Marcus Welby is an Establishment Quack!

A new generation of doctors is forcing the medical profession to examine itself.

May 1973By Comments

I HAVE THIS FRIEND IN Houston. Let’s call her Gloria. She’s a hypochondriac, an incipient alcoholic and has lots of money. When she was admitted to a private hospital in the Texas Medical Center last year, she packed five sexy nighties, three flimsy negligees and two bed jackets for the trip. She swears she wore them all out.

Gloria’s health is big business. Maxine, The Houston Chronicle’s gossip columnist, reported her hospitalization. Specialists trooped in and out of Gloria’s room focusing their opthalmoscopes on her pupils, palpating her tummy, hammering her knees and sampling her blood in such an orgy of flesh-handling that it seemed as if that TV hung from the ceiling of her room was a camera put there to record a group-grope session for The Annals of Encounter Psychology.

Gloria loved it. That is, she loved it until “the incident.” I dropped in to see her that day. She had just put on sexy nightie number four; her feet were being pedicured by a beautician who makes house calls, flowers were everywhere.

“Gloria,” I asked. “Are you feeling better?”

“I felt super until about an hour ago,” she said, taking a long drag on her Dunhill cigarette holder. “That’s when this little bastard comes marching in here saying he’s a student doctor and wants to ask me some questions. He’s got long hair and a beard, mind you. First he tells Jane here—who’s left the beauty shop to come down here and do my feet—would she mind leaving the room. Then he’s got the nerve to start asking me about how many cocktails I drink at night—implies I’m some kind of lush. He gave me such a headache I finally told him to get the hell out of my room—that I didn’t want any students practicing on me anyhow.”

Poor Gloria. Poor med student. It just happens both are my friends. Oh, I don’t actually know which student she encountered. But I do know a lot of long-haired, bearded med students and most of them just aren’t Gloria’s type. I could have predicted that after five minutes of togetherness, Gloria and student would despise each other.

Oh well. Not to worry. Gloria will get her liver problem fixed up without benefit of students. And the student who interrupted her pedicure probably chalked up his experience as just another example of how “irrelevant” to his educational needs taking care of some private doctors’ patients can be.

Gloria’s private doctor—we’ll call him Dr. Viejo—may not be the medical students’ darling, but Houston Society adores him. VIP’s line his waiting room. No, he’s not a Dr. Feelgood type. He dispenses neither live chicken embryo nor pig testicles to rejuvenate cells. Au contraire, he’s almost stuffy about playing the medical game according to the old established rules.

Dr. Viejo’s credentials are impeccable. When he was at that sacrosanct medical school in the East 25 years ago, he didn’t exchange words with a patient until his third year. His first two “pre-clinical” (i.e., before seeing patients) years of basic science study were two years of hitting the books all week, memorizing metatarsal bones and the rest of the Gray’s Anatomy, and drinking beer on Saturday nights. He was perpetually broke well into his residency which he did at “one of the finest teaching hospitals in the East,” as he usually describes it, for the magnificent sum of $125 a month plus a tiny room in the residents’ quarters and all he could eat at the hospital cafeteria (residents’ salaries now run between $9-13,000 a year). Only Mrs. Viejo’s salary as a nurse allowed the Viejos to get married just before he completed a residency in internal medicine.

Dr. Viejo worked damned hard to get where he is today. He drives a Cadillac, sends his kids to private schools, belongs to a posh country club (admission fee more than $10,000), and though he never uses rough language in the company of ladies, he was overheard at a dinner party last month to say, “those new students give me a pain in the ass!”

“Who the hell do they think they are telling us what they need to be taught?” he said, the back of his neck visibly reddening. “The young residents are just as bad. They all want to go home at 5 P.M. and never take night duty. Why, I used to be on duty every other night and weekend when I was a resident —and that meant staying at the hospital all that time, not just being on call. I never bitched about that —wouldn’t have dreamed of it. That’s how I learned so much. That’s why I’m a damned good doctor today. These kids want the gravy but they don’t want to work. They all want to be chiefs. We’ve got to have some Indians, you know.”

“Do you know what my interns and residents did last year?” Dr. Viejo continued his tirade. “They announced they’d all quit if I didn’t let them write the order on my patients. My private patients, mind you! Then if my patients get bollixed up, guess who’ll get sued for malpractice? Me. The whole thing is crazy. What ever happened to Hippocrates’ idea that students should respect their teachers?”

Dr. Viejo thus vents his spleen about today’s young doctors. “I’ll never understand them,” he says. Of course it’s mutual—a sort of generation gap badly in need of sutures. Viejo is quite correct in feeling that today’s typical med student is a far cry from the med student of the thirties and forties, the ones Sinclair Lewis described in Arrowsmith as “carefully dull,” who aspired to a Society practice and two Cadillacs. Sure, there are still a few of those guys around. But they keep quiet about it.

The noisy ones are the activists. They complain that the teaching in private hospitals “doesn’t tell us about the real world,” as one of them put it. Activists are interested in new ways of practicing medicine, in how to improve health care delivery to the poor, how to recruit and train more minority physicians and how best to make ethical decisions in medicine. Those ideas never occurred to Dr. Viejo 25 years ago. He would say, if anyone dared to ask him, that he had neither the time nor the money to spend on such considerations. Besides, such thoughts weren’t fashionable in his student days. Today, they are terribly in.

Furthermore, med students today aren’t spending four years just hitting the books the way Viejo did. In the first place, they can complete some med schools in three years if they wish. But secondly, they’re either all over the map practicing medicine in remote areas, or else staying in the city where they’re getting involved in inner-city clinics or in giving drug information to kids.

Says Ralph Dittman, senior at Baylor College of Medicine in Houston, “Yes, the students entering Baylor today really are different from those of us who entered four years ago. We’re the last group that was screened by the old dean. We’re the last to go through the old four year curriculum. You take any issue—dress, drugs, future commitment, political stands or whatever and you’ll find our class is more conservative.”

Dittman’s view is confirmed by Dr. Edward Lynch, associate dean at Baylor, who notes that Dittman’s class which graduates this June differs from the most recently entered class not only in attitudes and interest but in size (92 vs. 169), the number of women (5 vs. 21) and the number of minority students (3 vs. 16).

Baylor has, apparently, like so many medical schools, been changing fast. Up until 1968, Baylor had not a single black doctor graduate. Mexican American Jose Garcia tells minority college students considering applying to Baylor these days that during his two years as a med student he has seen Baylor evolve rapidly as a medical school that is not solely concerned with turning out scholars but is also developing into a community-oriented medical school. It has become, he says, “a sort of ‘people’s medical school’ which has placed emphasis on medicine for the farm laborers of South Texas, the chicanos of North Houston and the blacks of the Houston ghettoes.”

What happened to change Baylor and other schools like it? According to most observers, the students had plenty to do with it. In the late sixties, a rising crescendo of student discontent and a parade of departmental chairmen resignations began to signal that if Baylor did not change, it might not survive. Dr. Michael DeBakey, who took over the presidency of the school in May, 1968, and who engineered many of the controversial changes which followed thereafter, (including the separation from Baylor University and the Baptist General Convention of Texas), puts it rather mildly, “Before I took over, there was considerable unrest.”

Another observer is more specific: “Baylor in those days was a parochial outfit where the Board of Trustees and the dean’s office made all the decisions—no one cared what the faculty or the students thought. The Baptist influence meant not only no liquor at dinners, but worse, no federal funds could be accepted. You can’t run a good med school these days without government money and who wants to work at a place where the board is calling all the plays a la Frank Erwin up in Austin?”

So at that crucial point in the summer of 1968, three important factors forced the school and therefore its graduates in new directions. Similar factors were operating at med schools all over the country.

First, DeBakey was gathering together a new board which would back up his commitment that “the school’s policies should be established by the faculty.” DeBakey persuaded an array of Houston business and industry superstars to serve on the Board of Trustees. Men of impressive talent, power and wealth. Presto. Baylor the church-mouse turns city slicker.

Second, there was a national trend for medical schools to streamline and modify their highly structured, relatively, inflexible, four year curriculum and to recruit minorities. This trend was reflected in a new availability of government grants for these ends. At the same time, Texas was clamoring for more doctors and it looked like the state Legislature might sweeten the pot for Texas’ only private med school if it would increase its enrollment. It did.

Finally, the students who had just entered Baylor, like their contemporaries throughout the country, began protesting the rigidity of their curriculum and the policies of the admissions committee which they said were exclusionary, if not racist. They complained bitterly about shortcomings of their training, noting particularly their inadequate exposure to community medicine.

In short, they raised hell. At a school long accustomed to crew-cut, conservatively dressed students, not a few faculty were appalled at the sudden appearance of hirsute fellows in sandals and overalls, T-shirts and jeans, at their lectures. One professor who three years previously had been heard to tell a med student in a sports shirt not to return to his lecture until he was “properly dressed in coat and tie” relented over a few months’ time to the point where his one demand was “you have to wear shoes!” So the brief clothes hassle was gradually solved by the tacit understanding of all concerned: students dressed as they damn well pleased for lectures but “looked like doctors” when they started seeing patients.

Attitudes about curricula were not changed so quickly. Students took the initiative, forming their own committee which was given official status by Dr. DeBakey. Their recommendations eventually led to the present flexible curriculum, which includes off campus electives of such variety that in a fit of whimsy one sometimes wonders, did these fellows take up medicine to heal the sick or to see the world?

Take Ralph Dittman, for instance. Dittman, 26, a Harvard graduate from Goose Creek, Texas, arranged his elective last year in Central America through Amigos de las Americas, a youth-oriented voluntary agency set up to supervise immunizations and health clinics, particularly in Guatemala and Honduras. Dittman says he spent the three months before he left gathering some $20,000 worth of drugs plus basic surgical equipment, most of which he got from drug companies.

Dittman travelled from one village to another setting up clinics and teaching local villagers to suture lacerations. He says his experience in Central America strongly influenced his decision for a surgical residency.

“I really saw down there the quantum leap from medicine man to surgeon,” he says, adding “I did a lot of surgery myself. I amputated a lip, an ear and two fingers. My rule was—if it looked like cancer, I cut it off.”

Juan Campos, who graduates from Baylor in 1974, also designed his own off-campus elective, which turned into a kind of campaign. But let him explain:

“My freshman year,” says Campos, “I made several trips to South Texas with two of my professors from med school who were doing a health survey among the migrant workers there. Jose Garcia [another Baylor student] and I were observers and interpreters. The people in those communities kept asking Jose and me ‘what are you going to do about our health needs?'”

Although Campos claims he and Garcia were “young and scared and our approach was conservative—we said ‘be patient'”—as soon as they got back to Houston they began talking with their professors about developing a student health project in South Texas. That was the beginning of what is now a credit elective at Baylor, known as the South Texas Health Project.

Some med students, led by Campos, wrote 150 physicians in the area—(50 responded)—exploring the idea of setting up a program which would benefit the doctor, give the student experience and help the community. Now that the project is off the ground, Campos says, several doctors have decreased their work loads considerably by delegating work to students. At the same time, students are encouraged to acquaint themselves with and to mobilize community resources—perhaps taking an evening to discuss things like nutrition, drug abuse, breast cancer or dental hygiene with small groups. Students also work with youth groups in an effort to recruit young people to enter professional health fields.

Campos shares a feeling with many of his activist classmates that students really do need exposure to clinical situations away from the large medical center and city hospitals where patients tend to be “treated like cattle…where we don’t worry about their transportation or their income or the problems of their personal lives…we don’t really learn medical and social ethics.”

With this opinion Ted Simmons, senior student and president of the Baylor chapter, Family Physicians Students Association, thoroughly agrees. Simmons says he first realized what family practice was for him when he took an elective with a general practitioner in Houston. That doctor, says Simmons, took care of the patient totally and referred to specialists only the few problems he couldn’t handle. Even then when he referred a patient, he stayed in touch with the patient and his consultant and usually continued to manage the patient.

That was quite a different experience, Simmons says, from his training at a Texas Medical Center hospital where, for example, he saw a patient with pulmonary disease referred to four different consultants for problems which one man could have handled.

“There was a dermatologist called in first—I could have diagnosed and treated the athlete’s foot myself,” says Simmons. “Then there was a psychiatric consultation to evaluate the patient’s depression—but the poor fellow had lost his job because of his shortness of breath and he just needed some understanding from his doctor. An endocrinologist was called in to treat the man’s diabetes—that’s easy enough to treat. The doctor I’d worked with saw all these things and treated them himself. The medical center doctors were always disease and crisis-oriented instead of being people-oriented.”

Simmons started a Family Practice Club at Baylor made up of students who were thinking along the same lines. The club, which has grown to 60 members within a few months and an affiliate group across the street at the University of Texas med school, recently arranged their own teaching sessions—a 12-lecture seminar, the first of which was a panel of general practitioners (G.P.’s) from four different geographic and socio-economic areas describing what they do in a typical week.

Simmons explains the difference between the G.P. and the family practitioner by saying that the old G.P. had only one year of residency after four years of med school, which qualified him for 75 per cent of the problems he would handle. The family practitioner, says Simmons, will be trained to handle the other 25 per cent as well. He will have at least three years of residency training. Baylor is one of some 50 med schools throughout the U.S. to set up Family Practice departments recently. Family practitioners may become board certified, in which case they are required to be recertified every six years and to take a minimum number of hours of continuing education.

If Ted Simmons sounds different from the med student of ten years ago, how about Mike Hemphill? Hemphill, 25, who graduates in June, 1974, is taking a whole year, for which he will receive one quarter’s credit from Baylor, at the Harvard School of Divinity in Cambridge, Mass. He is taking an interfaculty program in medical ethics which exposes him, he says, to ethical theory—such questions as “What are human rights?” “What is good?” and the legal side of human rights and health—the rights of women, or of the foetus, for example.

Hemphill attends ethics rounds at the Children’s Hospital in Boston where specific cases are discussed.

“There the doctors discuss cases,” he explains, “where there are conflicts of values. For example, a doctor may encounter parents who don’t want to take his suggestion. Should he pressure them if he feels it’s in the best interests of the patient? Or perhaps a doctor has to decide whether a mongoloid child should be operated on or allowed to die.”

Hemphill is in some ways typical of the “new student”: his interests go far beyond the conventional clinical curriculum. He is, he says, more interested in the humanistic aspects of medicine—such ethical problems as prolonging death, human experimentation, genetic counselling and cloning. Some of these questions have been around for centuries, but many are the result of new technology or new knowledge. Hemphill points to experimenters who have found it is possible to manipulate behavior in animals by electrical means.

Hemphill’s fascination with ethical problems stems in large part from a seminar he participated in last year at the Institute of Religion at the Texas Medical Center. The Institute’s director, Dr. Kenneth Vaux, an ordained Presbyterian minister and professor of ethics, has long been involved in programs to make doctors ethically sensitive to a world where medical ability outstrips ethical sensibility.

According to Dan Davis, a classmate of Mike Hemphill’s in Vaux’s seminar, students explored just how values in medicine are established. He and five other students spent a summer elective studying decision-making in medical institutions all over the world. These students moved in pretty heady circles. Davis, for example, who had been a Russian major at college, talked to the head of the Bordenko Institute of Neurosurgery in Moscow and went also to the Max Planck Institute in Munich to see Carl von Weisaker, physicist in charge. Davis asked them such questions as “How do you decide what you do is important? How can you justify to society and to your government the money and resources your institution spends? How did you determine that you had the responsibility to do it yourself?”

“To paraphrase,” says Davis, “I was asking them ‘why are you so great?'”

Davis, a native of Fort Worth, graduates this June from Baylor. He goes from there into a residency in internal medicine, but like Hemphill is uncertain about his future.

While students like Hemphill and Davis have been busy at off-campus pursuits, John Rose, 25, a senior, has been staying in Houston, where he has organized and is now chairman of the drug information committee of Baylor’s chapter of the Student American Medical Association.

“The first billboard I noticed when I drove into Houston back in 1969,” remembers Rose, “had a picture of a man’s forearm with a tourniquet and a needle. MEET THE GRADUATE. IT STARTED WITH POT was the message. That interested me—that inflammatory and incorrect message made me realize that maybe Houstonians could use some factual information about drugs.”

That included the kids, who, he soon learned, were being bombarded with drug education—much of which they did not believe. Yet they had no idea of general concepts of pharmacology, things like the appropriateness of dosage.

“You know,” he explains, “they had that ‘if one’s good, two’s better’ concept that’s so common in our society.”

Rose says that he and some friends with backgrounds in chemistry thought it would be an interesting educational project to form a group to dispense the real word from the scientific community to the public. Twelve or so of the students spent the next two years collecting factual material in the library. Each one took a subject, reviewed the literature and wrote a monograph on it. Subjects involved alcohol, tobacco, barbiturates, hallucinogens, and stimulants. Several of these monographs were later published in Texas Medicine, official publication of the Texas Medical Association, in the hope that Texas physicians might find the information helpful in dealing with drug problems.

Once Rose and his colleagues were aware of the documented facts available about drugs, they organized a speakers’ bureau of med students to go to junior and senior high schools to rap with the kids.

“We had the great advantage of being associated with medicine. That gave us legitimacy,” says Rose. “We could understand and transmit the facts.”

“Being young and hairy,” he adds, “we had credibility with the kids who often either don’t listen to or don’t believe older authority figures.”

“We don’t take any philosophical or moral line about the use of drugs; we just want them to know there are intelligent and stupid ways to use them. Also we talk in terms of all “recreational drugs”—that includes alcohol, cigarettes, coffee, barbiturates, hallucinogens, stimulants like amphetamines and drugs like quaalude.”

When the visiting speakers are asked by their listeners “do you take drugs?” they always respond: “Whether I’ve used them or not is irrelevant to our conversation. They’re illegal and I wouldn’t ask you a question like that. I’m just here to bring you information.”

Of course the youngsters’ questions bring up the inevitable speculation of just how much medical students do use what John Rose calls “recreational drugs.” Regarding drug use at Baylor, first year student Don John says Baylor is “straightness incarnate” compared to Haverford in Pennsylvania and the University of Vermont.

It’s hard to get a feeling for just how much students do use drugs—estimates of marijuana use vary from 25-60%, for example—because it depends on which student you ask. As third year student Claude Manning put it, “We’re just like other young people. Some of us are freaks and some of us are straight.”

Why do med students need alcohol and other recreational drugs? They say the stresses are tremendous. At least four different students independently described “most med students” as “obsessive-compulsive types” who are “achievement oriented.” Stresses, particularly for first-year students, are worst at exam time and just before going to Austin to take the exams for the Texas State Board of Examiners, when, incidentally, the hairy ones usually shave and cut their hair, or at least pull it back in pony tails so they won’t scare off the older doctors examining them.

Several students said that stress results not infrequently in divorce (half the student body is married) and occasionally in psychiatric breakdowns. Says one third year student, “I’d say about a third of my class are getting psychiatric counselling.”

With all the stresses, one wonders how students manage to get involved in so many voluntary activities such as the drug information speakers’ bureau; but some students like John Rose have two and three such projects going. Roses’ second project is called the Work and Study Program or W.A.S.P.

W.A.S.P. was the students’ answer back in 1969 to the oft-heard excuse, “Yes, of course Baylor is committed to educating more minority physicians, but we just don’t have enough applicants.” In those days, there were no Juan Camposes at Baylor and an Afro was as rare as a case of diphtheria.

In early May, 1969, several medical students conceived and proposed a program by which a group of minority pre-med students would be recruited to study and work at jobs that summer at Baylor. W.A.S.P. organizers hoped that after getting to know such students, Baylor faculty would be more apt to accept their admissions credentials despite deficiencies on certain criteria. The med students also proposed that the pre-med students receive intense preparation for the M.C.A.T.’s (Medical College Admissions Test) which are to medical school what Scholastic Aptitude Tests have been to college.

That W.A.S.P. was a success despite severe time and funding problems can be seen not only because each successive summer the number of participants increased (from 18 in 1969 to 31 in 1972), but because of the change in minority students’ attitudes.

Said Gilbert Blancarte in 1973, “The W.A.S.P. program kept me in Texas. When I was an undergraduate at the University of Texas, I planned to apply to med schools out of state because I hadn’t heard anything good about Texas med schools as far as minority students went. The summer at Baylor made me change my mind.”

W.A.S.P. is entirely student organized and administered. According to John Rose, who was co-director of the program in 1970, “it had many goals, one of which was for students from different cultures to be exposed to each other. As it evolved, we also began to realize that the M.C.A.T. is a culturally-biased exam. As we were educating the admissions committee that the test was not totally valid, we were also trying to improve the learning-study skills of the students so they could improve their scores.”

Michelle McIntosh, who was co-director of W.A.S.P. in 1971, agrees that she learned a lot by being exposed to students from different backgrounds. McIntosh, who was never discouraged from going into medicine herself —her father is a Missouri pediatrician—began to recognize the problems of less fortunately situated students who aspired to practice medicine.

“When students coming out of the ghetto tell me, ‘You don’t expect us to back and practice there, do you?’, I understand their problems now. We must solve the problem of delivering health care to ghetto communities somehow, either by drafting doctors to work there or by improving the facilities there. I for one would like to see better facilities. If the facilities were attractive and I weren’t swamped with work, I wouldn’t mind working in a family practice in a city neighborhood.”

While McIntosh, who graduates this June, says she thinks many of her classmates will be going into family practice, one student says “it’s just a fad” and another says “it’s just a new idea so there’s a lot of talk about going into family practice, but it’s not what you would call catching on like wild fire.”

In fact, interest in specialty practice is still strong and many students feel that exposure to Gloria and her ilk is a very important part of their training.

“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?

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