How six medical trends will shape the new millennium
From the January 2000 ACP-ASIM Observer, copyright © 1999 by the American College of Physicians-American Society of Internal Medicine.
With internal medicine entering a new year—and a new millennium—it is a good time to examine how some of the major developments of the latter part of the 1900s will help guide medical practice in the year 2000 and beyond. While no review would be complete without examining the development of antibiotics and the creation of Medicare, we also wanted to look at more subtle influences on medicine, like the effects of medical computing on physician practice and how workforce issues will help shape future generations of physicians.
ACP-ASIM Observer staff talked to experts in six areas important to internists: the physician workforce, the practice environment, health policy, medical education, clinical medicine and medical computing. Here are what the experts identified as the most important developments in each field, and their take on how those developments will guide internists into the new millennium.
Workforce: a weak guild
As the number of U.S. physicians continues to grow, doctors can expect workforce issues to continue to affect the profession into the 21st century, particularly in terms of negotiating power within the medical marketplace.
According to Alvin R. Tarlov, MACP, one of the nation's elder statesmen of physician workforce analysis, this country suffers from an imbalance in the ratio of clinicians to patients. Because that supply-demand equation is skewed, he said, physicians are a "politically and organizationally weak guild" that cannot effectively negotiate demands by the buyers of their health care services.
"My own sense is that when we increased the number of medical school graduates, we created a ratio that weakened physicians," he said. "Every time physicians were imposed upon, say by managed care, for example, physicians weren't powerful enough to resist it. There were always enough physicians around for hire."
Dr. Tarlov predicted that the economic and political systems driving the education and training of physicians aren't about to change anytime soon. "The market approach to medical services is going to continue," he said, "and there will be continued downward pressure on physician income because of the nature of competition."
Dr. Tarlov, who now leads the Texas Institute for Society and Population Health in Houston, chaired the Graduate Medical Education National Advisory Committee, which in 1981 issued a widely acclaimed report on the country's physician workforce that forecasted a physician oversupply. He also was instrumental in starting the National Study of Internal Medicine Manpower, which is still involved in collecting data on internal medicine residencies with the goal of projecting the number of general internists and subspecialists needed in the country.
To help medicine regain some of its lost market power, Dr. Tarlov thinks that internists need to reinvent themselves with an eye to workforce issues. He believes internists should be looking at how they can reduce the size of their practices, in part to offset the oversupply of physicians.
"An average internist takes care of somewhere between 1,100 and 1,300 patients," he said. "I suggest we go down to 900, but then expand the amount of time per patient and give each patient greater depth, more diverse opportunities for expression of what's bothering them and greater opportunity for health education and counsel.
"The one thing that has made medicine a noble profession is that we take care of one patient at a time," Dr. Tarlov said. "Only 20 years ago, we were highly valued and admired by our patients, and that has slipped out of our hands now. We have to return to that, and the only way is to do for the patients what we were considered to be noble for."
It would also help balance the supply-demand equation if the profession could "do some innovative thinking on what might be the role of senior physicians, aside from trying to maintain their practices in a rapidly changing world."
Finally, Dr. Tarlov predicted that while the nation's medical workforce will continue to expand, it will also become more diverse. Because of the nation's basic pride in being a nation of immigrants, he said, there is very little chance that the stream of international medical graduates training and working in this country will be cut off. He also predicted that the proportion of women in the medicine workforce will continue to increase, which will force the profession to learn how to cope with family-work tradeoffs.
The practice environment: professionalism
As physicians enter the new millennium, one of their biggest challenges will be to cope with the forces that are eroding medical professionalism.
According to College Executive Vice President Walter J. McDonald, FACP, many of the qualities that have traditionally defined medicine—autonomy, authority, community standing and deep personal satisfaction—are being jeopardized by the financial pressures that characterize modern medical practice. Shrinking reimbursements, risky contracts and fiscal problems caused by the Balanced Budget Act are all bearing down on physicians, chipping away at core professional values and emphasizing cost control and payment incentives over patient care.
Perhaps the most significant threat, however, is the time crunch that requires many physicians to function more as administrators than as healers. With health care delivery now hemmed in by cost and time constraints, the core component of doctors' sense of their profession—the physician-patient relationship—is under siege.
"What physicians love about practicing medicine is the time they spend with their patients," said Dr. McDonald. "When they can't spend those extra five minutes to turn a business transaction into a personal encounter, that creates real concern and challenges physicians' sense of themselves as professionals."
Dr. McDonald noted that other growing pressures on academic medicine are also compounding those challenges. Academic physicians find themselves deprived of research time, which inhibits the achievement of their professional goals. Physicians in private practice are taking on bigger research roles.
The net result, he said, is that many of the distinctions between academic and clinical practices have blurred. "The academic physician now has to be a practicing physician, while the practicing physician has to be up on the latest and greatest in medicine," Dr. McDonald explained. "The old differentiation between the two has almost been lost."
Another casualty of the trouble faced by academic medicine is indigent care. "As academic physicians find that they can no longer fulfill that mission," he said, "practicing physicians are going to be called on to help get the job done. It's going to make all of us go into our 'professionalism reserves'—remembering why we became doctors in the first place and addressing ethical, rather than financial, concerns."
Despite all of the challenges, Dr. McDonald said he is heartened by several developments. For one, he finds the recent shift by some managed care companies toward returning medical decision-making to physicians encouraging. He hopes that the move helps restore some sense of physician autonomy.
Even more importantly, he is encouraged by the new attention being paid to what he called "the biggest challenge to our profession," treating the uninsured.
"This is becoming enough of a problem that I believe our society within the next five years will do something about that," he said. "That would take some of the pressure off of physicians."
Clinical medicine: antibiotics and vaccines
Ask infectious disease specialist Kathleen E. Squires, ACP-ASIM Member, what advances in the last century had the biggest impact on clinical medicine, and she has a ready answer: the parallel developments of antibiotics and vaccines.
"Their use has dramatically changed our approach to infectious diseases and has actually influenced the kind of infectious diseases we now see," said Dr. Squires, associate professor of medicine at University of Alabama at Birmingham. "Smallpox is gone, we're essentially at the end of polio and we virtually don't see many of the childhood infectious diseases, like hemophilus influenza, any more."
The 20th century began with an outbreak of bubonic plague in San Francisco and with physicians still depending on herbal compounds to fight disease and ended with a vast arsenal of antibiotics and vaccines. Yet Dr. Squires pointed out that clinicians' excessive use of antibiotics has physicians grappling with a new dilemma: Organisms that doctors were convinced they could control—like streptococcus, staphylococcus and tuberculosis—have roared back in drug-resistant forms.
"The irony is that we had too much of a good thing," Dr. Squires said. "We now have to develop even better antibiotics to act against the resistant bacteria we helped create. We also have to get a lot smarter about the way we use them."
(The College plans to highlight the issue of antibiotic resistance in its first clinical theme, which will be unveiled at this year's Annual Session in Philadelphia. More information will appear in future issues of ACP-ASIM Observer.)
As medicine tries to re-conquer some old killers, it is also battling a new spectrum of diseases that has emerged, again with a little help from humankind. As remote areas such as rain forests and parts of the Southwest United States are developed, isolated viruses like ebola and hanta spread.
Air transportation has also made many diseases more mobile. According to recent figures from the World Health Organization, 50 million people worldwide have been infected by HIV in less than 20 years. The death toll from AIDS now stands at more than 16 million, while in some parts of the world, infectious disease remains a dominant force.
While antibiotics saved the day in the last century, Dr. Squires said that vaccines will serve as the ultimate weapon against many emerging infections, including AIDS. Researchers anticipate a future in which vaccines for conditions like HIV will build on methods perfected in the last century to isolate, synthesize and mass-produce compounds. Right now, however, research for this new wave of infectious disease is at the point where antibiotic production was 60 years ago: in its infancy.
"We have to get at these pathogens at a genetic level to be able to impede their ability to replicate and grow," Dr. Squires said. "Gene research and molecular biology will be the key." One such breakthrough was recently announced: the creation of a genetic map of the parasite that causes malaria, an organism that causes 2.5 million deaths worldwide each year.
As Dr. Squires is quick to point out, new treatments are just the beginning. Clinical medicine will still have to wed itself to political and social will. "We have to get those vaccines to the people around the world who are the most affected but don't have adequate medical infrastructures," she said. "That will be another great challenge."
Medical education: losing ground
While the 20th century produced a revolution in medical education that helped make American health care the best in the world, many of those gains appear to be coming undone.
"I would suggest that everything is coming apart," said Kenneth M. Ludmerer, FACP, the nation's leading historian of the American medical education system. "The managed care environment has been injurious to the training of physicians."
Dr. Ludmerer, a professor of medicine in the school of medicine and a professor of history in the faculty of arts and sciences at Washington University in St. Louis, said that American medical education is abandoning the principles that made it great. In the past, he said, medical schools and teaching clinics offered rich learning environments, recognizing that medicine is "learned, not taught." Faculty at these schools were encouraged to keep active in scholarly research, as well as teaching and clinical care. Moreover, Dr. Ludmerer said, medical schools existed to serve society first, the profession second and themselves third.
According to Dr. Ludmerer, part of the problem is how academic medicine's leadership has reacted to a tightening economic climate. In his new book, "Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care," he argues that it's important to distinguish between the survival or financial viability of academic medical centers and the endurance of exemplary medical education. "You can run fast enough and see enough patients quickly enough that you are in the black as opposed to the red," he said, "but that can come at an enormous cost to the quality of your educational programs."
As leaders in academic medicine have focused more on survival and less on education over the last decade, Dr. Ludmerer said, there has been a gnawing away of the learning environment. "The educational tenet of medicine is that you allow students the opportunity to learn by doing," Dr. Ludmerer explained. "But if you are discharging patients in three days, you don't observe the natural history of disease, you don't see the results of diagnostic tests, and you don't see the results of therapy. To have good education, by definition, you will not be trying to see the maximum number of patients."
In Dr. Ludmerer's view, two other basic precepts of medical education are also being threatened. Some medical schools are withdrawing from universities, and others are hiring faculty whose primary job is to see patients, not to teach and do research. As a result, some academic health centers are no longer significantly different from community hospitals.
One of Dr. Ludmerer's solutions includes "slowing the pace of patient care to allow the learning environment to be restored." The profession must also demand that medical education be allowed to occur in a "noncommercial environment" and that future physicians be taught by faculty engaged in scholarly activities.
If medical education returns to these core philosophies, he said, other details—where and what students are taught, for instance—will better reflect both new subject matter and current public needs.
Health policy: Medicare
Looking ahead to health policy in the new millennium, one issue—how Medicare will deal with aging baby boomers—is likely to dominate much of the debate.
From its inception in 1965, Medicare has guided the nation's thinking on health care policy. And while many physicians regard the federal program's arcane rules and requirements as interfering with their practice, the program has affected their lives in much more profound ways.
According to Robert B. Doherty, the College's Senior Vice President for Governmental Affairs and Public Policy, Medicare has contributed to an overall rise in physician pay. Before Medicare, he explained, physicians viewed working with the elderly as charity care, or they heavily discounted their fees. At that time, insurance plans typically covered inpatient care only, and most seniors had little resources to pay for their own care.
Once Medicare began reimbursing physicians to care for the elderly on an outpatient basis, Mr. Doherty said, physicians began receiving regular reimbursements for services they had typically been discounting or giving away. "There was a huge influx of dollars from the federal government to physicians taking care of those patients," he said.
Mr. Doherty pointed out that Medicare also helped boost the ranks of subspecialists. Before Medicare, physicians who subspecialized spent considerable time and money without any guarantee that their extra educational efforts would pay off financially. Medicare guaranteed that subspecialty care of the elderly would be reimbursed, creating a boom in subspecialty medicine.
The question facing doctors in the 21st century is how Medicare will evolve to face a growing elderly population—and how they will be affected by those plans.
Physicians have already had a taste of that future with the government's campaign to stamp out fraud and abuse in Medicare. The campaign, which was created in part to help keep the program solvent into the future, has made physicians resent the need to thoroughly document patient visits to avoid the wrath of fraud investigators.
As the effort to preserve Medicare kicks into high gear, physicians can expect even more activity from the government. As legislators and policy-makers look at how they can preserve Medicare for future generations, Mr. Doherty pointed out that many are already scrutinizing how the country pays for physician education.
Lawmakers and policy analysts are questioning whether a program designed to care for the elderly and disabled should be in the business of paying for the education of doctors who will eventually treat patients from all health payers, not just Medicare. Some would like to remove funding for graduate medical education from the program to make it financially stronger.
Radically changing the funding of graduate medical education, Mr. Doherty said, raises serious questions about whether the resulting physician workforce would be prepared to care for the elderly. It also raises questions about who would finance indigent care, which is currently subsidized by Medicare payments.
For now, however, medicine and physicians have something of a reprieve. With the country in an economic boom and Medicare flush with funds, the financial threat to the program is not as imminent as once thought. "We've pushed back the day of reckoning a few years," he said.
Medical computing: the Internet
Less than a decade ago, few people had ever heard of an obscure technology known as the Internet. Now, the combination of the Internet and the World Wide Web is transforming the doctor-patient relationship, and it may even help physicians put more technology into their practice.
Edward H. Shortliffe, FACP, professor and chair of the department of medical informatics at Columbia University's College of Physicians and Surgeons, pointed out that while it took nearly 80 years for the telephone to reach the 50-million-user mark, the Web reached the same number of users in less than four years. One of the results is a boom in the number of health-oriented Web sites and a change in the way that patients approach their health. "It's a rare physician who hasn't had patients show up with information about their condition that they've printed out from the Internet," said Dr. Shortliffe, who is also professor of medicine and computer science at Columbia.
One of the benefits of the Internet, Dr. Shortliffe explained, is that patients sometimes find information on the Internet that is new to their physician. "There's no way for physicians to keep up-to-date on everything, and no one is more motivated than that patient to really research their problem," he said. "Sometimes you learn from the patients and the things they've found."
The downside is that much of the information patients find is useless because it does not pertain to the patient's condition or because it is wrong. "We often need to convince them that something they have found is simply wrong or doesn't apply to them," Dr. Shortliffe said. As physicians struggle to deal with the deluge of patient information—and misinformation—on the Internet, many are finding themselves more pressed for time than ever.
Slowly, however, physicians are beginning to realize the timesaving potential of Internet features like e-mail. While physicians are wary of being flooded with patient e-mail, Dr. Shortliffe said that some practices are learning to manage the flow and help make their practices more efficient. Some, for example, are learning to use e-mail to process requests for prescription refills and even referrals to subspecialists. Because e-mail helps physicians avoid playing telephone tag, some practices are actually saving time by using e-mail.
The big question is whether physicians' use of Internet technologies like e-mail will lead them to embrace the other major medical computing development of the 20th century, electronic medical records. While Dr. Shortliffe said that doctors will need a push from the government or society to really begin using electronic records technology, he thinks physician acceptance of Internet technologies is a good start.
While most physicians currently complain that entering patient information into a computer simply takes too long, he is hopeful that they will learn a valuable lesson about how time invested in technology often pays off. "People need to get a little more sophisticated about how they spend their overall time," he said. "If by spending an extra two minutes on electronic medical records software you create a really useful document that's electronic and can be shared by other people, an investment of two minutes now may save you a lot of time later."
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