Flashback in Medical Economics
Over the years there'd been a growing clamor for medical schools to reorder their priorities in screening applicants. Personality and potential for relating compassionately with patients should be given at least as much weight as a candidate's intellect, the advocates for change had insisted.
Their insistence had paid offtoo heavily, Contributing Editor Michael J. Halberstam maintained in his essay, "How Smart Does a Doctor Have to Be?" The pendulum had swung so far, Halberstam warned, that med schools were in danger of passing over the smartest applicants in favor of those with the most evident "human" instincts.
The Washington, DC, internist (whose brother, David, is a noted journalist and author) examined "fallacies" that he felt were taking hold among admissions officers, professors, and consumerists. One such fallacy was that the "art" of medicine is unteachable. "Nonsense," wrote Halberstam. "The reason the art of medicine is rarely learned is that it's rarely taught."
How should it be taught to med students, including those who have the intellectual capacity to learn it even if their compassion quotient seems low? "Putting excellent practicing physicians among medical students and allowing them to make rounds together isn't enough," he argued. "Student and house officers' interactions with patients should be taped and restudied with the same care a football coach gives his game films."
Another fallacythat compassion and intellect are mutually exclusivealso drew Halberstam's fire. "Motor skills among bright children are consistently better than those among average children," he noted. "In the same way, raw intellectual ability and the ability to practice the art of medicinethat is, to see patients as fellow humans rather than as casesare complementary."
Stressing the importance of intellect in doctors-to-be, Halberstam wrote: "Medicine is not a field for the average intelligence. The discrete bits of the art of medicine that we can identifyknowledge of, and interest in, the world around; ability to listen with the third ear; ability to communicate one's beliefs effectively to bureaucrat and parking lot attendant alikethese presuppose a high degree of intelligence."
Halberstam offered this suggestion to med school admissions officers: "Ignore applicants' expressions of a desire to 'serve humanity,' or high scores for 'compassion' on psychologic tests. Look at who the candidates are and what they've done. I still think personal interviews are essential for thisyou can find out more about an applicant's social skills and potentials in a half-hour's talk than from two hours of psychometric testing."
Savvy advice from a doctor whose intellectual abilities rivaled just about anyone's. But sadly, the medical profession had little time left to benefit from that intellect. A few years after this essay was published, Mike Halberstam was killed by an intruder in his home.
Only a few pages apart in our August issue, passionate arguments were mounted for and against a federal health insurance program. The "for" spokesman, predictably, was an official of organized labor. Just as predictably, the voices of opposition came from the leaders of the American Medical Association.
"The demand for health insurance should be met by a comprehensive health program developed within the framework of our national Social Security policy," said Harry Becker, director of the UAW-CIO's Social Security department. "Such a program would further medical research, preventive medicine, the training of professional personnel, the establishment of hospital facilities, and the financing of medical care needed by all members of society."
Becker slammed the AMA for championing private insurance as part of an aggressive campaign to block a government health plan. "The insurance companies at best give only cash benefits," Becker noted, "and these bear no direct relation to the cost of the worker's medical care." He aimed an arrow at practicing physicians, as well. "In many instances," he charged, "the existence of [a patient's private insurance] is interpreted by the physician simply as increasing the worker's ability to pay. Therefore, his fee is larger than it might otherwise have been, and the worker pays the difference."
The union official warned doctors, "Labor will not soon forget that the entire resources of the AMA have been thrown into the fight to oppose giving our people the health protection they so badly need."
To make its own case, the AMA rolled out heavy artillery. Cheered by delegates to the annual convention in San Francisco, the association's leaders took to the battlementsoratorically, at leastand vowed that the nation's physicians would never yield to the forces of socialized medicine.
"I call upon every doctor in the United States to dedicate himself not only to the protection of the people's physical health, but also to the protection of our American way of life," proclaimed AMA President Elmer Henderson, a Louisville surgeon. His address was beamed by radio to Washington, DC, where members of Congress had been exhorted to tune in.
Echoing Henderson was President-elect John Cline, a professor of surgery at Stanford. "I pledge a vigorous, continuing fight against both socialized medicine and socialism," said Cline. "In every great struggle, there are certain crucial battles that determine its outcome. The future of medicine may well hinge upon the Congressional elections in November."
Leaders and rank-and-file AMA members had reason for concern: Clearly, the Truman administration was seeking a major, perhaps dominant, role for Uncle Sam in the nation's health care system. As a key part of his strategy, the president wanted to elevate an existing body called the Federal Security Agency to cabinet status, with a new name: Department of Health, Education, and Security.
The AMA was quick to challenge that idea. One of its Washington lobbyists wired to the convention delegates a government report showing the FSA to be "inefficient, wasteful, overstaffed, and engaged in outrightand illegalpropaganda for national health insurance."
If socialization of American medicine was indeed Harry Truman's goal, as the AMA maintained, he was thwarted. A decade and a half went by before another Democrat, Lyndon Johnson, was able to push through the biggest federal health program of allMedicare.
"The trained nurse can go far toward putting a quietus on the cults and faddists if we of the medical profession will help her along."
In a call to arms titled "Queering the Cult," William L. Gould, of Albany, NY, exhorted his fellow physicians to seek nurses' support in fending off the "nonmedical practitioners" invading the profession's turf. Among the invaders, he cited "the chiropractor, the 'foot doctor,' [and] the beauty and corrective eating 'specialists.' " (This was 75 years ago, remember. Let it be noted that the vast majority of today's physicians hold to a more tolerantand realisticview of alternative medicine.)
Who left the door ajar for these invaders? Medical practitioners did, Gould contended. Physicians were too busy with patients' big problems to address little onesand that preoccupation sent patients looking elsewhere for help. "For example," Gould wrote, "what physician desires to be troubled with the usual run of corns and calluses? We gladly allow or even recommend those afflicted with minor foot ailments to go to chiropodists and 'foot specialists.' "
Patients who'd gotten used to having chiropodists remove their corns and trim their toenails began going back to those practitioners for other foot problemsand that was dangerous, Gould warned. "Not long ago," he wrote, "a man came to me with a malignant growth of the heel. He had been treated with high frequency by a 'foot doctor' at $5 per treatment."
To halt incursions by nonphysicians, Gould continued, treatment of lesser problems should be entrusted to somebody "who is allied with the recognized medical profession. And that somebody can be no one better than the trained nurse, graduated from a reliable institution. While [the physician] is caring for the grosser manifestations of disease, [the nurse] could treat the minor ailments, which, when neglected, give the cultist his much-sought-for opening."
Nurses should be allowed to do more than "carry pills and empty bedpans," he argued. "If the orthopedist will set aside a little space in his office for a trained nurse, purposely to care for minor foot ailments, we would have no occasion to refer our cases to chiropodists." (That idea sure didn't fly.) "If surgeons and medical men hired capable, graduate male and female nurses as masseurs, a great step would be taken toward the eradication of the chiropractor." (Neither did that one.)
James D. Hendricks, Executive Editor
James Hendricks. Flashback in Medical Economics. Medical Economics 2000;15:125.