Oslerian February 2008

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AMERiCAN OSlER SOClHY February 2008 Volume 8, Issue 4 The Oslerian A Message from the President Intern I Medicine s Vocation ing rapidly/ and the projected futures of internal medicine look mainly glum. The reasons for this dour outlook seem two-fold: the lure of specialization that Osler warned against, which pulls candidates away from primary care, and a decreased influx of new generalists from the medical schools.' Now, the road to proficiency in internal medicine has never been easy
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  February2008Volume 8, Issue 4 Insidethisissue: InMemoriam:EarlF.Nation(1910-2008)InMemoriam:CharlesF. Wooley(1929-2008) Secretary-Treasurer's ReportDalesandLocationsfor 2008,2009,and2010AnnualMeetings FrankA.Neelon AMERiCANOSlERSOClHY TheOslerian A Message fromthePresident InternIMedicine 4 Greetings,Fellow Oslerians In1897,WilliamOslerad- dressedtheNewYorkAcad-emyofMedicineonthesubjectof InternalMedicineasaVo-cation ]InhisspeechOsler definedinternalmedicineas thatwhichremains[ofgeneral practice]aftertheseparationofsurgery,midwifery,andgynae-cology. AlreadyOslermust havebeenleeryofthepitfalls ofspecialization,becausehesaysthatsuchinternalmedicinepractitionerscouldnot becalledspecialists,butbearwithoutreproachthegoodoldnamephysician, andfurtherpointedoutthat thestudentofinternalmedicinecannotbea specialist. NodoubtOslerenvisionedtheinternistasacounselorindifficultordoubtfulcases,adiagnosticianandallyofthe generalpractitionerandsur-geon,butthereisnohintthatheanticipatedtherolethatwouldevolveforgeneralphysi- cians (internists,pediatricians andfamilydoctors)inthelate20 th centuryUnitedStates. That'snotsurprisingsincethenotionofaprimarycaredoctorwhoprovidesfirst-contactandongoingcareforpatientswithchronicdiseases-indeed,the veryideaofchronicdisease(letaloneitschemicaltreatment)- wasnotvisibleontheradarscreenofmedicinein1897. Nevertheless,asthemeansof 4 s 6 s Vocation detectingandmeasuringthedisturbedphysiologicalproc- essesthatwecallchronicdis-easesbecameavailable,doctorswererecruitedtocareforthosepatients.Whenspecialization madetheideaoftruegeneralpracticenolongertenable,gen-eralinternalmedicineandpedi-atricandfamilymedicinedoc- tors(andlaterphysician'sassis- tantsandnursepractitioners)wereenlistedtocareforpa- tientswiththeheartdisease, cancers,stroke,chronicob-structivepulmonarydiseases,anddiabetesthataccountfortwo-thirdsofalldeathsintheUnitedStates. I suspectthatOslerwouldhavebeenhappy withsuchageneralroleforinternists,justasheapplaudedthelifeandworkof19 th cen-turygeneralpractitioners.He mightevenembracetheideaofa primarycarehome,,2- apracticelocationwherepatientsstartandcontinuetheirqueries abouthealthandsymptoms,wherethecliniciansknowandvaluetheirpatientsashumanentitiesandseethemmorethanonceinalifetime;aplace where,asRobertFrostsaid, whenyouhavetogothere,!Theyhavetotakeyouin. TheGeneralistasEndan- geredSpeciesValuableasprimarycaredoc-torsare,theirranksareshrink-ingrapidly/andtheprojectedfuturesofinternalmedicinelookmainlyglum. Therea-sonsforthisdouroutlookseemtwo-fold:thelureofspecializa- tionthatOslerwarnedagainst,whichpullscandidatesaway fromprimarycare,andade- creasedinfluxofnewgeneral- istsfromthemedicalschools.'Now,theroadtoproficiencyin internalmedicinehasnever beeneasy.Atatimewhenpost-graduatemedicaltraining barelyexisted,Oslerrecom-mendedthatthenascentinter- nistdevotethefirsttenyearsaftermedicalschooltoekingoutalivingthroughgeneralpracticeorautopsyworkorserviceinadispensaryandusethefewdollarsaccruedtofi- nancehisself-educationthroughbriefstintsintheclin-icsandlaboratoriesofEurope. Sincecandidateswouldhavenofreemoney,Oslerinter- dictedallromanticentangle-ments( put[your]emotionson ice;theremustbeno 'Amaryllisintheshade,'and... bewarethetanglesof'Naera's hair' ).' Notonlyweremar-riageandfamilynotpossible but,astheallusionstoMilton's AmaryllisandNaeraimply,Oslerforbadeevendalliances,whichmightdistractthecandi- datefromhisgoal.Thoseten yearsofpenurywouldbefol-lowedbytenmoreyearsof (Continuedonpage2)  Volume8,Issue4heOslerianPage2 President's Message (continued) subsistenceliving,afterwhichthenowmaturegeneralistwouldbepoisedformarriageandfamilyandtherewardsofconsultative life.GiventherigorsofabnegationprescribedbyOsler,itisper-hapsawonderthatinternalmedicinesurvivedatall.Isuppose thatcodifyingthetrainingtoformalresidencyprogramslasting threeorfouryearshelpedmaketrainingmoreattractive,asdidpayinghouseofficersmodestbutcertainlynotinconsiderablewages.Still,anumberoffactorsworkagainstsustainingtheranks ofdoctorsdevotedtogeneralmedicine, perse. Osler'swarnings aboutthe driftintospecialism havecometopass.Inpart,this reflectstheattractionofhigherincomeavailabletothecardiologistorgastroenterologist-nosmallmatteratatimewhentheaverage indebtednessofgraduatingmedicalstudentsis$130,000andspe- cializationoffersthechancetodoubleortripleone'syearlyin- come.Inpart,too,itreflectstheshallowportraitofthedoctorasa knowledge automaton' or talkingbook thatisoftenpromul- gated(perhapsunwittingly)duringmedicalschool.Sincestudentsdespairofeverknowingeverythingabouteverything,theycon-strictthehorizonofwhatistobeknownbyspecializing. I hinkthatstudentsaremistakenintheirappreciationofwhatdoctoring isabout,butgainingthatperspectivetakesyearsbeyondthedeci- siontospecializeornot.Oslersaysthatthe physiciandevelops moreslowlythanthesurgeon,andsuccesscomes later' ; wemightsaythesameofresidentswhoare,alas,forcedtochooseata youngagebetweenspecializationorgeneralism.Thereisnoget- tingaroundthefactthatsuchlifedecisionsareandmustbemade ontheshortsideofexperienceandwisdom. TheTyrannyofTimePressure Evenmoreworrisomethanthepulloutofgeneralismintospeciali- zationisthelackofattractionofprimarycareitself.Thereare nowapproximately900,000licensedmedicaldoctorsintheUnited States,andthenumberhasbeengrowinglinearlyforthepast4decades. Overthatsametimespan,thepercentageofmedical practitionerswhodevotethemselvestoprimarycarehasfallen, againalmostlinearly,from40%to34%.Isthatanacceptable proportion?Thisraisesthequestionofhowmanyprimarycare doctorsthiscountryneeds,andthatisnotaneasynumberonwhichtogetconsensus,soletmesharealittlethought-experiment ofmyown.Truls0stbye,KimberlyYarnallandtheircolleagues atDuke 7,8 haveestimatedtheamountoftimeitwouldtakeapri-marycarepractitionertofulfilljustthecurrentguidelinesforpre- ventivehealthandchronicdiseasemanagement.Theymadetheircalculationsbasedoneachdoctorhavingapanelof2500primary carepatientswhoseage,genderanddiseasedistributionsmirrortheUSpopulation.Theirveryconservativeestimateisthatapri- marycaredoctorneeds1.04hoursperpatientperyearjusttocarryoutthesenon-urgent(andoftennotsymptom-driven)tasks.Eachdoctorwouldthusneed2600hoursperyearjustforalltheauthori-tativelymandatedpreventiveandprotocol-driventasksforanav-erage-sizedpanelof2500patients,buteachdoctorhasonlyabout 2000office-basedhourseachyearforpatientcare.Howdotheysqueeze2600outof2000?Obviouslytheydon't-theyeitherhavephantompatients(technicallypartofthepanel,butwho - nevercometothedoctor)ortheyglossovermanyoftherecommen-dations.Ithinkthatourmedicalstudentshavesensedthetimedilemma confrontingprimarycare andhavevotedwiththeirfeetforseem-inglymoreluxuriantpastures.Couldwerectifythissituation?Couldwefindwaystolessenthetimeburden?Let'sassumethatprimarycaredoctorsshouldspendhalftheirtime(~l000hours/doctor/year)onpreventiveandprotocol-driventasks;thismeanseachdoctorhas roomfor apanelof1000patientsandeachofthesepatientshas,onaverage,twohourswiththedoctor/year.Of coursesomewouldrequiremuchlessandsomemore,butthatseemsareasonableallocationforensuringthatbothroutineandurgentproblemsarecovered. HowManyDoctorsDoWeNeed? Dowehaveenoughprimarycaredoctors?Well,mycalculations suggestthat300,000primarycaredoctorscouldcareforeveryoneofthe~300,000,000men,womenandchildrenintheUS.Rightnow theUShasapproximately920,000doctors,ofwhomabout280,000 areengagedinprimarycare. Soatpresentweareabout20,000 primarycaredoctorsshort,butifpresenttrendscontinue,bytheyear 2010,thepopulationoftheUSwillhaveincreasedto310,000,000 andwemayhaveasmanyas285,000primarycaredoctors.Injust2 yearsthedeficitwillincreasefrom20,000to25,000!Thesedemo- graphictrendshavemostobserversveryworried. I0,1I Theforthcomingpresidentialelectionmaywellleadtochangesin USmedicalcare.Thedialoguethatisongoing':'raisesmanyques-tionsaboutthenatureandthefinancingofourhealthcaresystem. Amongthosequestionsarethefollowing:Canwecontinuebyask-ingdoctorstoworkharderandfasterthantheylegitimatelycan?9Atpresent,theUShasoneprimarycaredoctorforevery1150citizens, butthereiswidegeographicvariationinthatnumberfrom1per800inMassachusettsto1per1500inMississippi.l'Canwecontinuetolargelyexcludeourmorethan40millionresidentswithnohealth insurance?Canwe-anddowewantto-r-fillthebreachinprimary carewithphysician'sassistantsandnursepractitionersv' RecoveringOsler'sParadigm Perhapsthemostimportantquestionis,canweresurrectOsler's vision 1 ofmedicalpracticeasasacredcalling,avocation,whoserewardsofpersonalandprofessionalsatisfactionwillmorethan compensateforthelongandarduousroadtowardthatgoal? I hinkmaybewecan,butitwilltakeconcertedprofessionalandpoliticalaction.Inthespiritofdialogue,Isubmitthefollowingimmodest proposalsthatmedicinemightadopt: 1.Lessentheindebtednessofgraduatingmedicalstudents byunderwritingtheirtuitionor,better,byminimizingtuitionitself. Howcouldwedothis?Iwillgiveoneexample.Frommyob- servation,theso-calledbasicsciencesofmedicinearetaughtnot asscientificendeavorbutascatechism,whiletheprinciplesthat scientificinquirymightteach-curiosity,skepticism,dogged- ness,learning-by-doing,forexample-havebeenreplacedby temporaryindoctrinationwithfactsderivedfromscientificdis- covery.Giventheavailabilityofmoderncommunications,it shouldbepossibletoinculcatescience-derivedinformationby  Volume8,Issue4 I TheOslerian Page3 distancelearning.Thatmeansthatasingle(smallandwell- paid)teachingfacultycould,viaelectronicandcomputercon- nections,servethewholecountrywithresultingsavingsin studenttuition.Furthermore,thatcoursecouldbetaughtas historyratherthantheindoctrinationoffactsandthereby demonstratehowscientificinquiryanddiscoveryhasunrav- eledourunderstandingofhowthebodyworksanddoesn't work.Regionalormedicalschoolsectionswouldstillpro- videthepersonalguidanceandtheremnantofpracticallearn- ing,suchasanatomicaldissection,thatisdeemednecessary. Howcouldwedothis?Iwillgiveoneexample.Frommy observation,theso-calledbasicsciencesofmedicineare taughtnotasscientificendeavorbutascatechism,whilethe principlesthatscientificinquirymightteach-curiosity,skep- ticism,doggedness,learning-by-doing,forexample-have beenreplacedbytemporaryindoctrinationwithfactsderived fromscientificdiscovery.Giventheavailabilityofmodem communications,itshouldbepossibletoinculcatescience- derivedinformationbydistancelearning.Thatmeansthata single(smallandwell-paid)teachingfacultycould,viae1ec- tronicandcomputerconnections,servethewholecountry withresultingsavingsinstudenttuition.Furthermore,that coursecouldbetaughtashistoryratherthantheindoctrina- tionoffactsandtherebydemonstratehowscientificinquiry anddiscoveryhasunraveledourunderstandingofhowthe bodyworksanddoesn'twork.Regionalormedicalschool sectionswouldstillprovidethepersonalguidanceandthe remnantofpracticallearning,suchasanatomicaldissection, thatisdeemednecessary. 2.Makethepracticeofprimarvcareattractiveoncemore bylesseningthetimeburdenonpractitioners,bybuttressing theideaofthemedicalhome,wherepatientsaretrulyknown andvaluedandtowhichtheyturnwhentheythinktheyarein trouble.Certainlythereareinformationsystemsavailableor possibletodevelopthatwillhelpthedoctorinthisdailytask. Weneedtofundthesustenanceofdoctoringaswellasthe wars wewageonvariousdiseases.l 3. Provideprimarycaredoctorsareasonableincome.Howmuchdoctorsshouldearneachyearisopentodebate. AtthepresenttimeUSprimarycaredoctorsmakeabout $150,000year. 16 Atthatrate,itwouldtakeabout $45,000,000,000/year topayforthe300,000primarycare doctorsIthinkweneed.Forty-fivebilliondollarsmayseem alot,butitrepresentsonly2.25%ofthecurrent $2,000,000,000,000thattheUSspendseachyearonhealth care.Infact,wecouldincreasecompensationto$200,000 peryear(tocarefor1000patientsperyear)andstillcomein at3%ofthetotalexpenditure.Averygood,ifnotlavish, yearlyincome,coupledwithajobdescriptionthatseemsdo- able,willattractdoctors. 4.Enlargetheperspectiveofthedoctor'sjob.Thesedays, evidence-basedmedicineistherage,andwhocouldobjectto theuseofevidence,eventhoughmuchofwhatisbeing passedoffas medicine ismerelyevidence-based treatment? ButIsubmitthatthedoctor'sjobismuchmorethanmere treatment.Perhapsincludingthepatient'snarrativeinthe bodyofevidencewill help. Perhapsawideracquaintance ofsucceedinggenerationsofstudentswiththepurposesofthe internalmedicineandotherprimarycaredisciplinesriskdeathby marginalization.ButIthinkOslerwasright.Ithinkthatweneed toencouragetheideathattheunspecializedcareofpatientsisa highcalling,unparalleledinitsopportunityforself-sustenance,for self-education,forself-fulfillment.Onlyifwedothiswillwe preventavocationfrombecomingavocation. FrancisA.Neelon neelo001@mc.duke.edu References1.Osler W. Internalmedicineasavocation, inAequanimitaswith OtherAddresses. Thirdedition,Philadelphia:PBlakiston'sSon & Co;1932.2.GrumbachK,BodenheimerT.AprimarycarehomeforAmeri- cans. lAMA 2002;288:889-93. 3.RichEC,MaioA.Latetothefeast:primarycareandUShealth policy. Am 1 ed2007; 120:553-9. 4.HemmerPA,CostaST,DeMarcoDM,etal.Predicting,prepar- ingfor,andcreatingthefuture:whatwillhappentointernalmedi- cine? Am 1 Med2007; 120:1091-6. 5.LarsonEB.Physiciansshouldbecivicprofessionals,nojust knowledgeworkers. AmJMed2007; 120:1005-9. 6.AmericanMedicalAssociation.PhysiciansintheUnitedStates andpossessionsbyselectedcharacteristics.(AccessedFebruary 14,2008athttp://www.ama-assn.org/ama/pub/ category/2688.html). 7.0stbyeT,YarnallKSH,KrauseKM,etal.Istheretimefor managementofpatientswithchronicdiseasesinprimarycare? AnnFamMed 2005;3:209-14. 8.YarnallKSH,PollakKI,0stbyeT,KrauseKM,MichenerJL. Primarycare:isthereenoughtimeforprevention? Am 1 PubHealtil2003;93:635-41. 9.MorrisonI,SmithR.Hamsterhealthcare. BMJ2000;321: 1542-2. 10.SandyLG,SchroederSA.Primarycareinanewera:disillu- sionanddissolution? AnnlntemMed 2003;l38:262-7. 11.SalsbergE,GroverA.Physicianworkforceshortages:impli- cationsandissuesforacademichealthcentersandpolicymakers. AcadMed2006; 81:782-7. 12.RelmanA. ASecondOpinion.RescuingAmerica'sHealth- care:APlanforUniversalCoverageServingPatientsOverProfit. NewYork:PublicAffairs;2007. 13.AssociationofAmericanMedicalColleges. 2007State Physi- cianWorkforceDataBook (accessed14February2008at ilttp.!/ www.aamc.org/workforce/statedatabookjan2008.pdfj. 14.MundingerMO,KaneRL,LenzER,etal.Primarycareout- comesinpatientstreatedbynursepractitionersorphysicians. lAMA 2000;283:59-68. 15.ShowstackJ,LurieN,LarsonEB,RothmanAA,HassmillerS. Primarycare:thenextrenaissance. AnnIntemMed2003;138: 268-72. 16.Physicianssearch.Physician'scompensationsurvey. (accessedFebruary14,2008at httpi/rwww.pbysicumssesrch.com/ pilysician/salary2.iltml). 17.CharonR,WyerP.Narrativeevidencebasedmedicine. Lancet 2008;371:296-7.  EarlNationonMay3,2007,justbeforeleaving Montrealaftertheannual meetingoftheAmerican OslerSociety. _:_t w:. f.···..·. TheOslerian Page4 InMemoriam EarlNation(110-2008) EarlF.Nation,chartermember,ninthpresident,andactivepartici- pantinallaspectsoftheAmericanOslerSociety,diedathishome inPasadena,California,onNewYearsDay,2008,twelvedaysshy ofhisninety-eighthbirthday.Hehadbeenactiveandwelluntil December27,havingrecentlyhadhisdriver'slicenserenewed andhavingregisteredforthe2008annualmeeting,whenheawak-enedwithaloudmechanicalnoiseoverhisleftearthatproved,onCTscan,toreflectacerebrovascularaccidentinvolvingtheleft temporallobe.AnMRlscandemonstratedalargelesionconsis- tentwithastrocytoma.Hereturnedhomeforseveralquietand largelyasymptomaticdaysbutlackedhisusualenergy.AfterwatchingtheRoseBowlparadeonNewYear'sDay,hetooka nap,thendevelopeddistress.Hislastwords,spokentohissonsBobandBiII,were 1loveyouall.Don'tcalltheparamedics. AmemorialservicewillbeheldforEarlinPasadenaonMarch 2,2008,andweanticipatethatthebiographicalsketchprepared forthatoccasionwillbereprintedinsufficientquantityfordistri- butiontoallAOSmembers.Inbrief,hewasborninZephyr, Texas,graduatedfromhighschoolandcollegeinSanDiego(the latteratSanDiegoStateCollege,wherein2005hewashonored asaDistinguishedGraduate),receivedhismedicaldegreefrom CaseWesternReserve,anddidaurologicalresidencyatLosAn- gelesCountyHospital.Itwastherethathecontractedtuberculosis, InMemoriam CharlesF.Wooley(192-28) CharlesF.Wooley,longtimememberandtwenty-sixthpresident oftheAmericanOslerSociety,diedathishomeinColumbus, Ohio,onFebruary15,2008,ofpresumedpulmonaryembolism followingotherwisesuccessfulhipreplacementsurgery.Hehad beeningoodhealthandplannedtopresentapaperentitled Anglo-AmericanCardiology:Osler,Lewis,Libman,Cohn,etaI., andtheMountSinaiConnection atthe2008AOSmeetinginBoston.Thecoveringlettertohisabstractsubmissionread: Conflict?-No!Enthusiasm-Yes?Onlyrequest-Firstmorning session. AnativeofNewJersey,CharliegraduatedfromProvidenceCollegeandtheNewYorkMedicalCollege,thendidhisintern- ship,residency,andcardiologyfeIIowshipatOhioStateUniver- sity,wherehewouldspendtheremainderofhiscareer.Asanac- tiveandprolificinvestigator,hewashonoredwithaCareerRe-searchDevelopmentAwardfromtheNationalInstitutesofHealth.Hisresearchincludedpioneeringobservationsontheuseofdiag-nosticultrasoundandtheuseofgeneticmarkerstoidentifyspe- cifictypesofheartdisease.HedirectedtheCardiologyCatheteri- zationLaboratoryatOhioStatefrom1962to1971,anerathatsawtheriseofopenheartsurgeryasweknowittoday.Hewasalso involvedintheearlyuseofcardiacpacemakersandelectrophysi- ology.Asateacher,Charliereceivednumerousawardsforexcel- lencefrommedicalstudentsandhouseofficers.Especiallysince Volume8,Issue4 leadingtoa24monthhospitalizationduringwhichhereadHarvey Cushing's LifeofSirWilliamOsler. Recovered,heenjoyedalonganddistinguishedcareerpracticingurologyinPasadenaand,later,a longanddistinguishedcareerasamedicalhistorian.TheAmerican OslerSocietywasbutoneofthenumerousorganizationsthatbene- fitedfromEarl'senergy,enthusiasm,andlargesse.Hiscontributions totheAOSwerelegion,butperhapsnoneofmorelastingvaluethan hiscompilationofthesecondaryliteraturethatledtothetwovol-umesof AnAnnotatedChecklistofOsleriana. Earlwaspredeceasedin1997byhiswifeof61years,Evelyn.Hislongtimesecretary, CarolynGuiditta,remainedhisfaithfulanddevotedfrienduntilthe veryend.-CSB CharlesWooleyatthe OhioStateUniversity MedicalCenter,wherehe madehismarkasclini- cian,teacher,researcher, andhistorian retiringfromfull-timefacultystatusin1992,hemadenumerous contributionstothehistoryofmedicineandespeciallyofcardiology. Hispresentations,publishedarticles,andbookswerenotedfortheir clarityandespeciaIIyfortheirsplendidiIIustrations.DuringhisAOS presidency,hepreparedabrochureforplannedendowmentgiving. AnobituaryrecognizedsuchOslerianattributesas akeensenseofpersonalandsocialresponsibility, thehighestethicalstandards, andhisservingasa willing,patient,andSocraticmentor. Charlieissurvivedbyhiswifeof53years,MaryLucia,adaugh- ter,threesons,fivegrandsons,fivegranddaughters,andasister.-CSB
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