William Marshall
Tucson, AZ

 

From Stories of a Country Doctor (1891) by Willis P. King, p. 155. Philadelphia: Hummel and Parmele. Via Internet Archive. Public domain.

The dissatisfaction with modern medicine felt by both patients and doctors occurs despite unprecedented advances and successes in disease treatment and prevention. Corporate Medicine (huge healthcare conglomerates that control much of medical care) and Big Pharma (giant research, development, and sales entities) are understood as prime exemplars of monopolistic greed. Income disparity between nurses, primary care doctors, procedural specialists, and biotech entrepreneurs illustrates the lower value given to more humanistic care. Rushed and impersonal clinic visits, often driven by an imperative for financial efficiency and guided by computerized algorithms, are impersonal and frustrating.

Young doctors may feel that these are indeed difficult times to be a physician; older doctors may feel that the practice of medicine is no longer rewarding. For many of these concerns, however, the basic dynamics are nothing new but rather modern versions, enlarged in scale or adjusted to a different time and place.

 

Ful redy hadde he his apothecaries
To sende him drogges and his letuaries;
For ech of hem made oother for to wynne,
Hir frendshipe nas nat newe to bigynne.¹

The physician and apothecary in Chaucer’s Canterbury Tales helped each other to profit. Seb Falk, in his entertaining The Light Ages: The Surprising Story of Medieval Science,² notes that the doctor’s motives were not seen as pure, and that Chaucer and other contemporaries described the for-profit collusion between the medicine prescriber and the medication dispenser. Of course, there have been changes in the intervening 700 years. The integration of medicine and pharmacy has evolved from the personal relationships in the towns of Chaucer’s time. Research and development on a global scale have replaced folk remedies of localized origin; the medications of today are actually effective, and sometimes curative. Physicians and pharmacists are employees of massive corporations or healthcare networks. Pharmaceutical detail representatives are a more recent manifestation of person-to-person relationships, but direct-to-consumer television advertisements, with their idealized images of farmers’ markets and family picnics, and health insurance formularies restricted to certain brands have supplanted the need for many person-to-person contacts. Whether understood as cooperation, collusion, or conspiracy between the prescriber and the pharmaceutical provider, the system results in patients being unhappy and cynical about the high prices they pay, and physicians feel caught in the middle. Chaucer would have understood the role of pharmaceutical companies and doctors in the current opioid epidemic and the sometimes-dark financial motives behind the care of patients.

 

“Alas! the scientific conscience had got into the debasing company of money obligations and selfish respects.”³

In George Eliot’s Middlemarch, Dr. Tertius Lydgate, like doctors today, had to weigh ideals against financial and personal reality. Then as now, ideals and reality change between the start of medical studies and completion of training. This has been, and continues to be, a theme in literature, movies, and television shows about doctors. In applications to medical school, students’ personal statements often include aspirations of serving the underserved and practicing primary care; these worthy goals often change as “money obligations and selfish respects” become more real. Empathy itself has been measured to decrease during medical school. Researchers in academia depend on grants for academic success, and the higher salaries in industry often poach talent and idealism away. Although many decry these trends as examples of professional decay, they are nothing new.

 

Dr. Hullah in The Cunning Man

In the post WWII Toronto of Robertson Davies’ The Cunning Man,⁴ well before the triumph of corporate managed care, electronic health records, and algorithmic care, Dr. Hullah chose an independent and idiosyncratic practice to allow himself and his patients the time to establish personal, healing connections. He found that mainstream practice at the time was almost practice by rote, devoid of the opportunity to really know his patients and, by extension, their illnesses. Doctors today voice the same concerns, and patients still often leave the clinic with the feeling that they were rushed in and out without having a relationship with the doctor or an understanding of their diagnosis and treatment. Hullah’s approach to his patients could be described as following Engel’s biopsychosocial model,⁵ in which care encompasses an understanding of not just the biology of the patient, but the mind and community the patient inhabits. Today’s dominant model might be called the biometric-epidemiologic paradigm, which focuses on laboratory and imaging data, combined with the population health statistics of Big Data studies. For patients with discrete, definable conditions, this tradeoff may be more than advantageous. For patients whose problems cannot be wholly characterized by tests and images, or for those needing more personal understanding, this model is found lacking.

Literature does not answer these modern-day questions, but it provides today’s doctor with the solace that these dilemmas are not new, but rather reconfigured for different times. How to navigate relationships with the existing healthcare system, how to conform ideals to reality, and how to provide the best care for patients have been, and continue to be, inherent challenges for doctors past and present. Present day research in medical education and training emphasizing empathy and compassion^6,7 and an increased societal emphasis on patient empowerment are encouraging signs for the future.

 

References

1. Chaucer, Geoffrey. The Canterbury Tales, General Prologue, Larry D. Benson, Gen. ed., The Riverside Chaucer, Houghton-Mifflin Company, lines 425-428. https://chaucer.fas.harvard.edu/pages/general-prologue-0.
2. Falk, Seb. The light ages: the surprising story of medieval science. New York. W.W. Norton & Company, 2020. 232-233.
3. Eliot, George. Middlemarch, A Study of Provincial Life, Foleshill Ed. Little, Brown & Co. 1900. University Press, John Wilson & Son, Cambridge, USA, 744, Google Books.
4. Davies, Robertson. The Cunning Man (1994). Rosetta Books New York, 2019.
5. Engel GL. “The need for a new medical model: a challenge for biomedicine.” Science. 1977 Apr 8;196(4286):129-36. doi: 10.1126/science.847460.
6. Dyrbye LN, Satele D, West CP. “Association of Characteristics of the Learning Environment and US Medical Student Burnout, Empathy, and Career Regret.” JAMA Netw Open. 2021 Aug 2;4(8):e2119110. doi: 10.1001/jamanetworkopen.2021.19110.
7. Roberts, Laura, Weiss MD, MA. “Advancing Understanding of Compassion and Compassion Training.” Acad Med. 2021;96(7):929-930. doi:10.1097/ACM.0000000000004131.

 

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WILLIAM MARSHALL retired in 2020 after teaching and practicing general pediatrics at the University of Arizona College of Medicine since 1980.

 

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