J. Joseph Marr, MD

Fall from grace J. Joseph Marr, MD The author (AΩA, Johns Hopkins as there a certain time when Whenever it occurred, the transforma- University, 1964) is a retired academic it happened? If so, probably tion of the physician during the sec- physician and business executive. He is the inflection point occurred ond half of the twentieth century from a member of the editorial board of The Win the nineties when business took over shaman to skilled labor was inexorable Pharos. formally. That was a watershed series and, in my opinion, will prove to be of events, surely, but the full process irreversible. Illustrations by Jim M’Guinness. seems to have been more like death from All of us who were active in medicine a thousand cuts, some self-inflicted. and medical science during these years 8 The Pharos/Winter 2014 played a role in its transformation. We Two things happened in 1961, when I their time to patient care and paid little were troubled—and then horrified— was a sophomore in medical school, that attention to the institutions in which observers, yet often more than a little were to some degree prophetic. I recog- the care was delivered unless there were complicit. Hubris had much to do with nized both of them as being significant, obvious issues of neglect or mismanage- it, and all of us were culpable to varying but did not see that they were harbingers ment. They also paid little attention to degrees. Is medicine today better, worse, of the future. An article in the Journal patients themselves beyond the office or just different? Does it matter? Perhaps of the American Medical Association or hospital visits. The problem of health not so much to people born in the late chronicled a study of the interpretation care delivery to the medically indigent twentieth century, but it matters much of chest x-rays read both by radiologists was left to municipal hospitals, chari- to those of us who practiced medicine and by a computer. The two methods table clinics, and the free care provided and loved it during the last half of the were about equally accurate. The con- by many medical practitioners. The fact last century. clusion was that computers were no that these municipal hospitals served To answer this question with any better than radiologists. My conclusion sometimes as superb training facili- hope of perspective, it may be valuable was that the radiologists were doing the ties abetted the situation. Management to consider the issue as having two com- best they could and the computer was and planning of indigent care largely ponents: the evolution of medicine itself learning and would do better as time was left to those who tried to respond and the effects of that evolution on the went on. The other event was a conver- to medical-social issues from a back- physician practitioner. The changes in sation with some physicians about the ground of social work, law, or politics. the institutions through which medicine management of hospitals. I wondered These are general statements—there is practiced, important as they are to if physicians should not be managing were physicians and physician groups our current situation, will be treated hospitals themselves since they knew that recognized the problem of delivery as a concomitant and parallel sideline. more about patient care. The response of care—but the emphasis remained on Permit me to be an observer and guide was that physicians could hire people fee-for-service with some charity care here and use some of my own history to do this; the medical staff actually ran done. to illustrate. I do not think of myself as the hospitals anyway. Yes, I thought, but The “threat” of Medicare and Virgil, but rather as a fellow traveler. The actually we work for the administrative Medicaid in the 1960s caused much of comments and illustrative experiences organization. For years afterwards, phy- organized medicine to react strongly I use are, within broad limits, common sicians who recognized this disconnect against governmental intrusion into to us all. and went into administrative medicine medical practice. In particular, the were considered, quite unfairly, as sim- American Medical Association (pre- A brief case history ply unfit for practice and their real im- sumed to be the spokesperson for phy- Those of us born in the late 1930s or portance not credited. Where did that sicians generally) lobbied against any very early 1940s entered medical school lead? Look around. changes in the fee-for-service practitio- in the later 1950s or early 1960s. It was ner model of medical care. The specter a time that I have heard described as “a Hubris of socialized medicine was raised when- Golden Age of Medicine.” A golden age, There was considerable hubris ever any governmental changes were of course, is relative to the observer. We among physicians in this time. We had proposed, but no alternative solution to were at the top of a revered profession social status, financial rewards, and the the problem of the uninsured and under- dedicated to the care of others and al- gratification of playing an important served was put forward. When Lyndon most solely responsible for the manage- role in our society. Did this play a role Johnson brought Medicare and Medicaid ment and delivery of that care; on the in the changes in medicine? I believe into law in 1965, two things happened other hand, that care was very unevenly so. A “cottage industry,” as medicine of among physicians: first, outrage—there distributed and closely related to abil- the time rightly has been called, had was much talk of “socialized medicine” ity to pay. The physician was priest and no incentive to look at the larger social and the downfall of the private practice seer; his opinions were respected, given picture, nor the mechanism to introduce model. Practice nevertheless went on great credence, and sought in areas out- change had it wished to do so. The revo- as usual, although with the realization side of medicine. He was a scholar in lution of biotechnology and biomedical that a major event had occurred, the the broad, liberal-arts sense of the term. engineering as applied to the physician consequences of which were yet to de- He was the alchemist who understood practitioner could be compared to the velop. Second, the slow realization that science, and he knew the workings of industrial revolution and the cottage in- the medical care physicians had been the human body and psyche as well. He dustries that it eliminated. No one saw it providing gratis now would be reim- was a shaman at the end of the age of coming: a computer reading a chest film bursed by the government. Predictably, shamans. It was like that. caused no alarm. Physicians devoted opposition softened. We gradually came The Pharos/Winter 2014 9 Fall from grace to tolerate, and then love, the beast. The in the civilian world (start IV fluid or not. I began my slow, yet steady, appre- words from Alexander Pope’s Essay on blood infusions; some surgery to prevent ciation of changing medical economics Man, intended for other situations, were or mitigate larger surgery later), they and the disparity of medical care in our never truer: also made the decisions to do so. Slowly society. it became clear that nonphysicians who Later, in the early 1980s, I was Chief Vice is a monster of so frightful mien, had some training could make these de- of Medicine at the same metropolitan As, to be hated, needs but to be seen; cisions. This had started with the corps- hospital and needed to conserve the Yet seen too oft, familiar with her face, men in World War II, and expanded time and energies of my medical resi- We first endure, then pity, then rapidly in the Korean War, but it came dents. They could not manage seriously embrace.1 into full flower in Viet Nam. And un- ill inpatients and a large outpatient clinic like the situations after the former wars, population without loss of quality of Expansion of the medical care these people came back home to a social care and exhausting themselves in the system milieu needing ways to lower costs while process. Those of us new to medicine in 1965 providing more care to the underserved The solution was to staff the diabetic paid scant attention to these changes or ignored. They began to fit into medi- and hypertension clinics with nurse in the payment system, as there were cine and alter its practice. The expansion practitioners and a single supervising internships and residencies to deal with. of the medical care delivery system and medical resident. This freed about five The familiar operational chain remained the dilution of the physician’s role had house staff from each clinic to man- solidly in place: physician, nurse, and begun in earnest. A very few years later, age in-patients. The nurse practitioners patient. Physician extenders had yet to the paramedic appeared, as early studies were knowledgeable, anxious to prove make a significant appearance. There of firefighters in several metropolitan themselves, and very popular with the were technical personnel in hospitals areas showed that such a rapid response patients, since they spent more time and clinics to be sure, but they provided system could save lives. The delegation with them than the house staff was able ancillary services in laboratories and of immediate care outside of hospitals to do. It was surprisingly popular for all radiology and not direct patient care. and physicians’ offices had begun.

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