Meltzer's Curse Upon Our House

"A considerable degree of separation of the signs of clinical medicine from its practice is ... desirable, because the requirements of sciences and practice are in a certain sense mutually antagonistic to one another and the simultaneous cultivation of both branches with equal attention is detrimental to the progress of either of them."

--Samuel J Meltzer, MD; first head of the Department of Physiology and Pharmacology of the newly formed Rockefeller Institute for Medical Research (1904); Founder American Society for Clinical Investigation (1908)

At the close of the 19th-century, medicine was victimized by the loose and iconoclastic ideas contained in ever-changing pseudo-scientific theories. Samuel J Meltzer, an influential medical leader of his time, wrote in the lead article published in the Jounal of the American Medical Association on May 16, 1908:

"...the knowledge of diseases and their treatment, remained for centuries still a prey of ideas, of ever-changing theories. The schools of the iatrophysicists, of the chimiatres, the Brunonian theory of irritability, the theory of vitalism and some other purely theoretic creations dominated consecutively the signs and practice of medicine up to the last century."

Among those who defied true science, he included the general practitioners of his time. They were "idea barren," even if they were considered successful and helpful to the patients. In an example where two physicians, one a learned professor and the other a popular but unscientific practitioner, consulted on the same case with the later "unlearned" clinician ultimately saving the patient, he wrote:

"Here, we had, on the one hand a professor, presumably full of ideas, who could not help his patient, and, on the other hand, an idea-barren practitioner, who at a glance knew the trouble, and with one prescription cured it. Curiously, my sympathy where not on the side of that idea-immune healing artist ... I still believe that medicine and mankind would fare better if we had fewer of them."

The "idea-immune healing artist" of medicine at the opening of the 20th-century - the general practitioner - is the ancestor to today's primary care providers who, at this new century’s beginning, still maintain their legacy (albeit barely). The disdain and condescension they first suffered over 100 years ago still persists. While these primary care physicians remain the "artists" of medicine, the specialists are still the "scientists," continuing their conflict. This is “Meltzer’s Curse,” incompatibility between the two competing arms of modern medicine.

They have two different, though not mutually exclusive, goals. Big medicine’s strength lies with the specialists and in the advancement of scientific medicine. Its weakness is patient care, left to the dwindling primary care providers. Business and industry are the natural allies of scientific medicine and readily promote its cause. Technological advances improve goods and service delivery while lowering costs and creating profits.

When the nascent modern physicians of the early1900's united laboratory science with the healing arts, primary care started its declined.

Samuel Meltzer prophetically said in 1908, "The future of the practice of medicine depends on the progress in its science." Pressured by the controlling efforts of health (read, "fiscal") reform and managed care, while driven by the engines of technology, the 21st-century will see the struggle end with the death of primary care by physicians, and with it, the lost "art" of medicine. (And, arguably, it’s “heart.”) Scientific medicine, meaning "specialty medicine", will dominate. Managed, controlled, and profitable, it will be supreme at last, and protocol driven.

alan berkenwald, m.d.