I view with alarm plus a note of optimism (2001)

ALARMING EVENTS Government programs (Medicare, Medicaid, and public hospitals) and the private sector (Health Maintenance Organization and insurance companies) have failed to create an efficient and adequate health care delivery system. I view this with alarm and recommend that we start over. Our poorly organized and cost conscience system of health care delivery prevents medical care from reaching those who need it. The system especially prevents the use of the results of recent medical research. A great deal of money is involved and more will be spent because health care delivery will cost more each year. It is regrettable that much of the money will be spent on the administrative aspects of a failed system. This should alarm everyone. Medical education is at a crossroad. Will there be an adequate number of devoted true teachers in the future? Will the teachers have sufficient time to determine if students and house staff are using the information that is hurled at them in a thought process that relates specifically to patients. Can the teachers of the future show nascent trainees that doctoring is more than knowing a large number of interesting facts. Doctoring is knowing medicine and caring about the patient by responding promptly and appropriately to the patient’s needs. Will Abraham Flexner rise from his grave and say, “please read my report on medical education?” Or should there be another Abraham Flexner? Nurses are vital to the care of patients. They are underappreciated and underpaid and the enrollment in nursing schools is declining. Nurses are sometimes dismissed from their position in a hospital to find money for more administrators to handle an increasing amount of paperwork! I read that one patient had to call 911 from his hospital bed because there were too few nurses to answer his signal. The lack of nurses is now a national crisis. This should cause great alarm in everyone. There once was a time when many of us said it was wise to administer as few drugs as possible. Now many patients take $10 expensive drugs each day. Patients take so many pills that some of them develop “pill esophagitis.” I continue to believe that we should use as few drugs as possible, but the expensive and persuasive hype in lay journals encourage patients to pressure doctors to prescribe the new drugs, although the expensive new drugs may be no better than old cheaper drugs. I suggest, with tongue-in-cheek, that a ridiculous solution to this problem would be to issue, as guidelines are issued, an unbiased pharmacology book to doctors every year. The doctors should prescribe no drug that is not in the pharmacology book. We are told that modern technology assures improved communication. This has not been my experience to date. Patients have more trouble than ever reaching a doctor by telephone. Patients talk to a machine or a different non-doctor each time they call. One patient was told by a non-doctor that she could not reach the doctor by phone. The patient was told to fax the doctor a letter. She did, but the doctor rarely picked up his faxes. She was then told by the nondoctor that the doctor loved his computer and usually read his E-mail. So the patient sent the doctor an E-mail. He got it and answered her by E-mail. Proper communication implies that someone sends a message (voice or script) and someone receives it and responds in such a way that the sender knows that the receiver not only received the message but also understood it. Still, patients desperately want to hear their doctor’s voice to be certain the doctor understands the problem. An intern asked me if I gave patients my telephone number. I was, with some pride, able to say that during my 30-year chairmanship in medicine at Emory University that patients had access to me 24 hours each day. I could also state that when I admitted patients to the hospital at night, I went to see them promptly. The intern looked bewildered, suggesting that he did not know that doctors did that. I viewed his look with alarm. I view with alarm that some trainees in internal medicine and its subspecialties do not develop the skill to interpret a chest x-ray film and electrocardiogram. I know they look at them, but that is not the same as understanding them; seeing is not the same as observing and thinking. Even history taking and physical examination is not always emphasized as being as necessary as it once was. Someone will say such an approach is old fashioned. I respond, that it is a very From Emory University School of Medicine, Consultant to the Divison of Cardiology, former Professor and Chairman, Department of Medicine 1957 to 1986, Atlanta, Georgia. Manuscript received and accepted March 16, 2001. Address for reprints: J. Willis Hurst, MD, 1462 Clifton Road, N.E., Suite 301, Atlanta, Georgia 30322.