Reformers and Practitioners

Dr Alper is a practicing internist in Burlingame, Calif, and a Robert Wesson Fellow in Scientific Philosophy and Public Policy, Hoover Institution, Stanford University, Palo Alto, Calif.

Physicians march to the beat of different drummers. The specialties we choose and the patients to whom we offer care vary across an enormous spectrum ranging from renal dialysis to cosmetic surgery and from plush society practices to inner-city clinics. How much of this variation results from differences in professional interests? And what do those differences say about the visions and passions that drive us?

I certainly didn’t have such weighty thoughts in mind when I assigned my current medical preceptee to visit and assess an old patient of mine at his home. Elie, as I’ll call the student, was at the end of his freshman year at the University of California School of Medicine in San Francisco. He had already established himself as one of the handful of truly exceptional students whom I’ve encountered over many years of teaching. Before enrolling in medical school, Elie participated in cutting-edge research on vascular regeneration after injuries. And before that, while in college, he pursued an interest in theater, both acting and directing.

The patient I chose is medically complex, with congestive heart failure, hypertension, diabetes, and severe prostatism, all of which were dwarfed by Parkinson’s disease as causes of his disability. Yet at age 82, former engineer Fred Barton (also a pseudonym) is fully alert and gets around with a walker. He lives with his wife, Harriet, who helps him with the few things that are difficult, such as putting on his shoes. The couple lives in their one-story home, located a few blocks from my office. They have Medicare and good supplemental insurance. Both have been my patients for more than 20 years.

Fred was not a random choice. As a patient, he offered a wealth of information that went beyond medicine—extending into health care delivery, the doctor–patient relationship, good support within the family, adequate health insurance, and much more. The amount that could be learned simply by visiting the home and interviewing the patient and his wife would be limited only by Elie’s perceptiveness and skill in eliciting the details. I told Elie that I hoped he would bring back information that would help me to improve upon Fred’s care.

Upon my return from Germany and Austria (to be discussed in an upcoming column), I set aside an entire afternoon to go over Elie’s findings gleaned during 2 home visits that he had made. No patients were scheduled that day, so we had the luxury of time and undivided attention—something that evoked a certain nostalgia in me, given today’s rush-rush existence. My student did not let me down. He picked up on how Harriet’s painful carpal tunnel syndrome was threatening her ability to assist Fred and how she, the daughter of two chiropractors, reluctantly decided to undergo surgery despite her ideological qualms, essentially for her husband’s sake. Both looked years younger than their age, yet their existence was now precarious. They had given up power boating, their lifelong passion, and with it most of their social life because of Fred’s diminished mobility.

Elie also came up with useful information, as I requested. There was duplication of allergy and prostate medications and possibly of potassium supplements that resulted both from formulary switching and previous medication changes that I had made. Because I had gone over these issues with Fred and his wife more than once, listing all medications and examining the actual bottles, this was a clue to early cognitive decline that would make future care more problematic. Elie was pleased to have made a contribution to the care of the patient.

The more I ponder these questions, the clearer it becomes that we were examining the same proverbial elephant from different perspectives.

He had done such a good job that I was surprised at his hesitation when I asked how his presentation of Fred’s case in class had gone back at the medical school. The instructors had seemingly glossed over his clearly masterful handling of a complex case and grilled him on what he had found about deficiencies in care, financial barriers, cultural and ethnic sensitivities, communication problems, and discrimination. Rather than receiving kudos for his work, Elie was left with a sense of their disappointment in him for not having brought forth more “problems” to discuss.

Indeed, the course is titled “family and community medicine,” and the full-time faculty at the university is heavily preoccupied with the underprivileged and undertreated segments of the population. I had inadvertently trapped Elie with a case that failed to provide expected support for the reform-minded viewpoints of the faculty. Most of his classmates were assigned preceptors in inner-city clinics and practices where deficiencies in care, support systems, funding, and ability of patients to cooperate were very real. Wow!

So who did wrong? I, or the full-time faculty? Who is the one who cares more about patients?

The more I ponder these questions, the clearer it becomes that we were examining the same proverbial elephant from different perspectives. I was teaching my student how successful medical care works. I think it’s very important to concretely illustrate the value of continuity of care and of social, medical, and financial resources to students. This begins the process of professional self-discovery and standard-setting for them and provides a yardstick against which to measure deficits.

But the implications are far broader. Am I, the community internist, ignoring the plight of the poor and the downtrodden while reveling in smug self-satisfaction with successes in my own largely middle-class practice? Or—while I concentrate on the positives in my own practice—are the “real” professors justified in their fixation on reforming what doesn’t work in both medicine and society? Who is the ostrich and who is the zealot?

Here, I believe, lies the conundrum of health care reform. It is one that occupies the minds of patients as well as physicians, because both groups must choose to view the health care glass as either half-empty or half-full. In fact, even this is an imperfect metaphor because—to give one prominent example—while 15% of the population does not have health insurance, 85% does. Even ignoring the argument that lack of insurance is not synonymous with lack of access to medical care, the vast majority of the population is insured. And even if some of that represents underinsurance, most people remain satisfied with their medical care.

This should not be disdained as merely an obstacle to progress, as some self-designated reformers do. Nor should physicians who contribute to what is good in medicine today have their pride undermined by a constant and one-sided focus on “defects.”

Internists, in particular, given the breadth of service we provide, have every right to be proud of what we accomplish, whether we do it in inner cities, posh neighborhoods, or the suburbs. As one reader put it, “I’m proud to be an internist.” I agree.

Yet another truth is that satisfaction with the present should not block constructive change. Equally true, reform-mindedness must appreciate present realities in a considered way to avoid confusing good intent with good works.

I suspect that we all have something of the reformer and something of a predilection for the status quo in us. What determines the balance remains a mystery.

Internists…have every right to be proud of what we accomplish, whether we do it in inner cities, posh neighborhoods, or the suburbs.