From the University of Washington to Washington University: a personal journey.

A human sternum with an imbedded arrowhead (Fig 1) from Patagnoia presents a dramatic image fit to make several points regarding life, medicine, and surgery. Things are not always what they seem (the arrow enters the inner side of the sternum and therefore crossed the chest). Life was as fragile then as it is today. New forms of trauma have replaced, but not completely, the arrow, and new diseases, witness acquired immunodeficiency syndrome, continue to arise or be recognized. Although the interval from then to now is great, the messages are timeless. My message is not timeless but focuses on two generations of physicians (dad and me), a decade of change, and the next generation. In less than a decade profound changes in the structure and economics of medical practice have surpassed those of the preceding 150 years. As I look back on my 32 years of practice that came after 13 years in education, training, and military service after college, I thought it might be appropriate to reflect on these changes and how they may affect physicians in the future. I was fortunate to have a father who practiced medicine in a blue collar community of ten thousand people, that was built around a United States naval ship yard. I was well aware of my father’s profession from an early age but did not participate in it as some sons might. I was occasionally exposed to the “evils of socialized medicine” through conversations between my father and other physicians. I also learned that the American Medical Association was solidly against this form of medical practice, which I did not fully comprehend. At that time it seemed a far off possibility and not particularly threatening even as I considered pursuing medicine as a career. It was during college that I decided that medicine would be a good career, for several reasons. I had a personal health problem that I wanted to research and correct for myself and others. There seemed to be a good market for physicians. Providing care was satisfying to one’s own mind and was associated with respect from the community. And if one were diligent and even modestly successful one would not starve. Medical school taught me enough to engender a new respect for my dad, who delivered babies, set fractures in his office, and then developed the x-rays of the same between pediatric patient visits, performed major abdominal or gynecologic operations in the morning before heading to the office, managed to make house calls at mundane as well as odd hours, and speak with patients on the phone in midst of family dinners (the phone was in its place beside the kitchen table where we ate). At that time I could recall Sunday drives in the country when father would point out a farmhouse where he had delivered a baby, where he had treated a patient with heart failure, or relate that he had to back his model-T Ford up the hill to another house as low gear did not provide enough power to make the grade. Mother told me how wonderful it was when the bridge was built across Port Washington Narrows in 1932 so that instead of a 10minute ferry ride it was a short drive across the bridge to make a house call and it saved a 1-hour drive home when dad missed the last ferry in the evening. These vignettes from the practice of a solo practitioner engaged in the great American fee-for-service tradition that existed from the founding of our country until recently are uncommon today except in very rural or remote areas. Occasionally my dad would mention that some patients had no money or not enough to pay for services, which never seemed to be a problem for him. The only vexation that I perceived was on occasion when such a patient would become unusually demanding of his time, such as a lengthy phone call while we were eating. Some less-well-off patients, but also those who did pay, were grateful in other ways by bringing something from the garden, the beach, the water, or something crafted by hand and dropped off at the office or our home. In my clinical years at the University of Washington Presented at the Forty-fifth Annual Meeting of the Southern Thoracic Surgical Association, Orlando, FL, Nov 12–14 1998.