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The Decline of an Old Amenity.

It has long been the prerogative of the elderly to mourn the passing of the old days and ways. The accelerating changes of the past decade have provided persons so disposed with a plethora of occasions for this kind of sorrowing. Older and even middle-aged physicians, while acknowledging and utilizing the phenomenal scientific advances of the period, have their own reasons for sadness. Among them is the erosion of one of the traditional principles of medical practice: that the attention given the patient by his doctor should be direct and personal. This precept is disintegrating under a number of identifiable pressures, some perhaps reducible, others probably not, and none easily. The heaviest pressure is that of time. The shrinking supply of that commodity, so far as the doctor is concerned, is owing to a number of factors: one is his enlarging patient load, resulting (to labor a familiar point) from the almost rabbit-like proliferation of the population and failure of the medical schools to turn out a proportionate number of graduates; another is the mounting burden of paper work incident to the rise in third-party participation in the economics of medical care on the part of private and, especially, governmental health agencies. In addition, even in many community hospitals no inconsiderable amount of the time of the attending staff must be given to devising and carrying out approved intern and resident teaching programs, without which, in today’s shortage of house officers, the hospital wallows hopelessly in a buyer’s market. And speaking of teaching, the accelerating growth of knowledge and technology has led in many places to the chief’s feeling obliged to spend more “ward rounds” hours in the conference room discussing such matters with residents and students than are spent with the patients, who, as a result, may receive no more than a head in the door and a perfunctory question or two. Finally, and this by no means exhausts the list, what reader of medical literature has the time to keep his chin above water in the towering wave of new information? It is almost inevitable that these and other events, conditions, and activities will steal more of the doctor’s precious hours as the years, or at the present rate even months, go by. These time robbers of personal attention, it appears, are likely to be reinforced by new developments now looming above the horizon, some in full view. There is the increasing tendency on the part of certifying specialty boards and residency review committees, hardly resisted by the young medical graduate, to require that residents and interns be given major or even “primary” responsibility for the hospital care of patients. This appears highly desirable from the standpoint of the trainee and is no doubt good for him, provided he has adequate supervision; but does it not imply that personal care by the patient’s ultimately responsible physician is almost bound to be mitigated? From another angle, belt-line methods of laboratory and even “clinical” study of patients conducted by auxiliary medical personnel are being employed in some prepayment centers, replacing in certain respects what used to be the functions of the physician himself.1 Will this give him more time with his patients, or will it merely allow him to see more patients with the present minimum of minutes allotted to each? Perhaps he will only be running faster to stay in the same place. In doing so he may be aided by the revolutionary and pretty certainly prophetic plan, now in operation at Duke University, to educate and train physician assistants, nurse associates, and the like who can do many of the things presently done by the master, even including physical examinations, leaving the genuine article, the conventional MD, to draw conclusions, make final decisions, and give advice with only the minimal laying on of hands. This is the doctor depersonalized, diluted, and distant. He may well become more so with the general adoption of the diagnostic computer and the development of the team concept of medical care outlined in the Coggeshall report. It will probably not be possible, and perhaps in the long run not desirable, to stem the tide of these trends. It is not likely, however, that the patient will adapt easily to this kind of care even though he must accept it. Illness will always remain an intensely personal thing. The crucial test of the new system will come when the physician himself becomes a patient.