversity in which the city finds itself could be used to push political forces into action. Hospitals are beginning to feel the pressure for such action, and the judicious application of political pressure might prove fruitful. DR. ZIMMERMAN. Dr. Weiss, you have partly answered the next question in what you have said. How will community-health and ambulatory care centers provide important medical education? Will those who work in the centers be trained as teachers, or do you propose apprenticeship training? DR. WEISS. For many years the major burden of clinical teaching was carried by practicing physicians in most major medical schools. Indeed, even today it is unusual not to have a large amount of teaching done by people who live nearby and work full time or who are in private practice within the medical center. This is a false issue to me; I do not see it as a major problem. Medical education is expensive, and I am not sure how that cost will be borne for medical students studying community medicine. If you look at the medical school course contents, the common aspects of primary care are taught in almost all specialty departments. It is rare that the department of obstetrics and gynecology does not deal with vaginitis. Just the importance they give it, the way they treat the patient, and the way they view the patient make it different. The same material will be taught, but it is difficult and expensive to have medical students in this setting. Let me give you one example of the use of health centers for education and the support of physicians. (I am sure that Dr. Endicott is familiar with this example.) In Seattle the Group Health Cooperative of Puget Sound, a prepaid plan, has decentralized a great deal, in terms of limiting its centers to a maximum of 15,000 people and using smaller groups of physicians. They tend to use primary practitioners in many of these outlying centers. They started a family-practice residency-a cooperative in which a medical group negotiates the capitation with the cooperative, which is run by a board. The physicians operate their own practice, and the cooperative operates the plan. It is a rapidly growing, very successful prepaid practice. The system for the payment of residents in family practice provided that in the first year Bull. N.Y. Acad. Med.
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the cooperative paid the total stipend for the resident; in the second year the medical group and the cooperative split the stipend; and in the third year the medical group pays the entire stipend because the residents by that time had increased their productivity to the point of earning it. There has been some talk about the financing of postgraduate medical education on the basis of physicians paying some portion of the cost. The Mayo Clinic has supported postgraduate medical education in that manner for a long time. In Hanover, N.H., the Hitchcock Clinic has paid its residents stipends all the way along. This practicing multispecialty group in Seattle has paid the resident's stipend. The federal government and the Congress have had some questions about the financing of postgraduate medical education. It is a very complicated problem. I do not have all the answers, and I do not think that what is applicable in the Mayo and Hitchcock clinics is necessarily applicable here. But I believe that arrangements can be worked out to provide this kind of education in primary care. DR. PLOTZ. As Dr. Zimmerman knows, two years ago I had a World Health Organization fellowship to examine a new medical school in Israel that is basing its entire curriculum on primary care, namely, Soroka Medical Center in Beersheba. Dr. Prywes, the dean, has tried hard to emphasize primary care in medical education. The results of that experiment are going to be watched with great interest by many people. DR. ZIMMERMAN. Dr. Harvey, in your endorsement of the nursepractitioner, physician assistant, and so forth how do you overcome consumer sensitivity to the issue of malpractice? DR. HARVEY. In Canada malpractice suits simply are not as significant as they are in the United States. Physicians in Canada do not feel that they have to protect themselves at every point against potential malpractice suits. I do not want to imply that Canadians have lower expectations about the standards of health care. I believe, rather, that they are less prone to litigate over it. In communities where adequate health care simply is not available I believe the chief concern in people's minds would be attaining accessibility to someone who could help them with their problems. That would be the primary consideration. If worries over malpractice were present at all, they would be secondary and of much less importance. DR. ZIMMERMAN. Dr. Harvey, do your studies include any educators who spend most of their time and derive most of their income from patient Vol. 53, No. 5, June 1977
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care? And if so, how do they differ from nonaffiliated practitioners or full-time educators in the attitudes you were examining? DR. HARVEY. Canadian medical schools do have a certain proportion of educators who are engaged in practice as well as teaching. Again, I would like to emphasize the great importance we attach to a medical school appointment. It makes one a member of the inner fraternity. It provides opportunities to become engaged in research, to secure research funding, to be consulted by the government, to be involved directly in the policy and planning process. This is far less true for the physician who does not have a medical school appointment. The degree of involvement in a medical school is not as important a question as whether one is involved at all. That is the critical consideration. In our statistical studies we have not yet gone into a detailed analysis of full-time medical educators versus those who also practice in the community to some degree. But it is my impression that the differences among medical educators are far less profound than the differences between medical educators and community practitioners. DR. ZIMMERMAN. Dr. Weiss, is there any economic reason why neighborhood health centers flourish in Boston and not in New York City? DR. WEISS. I suggested that physicians are not motivated wholly by economics. That does not mean that everyone does not like to have a salary and to earn an adequate income. But I can hire physicians in Boston to work in primary care for a good deal less money than in New York, partly because of what they see there as other than financial benefits. Boston is a preferred community, where they enjoy living. New York has attained a reputation in terms of people coming to the city to practice, which I do not think is based on economics. As a matter of fact, physicians are exploited in Boston's neighborhood health centers, badly exploited. They are paid an hourly wage for which we could not employ a physician in New York. They have no fringe benefits or long-term security. They do it because they are dedicated, but most physicians stay only a short time. In Boston I tried to get the physicians in the neighborhood health centers to incorporate themselves into a group to get some bargaining power. This was primarily related to obtaining admitting privileges to care for their patients in the city hospital. When Boston City Hospital was taken over by Boston University, and Tufts University and Harvard University were pushed out to make it more economical for the hospital (it did not do so, Bull. N.Y. Acad. Med.
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but it was supposed to), there was one service, and Boston University had that service. I met with the health-center physicians and urged them to incorporate so that they could bargain more effectively with the chief of the service at Boston City Hospital, but they refused. Boston University refused them admitting privileges because the chief of the service used the fees to pay full-time faculty members; thus, he was keeping neighborhood health center physicians from caring for their own patients. It is a complex situation. I do not think it is basically a matter of economics. DR. ZIMMERMAN. Dr. Plotz, are there any data available about the tendency for family-practice graduates to move later into the specialties or
superspecialties? DR. PLOTZ. There are not enough data yet to draw a conclusion about such things. I expect that most physicians have known an occasional graduate of a family-practice residency program to become entranced with one or another specialty. We had one who went into ophthalmology, and he will make a wonderful ophthalmologist. I believe that the drop-out rate is low thus far. Only the next 10 years or so will tell whether it will be significant, but I am inclined to doubt that it will. As the graduates get into family practice, they become attached to their patients and communities. I once asked the ambassador of a developing Asian nation how they solve the problem of getting doctors into the rural areas. He said it was very simple. Doctors are taken into the army for five years after finishing their training. They are assigned to various rural areas where their army duties occupy them from 9 to 12 in the morning; afternoons they are free to moonlight. They all set up practices in the communities because they are paid little. After five years, he told me, you would be amazed at how many of them stay. That is how that country solved its problem. DR. HERBERT BERGER. The title of this program was The Medical School and Its Surrounding Community, but the three panelists-whom I found interesting-have discussed this subject rather circumferentially. It has been usual for us to look upon the medical school as a threelegged stool-one leg being the training of physicians, the second, community service or patient care, and the third, research. I believe that this is an erroneous concept. The primary purpose of a medical school is to train physicians. The rest of its functions are secondary. Dr. Weiss pointed out that only one third of patients with symptoms applied for medical care. As Vol. 53, No. 5, June 1977
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a member of the Royal Society of Health in England, I have had the opportunity to observe there that where medical care is completely free similar figures obtain. It is not only an economic problem that keeps people from going to doctors. This situation is particularly characteristic of underprivileged areas such as Lime House and the dock areas in Liverpool. It is interesting to note that in England, when the British United Provident Association (a Blue Cross/Blue Shield type of organization) was established, this group enrolled two million people in the first year. This indicates that access to free care is not necessarily desired by the population as a whole. Those two million people were already paying dearly for medical care through taxes. Dr. Weiss has rightly indicated that there is inadequate care of patients with functional complaints in our medical-care system. This is particularly true because we have failed to cover these illnesses in our insurance plans. Some years ago I surveyed 1,000 consecutive consultations in internal medicine and, as I recall, I reported in the medical literature that 762 of them were for completely functional complaints. I have been called to task by the Medicare authorities in this city for caring for such people, since they must be seen at frequent intervals to manage their problems. Medicare claims that this really is not the practice of internal medicine. Someone must take the government to task, because the kind of thing we are accused of most-not giving our hearts, souls, compassion, and generosity to patients-is exactly what this care provides. The government, on one hand, tells us that we do not do this properly and, on the other hand, refuses to pay for this very time-consuming activity. Dr. Harvey mentioned the use of the nurse-practitioner or various paramedicals. Like Dr. Plotz, I have had the opportunity to study medical care in a large part of the world. Twice I visited Siberia and Mongolia, where they have the feldsher-a sort of nurse-practitioner. This is not a good source of treatment, primarily because the best skills should be available at the front line. I do not believe we should place individuals in rural areas who are not the most highly trained persons we have. We ought to be training our very best people, as Dr. Plotz is trying to do, to work where the first diagnosis must be made. Dr. Plotz already has been asked, "What happens to residents in family practice over the years? Do they stay in family practice?" If this program
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is supposed to provide medical care for the community in Brooklyn, I understand that it probably has not done so. Dr. Plotz, I have heard that only a few of your residents actually have stayed in Brooklyn, and that most of them have moved to other pastures. Is this correct? DR. PLOTZ. My residency-training program so far has graduated three residents, two of whom are in Brooklyn. DR. BERGER. I am glad to hear that. Since I have been complaining, perhaps I should suggest some remedies. Most physicians my age were trained by clinical teachers who practiced medicine. I think that the medical art, which has been mentioned several times by Dr. Harvey and Dr. Weiss, can best be taught by an actual practitioner rather than by a full-time academic person. With regard to insurance, it is imperative that we cover treatment costs of all kinds of illness, including the neurotic ones, with insurance-keeping in mind that there is a neurotic component to every illness. I cannot emphasize this too strongly. The man who has had a myocardial infarction certainly has an organic illness, but, more important, now he also has the threat of imminent death hanging over him for the rest of his life. This needs to be treated with the greatest skill; I assure you that it requires much more skill than simply giving him some anticoagulants in an intensive care unit. As an answer to the entire problem of providing community care, we need to reestablish compulsory rotating internships. When this is done, and when the boards and the various specialties demand that such training include some years in family practice, preceeding preparation for a specialty (a suggestion which is never greeted with any enthusiasm, but which I am sure has value), we would accomplish two things. First, it would teach our young physicians how to treat patients rather than diseases. We have to emphasize this repeatedly; this is really our job. Second, these physicians would get opportunities to determine their aptitudes and interests. Having made a mistake in this area myself, I am keenly aware of this need. I come from a family of surgeons, and was originally trained in surgery. After eight years of a sort of combination of general and surgical practice, I decided to become an internist and had to be retrained. My experience was not a bad one; it was very useful to me. With this type of program we shall eventually train much better specialists. For example, Dr. Plotz said that one of his students is going into ophthalmology. He will be a much better ophthamologist because he will
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know how to treat the whole person. The vast majority of people trained in this fashion probably will recognize the enormous challenge of family practice and probably will respond to it and stay in family practice. DR. ZIMMERMAN. Dr. Harvey, would you like to respond to any of Dr. Berger's statements? DR. HARVEY. I am certainly not unsympathetic to the point made by Dr. Berger, that it is desirable to try to put our best people on the front line. But what if we cannot do so? The weight of empirical evidence, at least in Canada, indicates that we are so far from realizing that aspiration that we had best explore vigorously effective interim measures. I am not convinced from my research that the feldsher program in other countries and the nurse-practitioner program developed in Canada are precisely comparable. There are ways of reinforcing the diagnostic capabilities of the nursepractitioner or, for that matter, the family practitioner who serves in a remote area without adequate backup facilities. I am thinking of methods that, perhaps, sound futuristic, such as computer-diagnosis linkups, but nonetheless these methods are becoming more feasible with advances in telecommunications. Many people I have talked with who are involved in health-delivery policy and planning seem to think that this is increasingly coming within the realm of reality. I would also note that academic family physicians are not necessarily regarded as the best people within the academic community. We have found that, despite the development of family-physician programs within our medical schools, the medical schools still remain very segmented. There is a good deal of invidious comparison among and between specialties. Dr. Plotz indicated that there was little or no danger of attrition from family practice. In Canada one of the underlying considerations in the development of family-practice programs was to provide a primary practitioner who would be knowledgeable about a wide range of health problems in a broad social and family context. It also was felt that by providing a more viable career line through family practice it would prove possible to stem some of the very serious attrition from general practice that we were witnessing in Canada. I am sorry to say that the results are somewhat disappointing. In some interviews with family practitioners we found complaints about income, conditions of practice, feelings of exclusion, being low man on the totem pole, and so on. I do not know why some of the matters I have commented on today should seem to differ from the experience in the United States. Perhaps it Bull. N.Y. Acad. Med.
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is because Canada is a more elitist society. Physicians are an elite within an elitist society and therefore may be particularly conscious of these distinctions. Also, our society may be difficult to decentralize for a number of reasons. Away from the narrow, urbanized strip along the American border, a physician finds that he has to do without a great many things, both as a scientist and as a person with urban tastes. As long as we cultivate certain values and expectations of a personal, social, and scientific character within the setting of the medical school, it will remain difficult indeed to realize the goal (laudable as it is) of putting our best people on the front line. DR. WEISS. I have to agree with Dr. Berger. I have always believed that the place for the most skilled and most experienced physician was where the first judgment has to be made. Once diagnosis and a management scheme have been made, the treatment for most conditions can be given by a lesser physician. We have never followed that plan; in most of our hospitals we put our interns in the emergency rooms. During 10 years at Dartmouth Medical School as chairman of the Department of Psychiatry, which grew quite large, I always insisted that a senior staff member be on call, and that no resident could make a disposition of hospitalization or send a patient out without the staff member on call seeing the patient. I kept myself on call during those 10 years, and came in to see patients at 2 and 4 in the morning. I found it one of the most rewarding and exciting times to teach. It is a little bit easier to do this in New Hampshire than in New York. I also agree with Dr. Berger that the role of the medical school is to train physicians. Medical school faculties do not believe this in general. Harvard Medical School turns 85% of its graduates into practice when they leave; I asked its faculty the question: "If you really are training research scientists, what's wrong? Either you are picking the wrong people or you are doing a bad job, because you are only successful with 15% out of the whole class." In reality, medical schools are not training medical scientists; they are training physicians. Some of the graduates happen to choose to become medical scientists. Indeed, unless the faculty recognizes that they are training physicians and that most of their students will end up in medical practice, they cannot do a very good job. It really concerns me that very bad medicine can be practiced by the best institutions, as you can see if you walk into the clinics. This does not mean that they are graduating bad Vol. 53, No. 5, June 1977
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doctors, but their whole ambience, atmosphere, and value system are contrary to what we see as the ultimate role of the practice of medicine. We have to reestablish a rightful place in the medical school structure for the people who do practice. They have a role to play, a great deal to teach, and a great deal to learn. Another thing bothers me terribly. The structure of medical schools and medical centers has tended to keep our best graduates within the institution for more training. Those that do not make it to the highest level are pushed further and further out of the educational system. The people who need more training most are pushed furthest out; we ought to make the greatest effort to pull them back. We have failed in this responsibility abysmally, almost as badly as France has failed in its system of training by setting up examinations as barriers to moving on to the next level of training. For example, graduates from the Sorbonne take an examination; those who score well receive an internship. After internship another examination is given and those who score best go on to residency. The ones who do the worst on graduation enter practice immediately. Our segregation and pushing people from the medical schools, medical centers, and teaching programs, instead of pulling them in-with graded responsibility if necessary-produces the same result. If we do not assume responsibility for those who do the worst, we have failed as medical educators in a
medically responsible community. DR. PLOTZ. I want to thank Dr. Weiss for so eloquently stating the case for family practice. And I agree with Dr. Harvey that family practitioners should have more of what the godfather calls respect. I think they are getting it. It may be some consolation to him, although it is a source of dismay to me, that of the four schools of the State University of New York which established departments of family practice, two of them-at Buffalo and Stony Brook-imported family practitioners from Canada to head their departments.
Bull. N.Y. Acad. Med.
