The science of medicine may have changed, but the art of healing remains the same. Our charter class reflects on how the practice of medicine has changed since they entered medical school 35 years ago.
In the mid-1970s, medicine seemed to be destined for great advancements.
At least that’s the way Donald Neumann, M.D., Ph.D., saw it. Neumann, a graduate of Case Western Reserve University, was eager to put his love for biology and interest in radiology to work in medical school. In 1976, he was chosen among several thousand applicants to be one of the 32 students who would make up Wright State University Boonshoft School of Medicine’s first class.
It was an opportunity to join a unique adventure, as Neumann and his colleagues saw it. The students quickly found themselves in a special partnership with the school’s faculty as they worked together to create the curriculum and mold a foundation for the school’s future.
The small class experienced a one-of-a- kind learning environment. They gained much of their basic instruction in one classroom and did their research in a small medical library. They participated in unconventional opportunities—like seeing patients in the first year and doing clinical rotations each summer—which many believe gave them a five-year degree for the price of four.
It was an exciting time. Technological inventions and the creation of new medications were growing, which offered a new way of practicing what had been taught inside the classroom. Just before Neumann entered medical school, the world was introduced to the CT scan. And by the time Neumann hit residency, he had a front row seat to how it worked.
“I remember distinctly doing a pediatric rotation at the Children’s Hospital in Dayton and I took a call about a little girl who needed a CT scan done,” said Neumann, who is now a staff member of the Cleveland Clinic Department of Molecular and Functional Imaging. “At the time there was only one CT scan in Dayton, and I got appointed to ride along with her in the ambulance to have it done.”
The CT scan unit provided a single-slice image and required the patient to lie down for an hour before it was finished. Neumann can still recall the radiologist trying to interpret the tiny little images while referring to a textbook. More than three decades later, multiple CT scanners are located in nearly every hospital— sometimes even in physician’s offices— and can scan a patient in just seconds while providing multiple image slices.
Such a transformation has reshaped the practice of medicine. Advances in technology and breakthroughs in medicines have made a physician’s job that much more exciting. But other forces, many of which could not have been predicted, have created new burdens that take doctors away from what they love and know best.
An increase in private insurance and government intervention has forced doctors to consolidate and devote more of their time to paperwork. Meanwhile, an imbalance of reimbursement rates has placed varying values on doctor’s jobs and made an incredible impact on what forms of medicine students now decide to enter.
In more ways than one, the medical atmosphere Neumann and his fellow graduates decided to enter 35 years ago has drastically evolved.
Technology that transforms
When the class of 1980 entered residency, physicians dictated patient notes on a little cassette, viewed X-rays on a single sheet of film, and clipped pagers to their belt. Any research that needed to be done on a particular case or condition was reserved for time in a medical library among shelves of journals and books.
Yet over the past three decades—and the past 10 years in particular—physicians have watched their jobs change right before their eyes with the birth of new technology, including new medical testing tools, advanced communication devices, and the research databases that are available by simply logging on to a web site. Physicians now experience greater mobility and increased efficiency in their jobs.
Less than 15 years ago, Evan Cantini, M.D., would wrap up his day by taking a daily walk to the X-ray department in the hospital where he worked. There, he would meet with a radiologist to discuss the results from a single sheet of film neatly nestled on a light box. Today, he can accomplish the same job from just about any location as long as he has a computer and a wireless connection.
“It makes decision making easier because you have the data far more quickly than before,” said Cantini, who now serves as medical director of Rehabilitation Medicine for Northwest Hospital in Lake Forest Park, Washington. “If I do need to speak with a radiologist, I can simply call them up. We don’t have to be in the same room.”
Better technological advancements— such as laparoscopic surgery—have meant fewer patients undergoing major surgery in place of a short day in the outpatient department. Robotic surgery is making procedures safer and more accurate, giving patients better outcomes and shorter recovery times.
Still, some believe technological advancements have come at a price. Some say physician collaboration and communication is not what it was 30 years ago when doctors were forced to consult with one another face-to-face, Neumann said.
Neumann appreciated when other physicians would visit his department during his early days as a radiologist. He could often set his watch to the moment they would all come walking in, ready to discuss cases and seeking his input.
“We would go through a patient’s cases one at a time. It was great interaction that was beneficial to patient care and management,” he said. “But personal interactions have fallen by the wayside now. I think radiology is viewed like pushing a button: You order a CT scan, and you get a quick answer.”
Advances in medicine and cures
It’s not just the technology that has exploded to new levels, but also the availability of medications to treat the diagnoses.
Wright State’s charter class has seen many new advances in medicine since they entered the field. Included in the long list were the first cholesterol-lowering drug, a safer antidepressant, the only cancer vaccine, an aid for children suffering from ADHD, and the first targeted cancer drug that could be used in place of traditional chemotherapy.
“There are so many medications we have today that we didn’t have 25 years ago that are both better and safer for patients,” said Samia Borchers, M.D., who practices dermatology in Dayton, Ohio.
Perhaps one of the biggest break- throughs in Borchers’ specialty was the creation of Accutane, a drug created in 1979 to treat severe cases of acne. The drug, which has gained popularity in the last 25 years, has literally transformed patients’ lives after just five months of treatment, Borchers said.
Each specialty has benefited in its own unique way with the creation of new medications. But few can argue that one of the biggest advancements came in the treatment of HIV/AIDS. The disease was first reported in 1981 by the U.S. Centers for Disease Control and just nine years later WSU graduate Robert Brandt Jr., M.D., would become a certified AIDS specialist, running a primary care practice devoted to the care of patients living with the disease.
“One of the things I was fortunate to be involved with is the treatment of this disease,” Brandt said. “This is one practice that has changed so dramatically, where at first we had no treatment whatsoever and people died within six months of being diagnosed. Now, it is like treating diabetes or hypertension.”
A growing force
Unfortunately, many physicians feel as if there’s a new force denying them the full benefit of the incredible advances in technology and medical treatments.
When he first started practicing medicine, Cantini didn’t have to consult with his patient’s insurance company before treating his patient. Now, it seems as if he needs pre-authorization to do just about anything. Slowly insurance companies and the government seem to be taking a bigger seat at the table when it comes to how patients are being treated. It has some doctors feeling restricted in how they care for their patients and weary from the added work it requires to make sure all of their decisions are sanctioned by someone else.
“They intervene in the process and place certain restrictions on hospital stays in such a way that now decisions aren’t being determined by the doctor, but the insurance company,” Cantini said.
Meanwhile, government health programs such as Medicare have placed extremely strict guidelines of what they will allow for reimbursements, placing a squeeze on what clinical applications doctors can perform. For instance, Neumann said, a patient might need multiple doses of a hormone injection to treat a thyroid disease. Yet because of its cost, an insurance company may require the patient wait six months between treatments, placing the patient under stress and discomfort, he said.
“There are forces that are counter- balancing what otherwise would be seen as a significant expansion of clinical applications,” Neumann said.
Carol LaCroix, M.D., who is a family doctor in Omaha, Nebraska, thinks the insurance companies can often serve as checks and balances. The rise in health care costs is happening for a reason, and LaCroix believes that some of it has to do with the rate at which many tests are ordered without a second thought.
“Sure it is true that insurance companies will say that you can’t do (a certain test), but a lot of times they are good restrictions,” she said. “The American public has to change its attitude that it can get everything for nothing. We can’t keep our costs down and offer everything.”
Survival of the specialist
Patient care isn’t the only thing being determined by insurance companies. So is the value of a doctor’s work. Insurance companies have placed invisible price tags on a doctor’s time by the rate at which they choose to reimburse their services.
Primary care physicians, in particular, are feeling the heat. As a family doctor, LaCroix gets paid less for spending 20 minutes with a patient discussing preventative health care than some specialists who conduct a 10-minute procedure on a patient they may never see again, she said.
“I would like to see pay among physicians more evenly distributed,” LaCroix said.
The number of medical students choosing primary care has steadily dropped over the past few decades as the potential pay has remained lower than in other specialties. Med students are gun-shy of a career in primary care where salaries nearly equal the school debt they’ll be carrying upon graduation.
The only way the trend will reverse is if certain issues are addressed, such as increasing programs to help medical students pay back loans and improving primary care payment, according to the American Academy of Family Physicians.
Primary care docs like Brandt, who entered the field three decades ago, have watched as their time for each patient has slowly dwindled. The two main causes have been the increased pressure from insurance companies to maintain a high volume of patient visits and an ever- growing load of paperwork that needs to be done for reimbursement.
“When I graduated, I thought my days would have been spent practicing more medicine and doing less paperwork,” Brandt said. “If I put in an eight-hour day, probably five to six hours of that is actually seeing patients. The rest of the time I’m typing and trying to do the paperwork necessary to get things accomplished.”
Rate of reimbursement is only one aspect haunting primary care docs. The other is the rising cost of malpractice insurance. Brandt opened a solo family practice upon graduation and handled everything, including the delivery of babies. But he closed his doors in 1990 when he could no longer afford the cost of malpractice insurance.
Malpractice premiums continue to increase in cost. Obstetricans, in particular, can pay insurance premiums anywhere from $20,000 to $200,000 depending on their location. In 2009, global professional services firm Towers Watson, reported that the costs of litigation avoidance had grown at more than 10 percent annually since 1975, one year before the charter class first entered med school.
A new medical model
Health care, like any other business, has had to change and adapt to survive the times. Unfortunately, some things have been lost through that process. The intimate patient-physician relationship that most doctors enjoyed when they entered the field in the early 1980s decreased as solo practices were forced to join larger conglomerates in order to stay alive and compete.
Rob Mascia, M.D. Rob Mascia, M.D., had the privilege of becoming a partner with three other physicians in a small family practice in Connecticut right after graduating with Wright State’s first class. The practice thrived and grew over the years to include six physicians, but in 1996 they decided to merge with a large multi- specialty practice to remain efficient.
The early 1990s was a time of transition for many practices in the United States. It was the start of a season where venture capitalists acquired practices with the goal of running them as for-profit models. But not even 10 years later, it became evident that the best people to run a practice weren’t investors, but those who had actually been trained in the medical field.
It provided a new opportunity for Mascia, who decided to pursue an advanced degree and in 2000 received his master’s degree in medical management from Carnegie Mellon. It’s a route that Mascia didn’t have in mind when he first graduated, but one that opened up as the market evolved. Now he is executive director and chief of primary care at Danbury Office of Physicians Services, a 300 physician specialty group practice.
Danbury Office is one of many medical home models gaining ground across the United States. Mascia said the model— which provides a patient-centric model where the primary care doctor leads a team of specialists—will help put primary care physicians back to their rightful position. The model is a collaborative approach to health care, which is frequently delivered in a fragmented manner.
Collaboration is vital for doctors in today’s environment, Cantini said, whether they are part of an official model or not.
“Successful patient care has to be team oriented,” he said. “If you fume over the fact that some aspects of patient care are influenced by others, then you won’t serve your patients well. Over time it could take a heavy toll on you as a physician.”
The one thing that remains
The advent of the medical home model may be telling of something. The broad effects of economics may play a major role in how medicine is practiced, but one thing will continue to remain vitally important to patients and physicians alike.
“I love the responsibility of being a physician, and I love the relationships I have with my patients,” Borchers said.
Rows and rows of medical files line Borchers’ Ohio dermatology office. Some of the manila folders are stiff and new, but more often than not they are worn and filled with dog-eared paper. Borchers calls the patient files, books. Not because of their size, but because of what they contain.
“Each time a patient comes in I put in a new entry, and after so many years they become chapters of the book,” she said.
Within the lines of diagnoses and test results are scribbled notes of when a daughter got married or a special vacation was taken. To Borchers, it is a testimony of what really matters and why she went into medicine in the first place.
“The interactions I have with patients are the same today as they were 25 years ago,” she said. “People all want the same thing: they want to come and know that someone cares. They want a place where they can tell their story, and a physician’s office provides that opportunity.”
Likewise, LaCroix believes her position as a family doctor gives her a unique responsibility to listen to patients and do what is right, even when it means no medical intervention.
“There are some patients who have had all these procedures done and they’re suffering from a terminal illness,” LaCroix said. “Why? Because no one has said it is okay to just stop. As a family physician who has a good relationship with a patient, I can do that. I can tell them that we don’t have to keep doing this.”
And when the patient agrees, LaCroix has a response.
“Sometimes all we can do and should do is hold their hand,” she said.
And that, she admits, is not anything she could have learned in med school, but only something she had to learn in her decades as a doctor. VS
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Tell us how the practice of medicine has changed since you graduated from medical school. We’ll publish highlights from your comments in the next issue of Vital Signs. Send your observations to firstname.lastname@example.org
Photo 1: WSU School of Medicine
Photo 2: Donald Neumann, M.D., Ph.D.
Photo 3: Evan Cantini, M.D.
Photo 4: Medical Library in 1976
Photo 5: Samia Borcher, M.D.
Photo 6: Medical students working on medical manikin
Photo 7: Robert Brandt Jr., M.D.
Photo 8: Man getting blood pressure check
Photo 9: Carol LaCroix, M.D.
Photo 10: Rob Mascia, M.D.