The medical profession today:
A dappled picture

aFall 1998

A GLANCE AT the practice of medicine over the last fifteen years could not be more disconcerting. Replacing what some perceive as the "golden age" of medical practice, we now have a system of managed care that imposes fee schedules, restricts practice opportunities by selective contracting, and-depressing to recount-authorizes or disallows clinical decisions. Medical specialists were once valued the highest; the trend today is to decrease their number, because, some experts argue, they increase costs without materially affecting outcomes. Where there was a highly protected, virtually impregnable profession, there is now a critical oversupply of physicians, 22.4 percent of which experience "significant difficulty" in getting a first job (JAMA, Sept. 2, 1998). Nor is this about to improve, since nonphysician clinicians (such as nurse practitioners, certified midwives, chiropractors, and others) are now entering the workforce at an unprecedented rate, and eagerly vying for a wider role — i.e., freer from physicians' supervision — in patient care. And quiet academia, where the scholarly and retiring used to find shelter from contingency and vicissitude, fares no better. Investor-controlled companies have actually bought medical schools (alas!). Which prompted our former surgeon-general, Dr. Everett Koop, to voice a rhetorical adjuration, lest the education of the next generation of physicians be controlled by "bottom-line oriented managers who buy and sell hospitals, medical practices, and medical schools, as if they were pork futures." (Science, Sept. 25).

I am hopeful that our profession will extricate itself from today's predicaments. But how it will look, or under what guise it will emerge from its trials, depends on the attitude physicians adopt henceforward. If our profession is to command respect, and recover lost prestige, then it must be uncompromising in its adherence to the altruistic ideals and humanistic concepts whence it originated.

Instead of invidiously and systematically shutting off nonphysician clinicians from unsupervised contact with patients, doctors should broad-mindedly examine each case on its merits, without preconceptions, and in the honest belief that a nonphysician perspective might, just might, contribute something positive to the care of the patient. Thus would physicians prove that, contrary to the businessmen they complain about, they care more about patients than profits.

Sadly, today the American medical profession excludes minorities. Underrepresented minorities (African-Americans, mainland Puerto Ricans, Native Americans and Mexican-Americans) together form about one-fourth of the population of the United States, but only eight percent of practicing physicians. In academic medicine, barely three percent(!). And this minuscule faculty faces greater difficulty than whites in getting promoted, even after correcting for years of service, peer-reviewed papers, or funded grants (JAMA, loc. cit.)

As the new millennium approaches, I am hopeful, but frankly not at all certain, that the medical profession will sort out the perils that threaten it, and regain prestige. Only it seems that this time recovery requires not just a keen intelligence, but also that rarest of human qualities: wisdom.

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