Marcus Welby is an Establishment Quack!
A new generation of doctors is forcing the medical profession to examine itself.
(Page 4 of 4)
"The private hospital is primarily a referral hospital," points out third year student John Uphold "and that's where you learn the esoterica. You're around a lot of very intelligent staff and you get to see some weird diseases. After all, if some guy in the sticks gets a child with a strange metabolic disease, he's going to send the kid to Texas Children. I myself think that's an important part of my training."
And another student view: "I spent a week with this Houston doctor in his private office. I swear he spent more time on the phone with his stockbroker and his attorney than he did with medical matters. He really turned me off to private practice."
"These fellows are young and idealistic," retorts a private man. "Just wait 'til they're married and have kids to feed and educate. Their tune will change. That's the way it's always been."
And back to the "new student:" "We want exposure to the real world—right now we're very much under a tutorial, authoritarian structure by which we spend half of our time in private hospitals where we have no part in the decision-making process. Why should we spend a week observing fancy open heart surgery which most of us will never do after graduation, when we really need to see ambulatory patients being treated?"
Answers Dr. DeBakey to this criticism, "It's one thing for a student to decide what he ought to do and quite another for a school to ensure that every student fulfills the minimum requirements for the M.D. degree and to be sure that he can pass his Boards. We must have a dialogue between students and faculty going all the time and we try our best to keep channels open."
But the question of how many and what type of doctors Texas is going to have has recently gone even beyond the local medical school scene where faculty and students make the decisions. Politicians, university regents, legislators, the A.M.A. and the Texas Medical Association are all getting into the act.
Dr. Charles Hoffman, American Medical Association president, noting the maldistribution of medical personnel and services for the American Indians, rural residents and those in urban ghettoes, has suggested that "We need to develop a national program, whereby young people will have their medical schooling paid for in exchange for their agreeing to go into rural areas and practice for three, four or five years."
Mr. Robert G. Mickey, Director of the Texas Medical Association's Office of Medical and Health Manpower, notes that Texas not only has a distribution problem (there are 23 counties in Texas without any M.D.'s at all), but an absolute shortage of doctors.
Mickey says there are various ways of evaluating needs, the usual one being to compare Texas, which has one non-federal doctor for every 861 people, with other state averages. The national average is one doctor for 674 people, and Texas' ratio is tenth among the ten largest states.
But a more realistic way of determining Texas' needs, says Mickey, is to compare the number of doctors in various specialties with the ideal. Our present ratio of one family practitioner for every 3,650 people doesn't stack up well with the ideal ratio recommended by the American Academy of Family Physicians (formerly A.A. of General Practice) which is one per 2,000. Just to achieve the national averages, Texas needs 770 more internists, 190 pediatricians and 180 more obstetrician-gynecologists, says Mickey, adding "these are nice working numbers, but if all these doctors suddenly appeared out of the sky, we'd still have a problem in distribution."
Mickey says the T.M.A.'s physician placement service is promoting Texas as a desirable place to seek opportunity. Last year the State of Texas licensed over a thousand new physicians.
The T.M.A. has also lobbied for state legislation which increased the number of med schools in Texas from three (in Galveston, Houston and Dallas) to six (adding San Antonio, Lubbock and another in Houston). That means that by 1975, says Mickey, there will be 1,040 freshmen in these six schools, almost double the number (512) in 1970. Now the T.M.A. is seeking legislative support for adequate funding for the med schools, which are enormously expensive to run.
No doubt the critical need for more doctors is due in large part to Texas' recent population growth. But it stems also from the view—of fairly recent vintage—that good medical care is every citizen's right and not just the privilege of those who can pay. The question of just how far this responsibility for providing health care goes is still in the realm of controversy. There are such questions to be answered as: Should health facilities come to the people (via satellite and neighborhood clinics, for example) or vice versa? Should medical schools participate in federally funded poverty clinics?
It was just these questions that allegedly touched off a crescendo of controversy in San Antonio last summer when Dr. F. Carter Pannill was fired as dean of the new University of Texas Medical School there by U.T. Chancellor Charles LeMaistre, also a medical doctor.
Dr. Pannill and San Antonio community leaders have charged that Pannill was fired because of his support of a pilot program providing medical personnel (mostly med students) and services to San Antonio's poor through the facilities of Bexar County Hospital District and the U. T. Medical School.
According to Dr. Leon Cander, chairman of the department of physiology and medicine and chief architect of the program (he and the school associate dean resigned in the wake of Pannill's ouster), the U.T. med students found it "a very popular elective." Members of the Bexar County Medical Society, however, were highly critical of the program and, according to Pannill successfully urged the board of regents to sack Cander and Pannill.
What Pannill calls "an important disagreement about the critical matter of the role of a great medical school in a changing society" demonstrates another gap in need of suturing in the Texas medical theatre—this gap being not so much between generations as between political philosophies.
It also brings up the sticky question of whether the T.M.A. in fact represents the views of its 11,500 members. Shortly after Pannill's firing, The San Antonio Express charged in an editorial the integrity of the U.T. system had been damaged by the action, primarily because of regent Frank C. Erwin (who announced the firing) and the heavy influence of the T.M.A. through regent Dr. Joe T. Nelson, who is a member of the board of directors of the American Medical Political Action Committee. Both organizations channel campaign contributions to candidates for state office. Nelson was accused by Bexar County Commissioner Albert Pena of being "a spokesman for T.M.A."
Not so, says Linc Williston, Executive Secretary of the Texas Medical Association. "The T.M.A. certainly did not seek Pannill's ouster. It's true that Dr. Pannill had many supporters and many who didn't support him, but just because a few members of the association may have been against him, you can't connote that as a policy of the T.M.A."
Furthermore, points out Williston, T.M.A. believed in good medical care for all the people of Texas and has, in fact, a very strong committee on health care for the rural and urban poor. This committee has just completed a study of migrant farm workers in Texas. Williston says that of the one million such workers in the U.S., about 30 per cent consider Texas home base. The T.M.A. committee report, which recommends a federally-funded, pre-paid program for migrant workers in Texas, will be voted on by the T.M.A. House of Delegates this month.
Williston says his organization has all types of members—liberals, moderates and conservatives, Democrats and Republicans. Since T.M.A. charters county medical societies and membership in the latter is a prerequisite to most appointments, most M.D.'s end up joining both. The 1,900 M.D.'s in Texas who haven't joined T.M.A. are mostly, he says, either involved in research and administration or are young doctors still in training.
A.M.A. membership is not a requirement for most county medical societies. Of the 11,500 T.M.A. members, 2,600 opted not to join the A.M.A. According to Robert Mickey of T.M.A., some just can't afford the dues ($110), but many doctors feel it doesn't represent their point of view.
"In Texas, the A.M.A. is often thought too liberal," says Mickey, "whereas on the east coast, it is considered too conservative." Obviously some doctors think, as does Baylor med student Michelle McIntosh, that the A.M.A. "wouldn't serve any purpose" for them.
"The A.M.A.," says one young doctor, "is more interested in protecting its members' incomes than in ensuring adequate health care delivery for all Americans."
Such comments are typical of the new breed of doctors—not just in Texas, but all over the country. Although young physicians may have been idealistic down through the ages, often turning conservative as they grew older, this particular generation is not just talking. They're acting. They're really changing the status quo.
Of course, it's just possible that Juan Campos, John Rose, and Michelle McIntosh, 20 years from now, will be tooling around in Cadillacs, going native in River Oaks and buying couture clothes at Neiman's on their way to the bank. It's quite possible.
Anyone want to make a bet?
My Library
