How Good Is Your Family Doctor?

A surgeon who graduated from the School of Medicine at the University of Pennsylvania in 1933, CALEB SMITH, M.D., explores with courage and candor the standards of the general practitioner in the United States. In his own career, Dr. Smith has had the good luck to combine the advantages of the small town with the stimulus that comes from teaching and hospital work. He is assistant professor of surgery at the University of Rochester School of Medicine, Rochester, New York, and chief of surgery in the Bradford Hospital, Bradford, Pennsylvania.

1

THE public has been told, until it must be weary of hearing it, that American Medicine is the best in the world. But what is meant by American Medicine (the kind spelled with capital letters for propaganda purposes) is medicine as it is practiced by the staff of a medical school in a university hospital, and this service can be offered to only a relatively small number of people. The large majority of our population receive medical care from general practitioners, and very little specific and reliable information on the quality of medical service offered by general practitioners is available.

Prior to entering practice in a small town, I had never worked with any doctors other than those on university staffs. For many months I was therefore confused by — and I must have been both amusing and confusing to — my new colleagues. Before opening my office I paid a call on every doctor in the vicinity, and let me confess it, in view of the frequent criticisms of the public for its inability to discern between the incompetent and competent doctor, I was often wrong in my first impressions. In fact I was most taken, what with his immaculate white coat and pince-nez glasses, with a man who is generally conceded to be our poorest —and possibly most prosperous — general practitioner.

After about a year, however, I had learned most phases of the general practitioner pattern, and was unhappy about many of my findings. At times I was tempted to abandon the whole project, but somehow or other I stayed on, and came to enjoy, after a time, the gratifying pleasures of small-town practice as I had originally envisaged them. And among these pleasures I cannot refrain from mentioning the satisfaction of knowing, especially while visiting some excellent metropolitan clinic, that the work is being done just as well, and sometimes better, at home.

In ten years I have known intimately the professional life of thirty general practitioners. Five of them I can dismiss, perhaps too briefly, by saying that they are what their teachers in medical school wished them to be. They do an enormous amount of work, averaging at least seventy hours weekly, year in and year out; they possess a sound enough knowledge of all fields of medicine either to give their patients good medical care or to direct them to it; nothing is able to dull their inquisitive, active minds; and although they are often known as frank people, they have the respect of the townspeople and every specialist who is privileged to work with them.

The other twenty-five general practitioners, or over 80 per cent of those I have known, I wish to discuss and analyze in some detail, and unless otherwise noted it is to them that I shall henceforth refer when I use the term general practitioner. Some of these men were old in their practices when I began; several were young doctors who gradually drifted into the ways of the older men.

By the very nature of his work, a general practitioner must see many patients each day. If the patients are to receive reasonable benefits from their short visits, the general practitioner must exercise consummate skill. And the general practitioner, of all doctors, has had the least formal training, thus rendering his task doubly difficult. The second factor militating against the general practitioner, and happily it is a lesser one, in my experience, is a desire to make money. Usually the two factors are blended in varying proportions, and often very subtly, in each general practitioner, whether he sees only a few or as many as sixty patients daily.

Considering all the technical advances made by medicine in the past half century, the most valuable means of arriving at a correct diagnosis is still an accurate history of the patient’s illness and a complete physical examination. Both these procedures are time-consuming; in fact, if they are rushed, they become not only worthless but actually confusing. The skillful general practitioner never loses sight of these valuable diagnostic means. Of course, he can almost never devote sufficient time to complete history and physical examination at the first visit, but he does the most salient parts of each at that time, and elaborates on both at subsequent visits, until finally his study is complete.

The ordinary general practitioner, because of difficulties already noted, with a feeling of lonely isolation abandons the whole arduous task, and resorts to what is known as symptomatic treatment. It is so much easier and quicker. He listens to enough of the patient’s story to convince the latter of his interest; does what physical examination, if any, is necessary to impress the patient; and prescribes not on the basis of a tentative diagnosis, but on the basis of symptoms. For example, when the patient with a chronic cough seeks the advice of a doctor who practices symptomatic treatment, he is promptly dismissed with a prescription for a cough medicine.

On a second visit in symptomatic treatment it is even harder to make a proper start, if there were a desire for one, because the easier pattern has been set and the patient might become suspicious of what occurred at the first visit. If, as rarely happens, some laboratory work seems indicated to maintain the patient’s confidence, the general practitioner finds himself in another quandary; since he has no tentative diagnosis, it is impossible to choose appropriate tests. The interpretation of laboratory work under such circumstances is of course utterly impossible, and is likely to result in confusing future efforts at diagnosis. Adequate office and hospital records are not kept, because of the work invoked, and this is just as well, for records of symptomatic treatment are worse than worthless. Because no sound working diagnosis has been established, it is not possible to conceive any logical plan for the hospital study or treatment of the more ill patients.

Under these conditions the general practitioner sends patients to the hospital either because they are obviously moribund, or because they are not doing well as ambulatory patients under symptomatic treatment, and are making such a nuisance of themselves that the doctor cannot comply with their demands for attention without sacrificing a disproportionate amount of his time and income. Most requests for hospital admissions by general practitioners are not therefore of an emergency nature, and a busy hospital, with a great demand for its beds, cannot comply with these requests. At the same time, the general practitioner sees his more competent colleagues admitting patients to the hospital regularly and without difficulty; does not understand how they are able, with a working diagnosis, to make reservations for them one or two weeks in advance; and complains that the hospital is discriminating against general practitioners as a whole, and himself in particular.

It is an interesting economic aside that symptomatic treatment as a hospital procedure is a waste of money. When the governing board of our hospital established the policy of having a competent doctor at the head of each department, to check the diagnostic status of each charity patient and to determine whether or not, or for how long, he would be benefited by hospital care, our charity load was reduced by one half, resulting in the hospital’s running in the black rather than the red, without curtailing needed hospital care to anyone.

2

SYMPTOMATIC treatment over a period of years leads to some bizarre practices which would baffle anyone who did not understand its pernicious course. When he abandons anatomic, physiologic, and pathologic diagnosis for a long period of time, the general practitioner actually loses contact with official medical nomenclature. His diagnoses become often unintelligible, and even a little fanciful, to the competent doctor. One general practitioner has degenerated to the extent that his diagnosis of any type of heart condition is apt to be “one of those heart things"; similarly, he also speaks of “kidney things" and “intestinal things"; and the major emphasis in all treatment is put on just “sitting tight.”

Therapy in symptomatic treatment follows an amazing design that would astonish any teacher of therapeutics. Competent doctors in all fields usually prefer to use the standard medicines approved by the United States Pharmacopoeia, because by long and careful evaluation they have proved to be the most effective ones — and, incidentally, markedly less expensive than the patented proprietary medicines. As time goes by, general practitioners receive their medical education from detail men whom drug manufacturers send to visit most physicians, to describe and extol the virtues of their new proprietary drugs.

Gradually the general practitioner abandons the standard drugs for the more glamorously effective ones, accepting the word of the manufacturer rather than studying independent medical investigations of these products to determine whether or not the new drug is superior to a standard one. And the wonder drugs of today have been far from an unmixed blessing. It is an almost providential circumstance that penicillin has scarcely any serious toxic reactions, for the public’s blind faith in it has been shamelessly exploited. Two instances come to mind: a general practitioner (he of the pince-nez) was administering penicillin to a patient with a chronic rheumatic condition and to another with a functional menstrual disorder. The drug was obviously of no benefit in either case, but it required rare imagination to prescribe it. With the likelihood of various hormones of the body, particularly those of the adrenal gland, becoming available for therapeutic purposes in the near future, a grave danger to the public exists. These substances exert a variety of profound influences upon the body, and the possibility of toxic sidereactions is real. What havoc might result if there was not currently such a scarcity of cortisone (the potent adrenal gland hormone effective in one type of arthritis) that it is distributed by a committee of experts only to competent specialists!

The record of the general practitioner’s intellectual contribution to his hospital is one of apathetic omission and, at times, of actual obstruction. Rarely can he be induced to attend scientific meetings, except by the enforcement of sound staff regulations. His refusal to present a scientific paper is absolute, although it probably should be excused on the basis of inability. Recently, when our hospital’s national approval — and hence its school of nursing, cancer clinic, and other valuable departments — was jeopardized by the negligence of general practitioners in keeping adequate records and attending scientific staff meetings, some of the general practitioners asked in open meeting why the governing board should require them to perform such duties, since “they got nothing out of it.”They seemed to lack a conception of, or cared nothing about, the vital position a hospital plays in community health.

Categorically, this has been my experience with over 80 per cent of the general practitioners I have known professionally in the past ten years. Many examples of their work come to mind, and one or two should be mentioned to condemn specifically symptomatic treatment. I realize there is a popular illusion among the laity that such exposes are contrary to professional ethics, but I must point out that the code of ethics adopted by the American Medical Association urges every doctor to expose improper practices ruthlessly. A middle-aged woman visited her general practitioner because of pelvic bleeding. No examination was made, the cause was evidently assumed to be menopausal bleeding of the functional type, and the patient was given a weekly injection of a sex hormone for about six months. Since the bleeding did not abate under this therapy, the patient consulted another doctor. A simple examination, a smear for tumor cells, and a biopsy which were done at once established the diagnosis: cancer of the neck of the womb. Another patient whose striking pallor would have suggested anemia to a layman was not examined, did not have a blood count, but was given periodic injections of liver for several months. A second doctor, in the course of a complete physical examination, discovered an obvious abdominal mass, which on X-ray examination of the intestinal tract proved to be a cancer of the right colon, a notorious cause of anemia in adults.

Tragic cases such as these are far outnumbered by relatively benign ones; for the great majority of patients who consult general practitioners have less serious, in fact often trifling, conditions. A few cases have their ludicrous side; a general practitioner told a woman she was pregnant, followed her through her prenatal care without an examination that would check his diagnosis, and finally admitted her to the hospital for delivery — only to discover that her husband’s skepticism bad been well founded, and that she would have little use for the layette she had purchased. The best that can be said for symptomatic treatment is that it is an expensive hoax.

3

NOW for the brighter side: what can be done about it. Two approaches appeal to me. The first one, inducing well-trained men to come to small communities, I have seen succeed. The second, improving the quality of the general practitioner, on which I have seen a small beginning made, I hope to see accomplished.

Let’s begin with the first method. In my ten years of practice, I have induced six doctors, whose training permitted them to be certified as specialists by their respective American Boards, to practice in my locality. In nearly all cases I offered them financial support. One left after a very successful year of practice to assume a full professorship; another left because his manner of living was more suited to urban than to rural living; four have stayed and succeeded.

What makes a well-trained doctor hesitate to come to a small community? The best practice of medicine depends on a state of mind. In the course of the three to five years of formal training which the specialist is required to take beyond the ordinary medical education, it is his pleasure and privilege to work with some honest, active, and disciplined minds— minds that have learned to collect evidence accurately, to weigh it with discrimination, and to arrive at sound conclusions. One name for this whole process, and one toward which mankind is apt to feel unkindly in this day, is the scientific attitude. Although he admires the results he sees it produce, he comes to admire more the attitude itself, until it becomes for him a way of life in which he finds a happy satisfaction.

Imagine, then, the dispiritedness that must come over him when he visits a small town and gets an inkling of the prevalent standard of medical practice. He is likely to find no associates or competitors who practice in the same manner that he does; no consultation facilities; no scientific meetings or lectures; unreliable laboratories; no library. All of which seems to mean abandoning the very things which hard training has led him to respect, to enjoy, and to live by. I have seen these circumstances win out more than once.

If, however, there is one well-trained man — preferably more than one—already in town with whom he can associate himself professionally, the young specialist is much more likely to stay.

After the young man begins practice in the small community, he has yet to face another disheartening circumstance. When the scientifically apathetic general practitioner divines that the normally uneventful relationship between him and his patients is threatened by some perverse interloper who has come to town from a university hospital, he is capable of a surprising degree of passive resistance. And when he is threatened by what seems to be actual loss of some of his patients (which he regards as his private property), he arouses himself to active resistance. I have seen general practitioners, in what they considered to be a facesaving maneuver, send patients in need of careful study some 150 miles to visit a specialist, when an equally competent man was practicing only a few blocks away. Another favorite practice with them is to seek consultation on only charity or very neurotic patients. The latter, when referred back to their general practitioner, have it carefully pointed out to them that the consultant did not find anything wrong either—an obvious effort to induce the patient to discredit the consultant, but a pathetic sort of reverse psychotherapy for the patient.

The competent minority of general practitioners welcome specialists as fellow practitioners. I have seen them coöperate with specialists to the great benefit of their patients. The remarkable side product of such consultations is a marked increase in the prestige, to say nothing of the actual competence, of the general practitioner. Patients do not look upon his practice of seeking consultation as an indication of ignorance, but rather as a high degree of concern for their welfare, which gives them an added confidence in him professionally. The incompetent general practitioner looks upon consultation within the area in which he practices as a confession of ignorance that might result in a loss of private property. Once again, we are up against a basic attitude of mind. In my own locality, experience is gradually changing it. This can change in other small towns, too; and as it does, welltrained young men will be encouraged to come into them.

The staff by-laws of a small hospital and the attitudes of the hospital administrator and the governing board of the hospital are also telling factors in the decision of the young specialist to come to a small community. The progressive improvements in medical service, in which every doctor should hope to participate, to say nothing of downright reforms, are impossible without sound staff by-laws and the coöperation of the hospital administrator and governing board.

The problem of staff by-laws is best explained by presenting the three commonest patterns, using general surgery as an example. In the hospital where I serve, any doctor who has had four years of training in general surgery in a nationally recognized institution will be given the privilege of practicing general surgery in the hospital, provided he is of good character. This is the sound and fair policy. A young surgeon will at once recognize that his associates and competitors have a background similar and equal to his; that he will not be required to work with incompetent self-styled surgeons; and that there are possibilities of working in a first-class department of surgery. He will be tempted to practice in such a town.

The second type of staff by-law is discriminatory. It ensures the hospital’s having an inbred and nonprogressive staff, and almost precludes a welltrained man’s coming to town. This plan requires every surgeon who wishes to practice in the hospital to serve one, and often two, years as a resident physician under the existing surgical staff of the hospital, even though his training may be, and often is, superior to, as well as more recent than, that of any member of the present surgical staff. This plan is purportedly a measure to “protect” the townspeople from a young surgeon, but it is obviously for the protection of the existing surgical staff. Such a town deserves what it gets.

The third plan makes a pretense of containing sound regulations, but it is actually a travesty of them. It allows a doctor who aspires to be a surgeon to assist an older surgeon, who has usually had no formal training. After a variable period of time, he may perform alone some of the so-called simpler operations. If he has the callousness or lack of intelligence to persist, he may in time perform any operation he desires. This plan is based on two false assumptions: that simple operations are never complex or fraught with dangers; and that after one has performed little operations improperly, one is entitled to perform major ones improperly. A well-trained surgeon will almost never consider entering practice in such a town. It is virtually impossible, under such a regime, to develop a firstrate department of surgery. And once the governing board of a hospital condones such regulations, it has a very difficult time amending them. In a near-by town, such an effort was recently made by the governing board, and the protests of the “persecuted” surgeons were overwhelming.

The possibility of closing hospital staffs to general practitioners in an effort to improve medical care in the hospital frequently comes up for discussion because it has certain merits, and it has proved feasible in cities which have more than one hospital. There is little open discussion of the matter at the moment, for it is very impolitic at a time when political solidarity is vital to survival of organized medicine as it now exists.

Under this system, general practitioners would continue to do office and home practice, but they would refer patients needing hospital study and care to well-trained specialists, who in turn would confine their practice to hospital work. During the period of hospitalization, the general practitioner would have an opportunity, but without imposing any fees, to follow the patient’s course. On discharge from the hospital, the general practitioner would again assume care of the patient, armed with a detailed report of the hospital studies and care. It is easy to envisage such a system resulting in improved medical care with no increase, and perhaps a decrease, in costs and with satisfaction for both patients and doctors. But it would work a grave injustice to the minority of competent general practitioners and would result in a loss of face for all of them, a circumstance that might well result in many patients being denied needed hospital study. Perhaps more important, it might further remove the general practitioner from contact with good practice and the opportunity to learn, an important aspect of the whole problem.

4

FUNDAMENTALLY, the apathy and degeneration of the general practitioner result very largely from his intellectual isolation in the field of medicine. When our small hospital became associated with a university medical school, there was a distinct improvement in general practice; a few general practitioners blossomed forth in a relatively short time into excellent doctors, and in the majority of the cases there was appreciable improvement in the standard of practice. The causes of this improvement were both tangible and intangible. The feeling of professional isolation in the hospital was partially and rather suddenly dispelled; a degree of pride — often pathetic in its incipience — in the caliber of professional work was noticeable on the part of the general practitioners. This change in professional atmosphere was of profound importance, for it tended to remedy specifically a fundamental defect in the incompetent general practitioner: his attitude of mind.

The reading of medical periodicals, too, began to be fashionable. Our hospital library was founded on a plan that is feasible for any small hospital. Several of us who were especially interested in having a workable library donated $1000 to make the first purchases, and arranged for each doctor to pledge at least $5 yearly for the purchase of a variety of periodicals covering the major fields of medicine. The hospital agreed, as its contribution, to bind the journals, which then became its property. General practitioners who had read no scientific literature for years began to delve into journals. Soon medical and surgical journal clubs were established. to review the current literature regularly.

Perhaps the greatest impetus to the improvement of the standard of medical practice was the coming to our hospital of the young doctors from the university hospital as part of their training. I only hope they are learning as much as they are teaching us. Nothing jolts, and then stimulates, the reposing mind like the questions of a young man intent upon learning. All our doctors became conscious that their work was being appraised. These young men routinely asked questions about patients, and when fuzzy answers were being made, healthy doubts began to creep into the minds of many of the general practitioners.

In my opinion, the rather experimental association of a medical school and a typical small-town hospital, in which I have participated, points the way to improve the standard of medical care. While having obvious limits, such a plan could easily be enlarged to include strategic hospitals throughout most stales. And as a worth-while by-product in these times when institutions of higher learning are finding it necessary to ask the public for increasing financial aid, such an association would increase the service rendered to the people and enhance the prestige of the university. Of course, as in all democratic procedure, there is the danger of a stifling bureaucracy, but this should be a minor evil, compared with the benefits that would accrue to both patients and doctors. And any measure less than actual participation in a hospital by a university is apt to fail. Clinics and postgraduate courses for country cousins are likely to be ignored by those most needing them, or at best turned into social functions.

Another measure which I have heard discussed is the suggestion that all doctors, working as they are in a field that is constantly changing, should be required to undergo examination for licensure every five years. Here the evils of bureaucracy might well exceed the benefits; furthermore, Americans— and particularly doctors—have shown themselves allergic to compulsion, and much more amenable to persuasion.

In conclusion, I should like to pay tribute to the satisfaction of medical practice in a small town. When my professional friends from urban areas visit me, they frequently remark that I live figuratively in a goldfish bowl. This is true, and at times seems oppressive, but it is also another way of saying that a small-town doctor is held in almost flattering esteem by his townsmen, and that he is privileged to participate in community life in an enviable position.

In a small community the capable doctor can in a very short time achieve a sound and happy position that compares very favorably with that of the most successful urban doctor. Most gratifying of all, he knows that he is providing good medical care where it is most needed.