It seems like a pretty simple question. I want to come in for an eye exam, and I’d like to know what it’s going to cost. Unfortunately, the answer is very complex and results from 40 years of trying to “fix” our healthcare system resulting in a mass of unintended consequences. Someone once said that the road to hell is paved with good intentions, which could not be more accurate for medicine. This article is based on my personal experiences in medicine from my pre-med days in the 1970s until now.
Above is a painting by Sir Luke Fildes titled ‘The Doctor”, painted over 120 years ago. Dr. Abraham Verghese, a senior associate chair of the Department of Internal Medicine at the Stanford University School of Medicine, described the painting, “depicting a physician sitting attentively at the bedside of a very sick child, whereas reported historically—he held a vigil for two or three nights. The painting speaks to the Samaritan function of the physician”. Most of the physicians before WWII demonstrated a fantastic amount of care and compassion. They would provide as much comfort and support as humanely possible to alleviate suffering. Sadly, the painting also depicts a glaring and terrible problem that plagued physicians before WWII. While helping their patients through these challenging times, they could not do anything to alter the course of their disease. For all we know, the child in this painting could have been suffering from mastoiditis, a deadly complication from a common ear infection. Like many of you, I was always getting ear infections as a kid. Yet, most of us never had a physician hold vigil over our beds for three nights as we recovered. No, instead, we got that bottle of pink liquid and were back outside playing in a few days.
This was a tremendous change in the practice of medicine. For the first time in history, doctors could alter the course of a disease and cure you. Of course, this is not entirely true. Before antibiotics, doctors could make some patients better and cure their disease, but nothing like after the development of antibiotics. Before antibiotics, most physicians were general practitioners who had small private practices. They made house calls, treating symptoms of diseases, and charged a modest fee. I clearly remember our family doctor coming to our home in the 1960s. After he finished, he headed for the door, turned, and held out his hand. This was when my parents paid him his modest fee. I was only six at the time, but I think it was around $5.
Something else happened around this time that scared the ^%#* out of us. The Soviets launched Sputnik, and America found itself woefully behind in the space race. This prompted the USA to begin a massive push for science and technology. Science education became supreme. Science fairs popped up at every school, and something called a computer was being developed. This explosion of science and technology flooded over to medicine, where new and bold discoveries and techniques were developed to cure diseases. Dr. Walt Lillehei developed techniques for open-heart surgery that could cure children with congenital heart defects. Imagine that poor child in the painting, “The Doctor.” She might have been suffering from a congenital heart problem. Instead of holding vigil night after night, slowly watching her demise, she would have been wheeled off to the OR, where her chest would have been opened and her defect fixed. What’s even more impressive is that she would have gone home and lived a reasonably normal life. Vaccines were advanced to the point where whole wings of hospitals devoted to polio were closed.
Physicians took center stage. In 1966, Dr. Michael Debakey performed open-heart surgery on TV, hosted by Walter Cronkite no less. That was a pivotal moment for this future surgeon.
Something else changed around that time. Patients took notice. No longer were they satisfied with the compassion and comfort of their family doctors. They wanted results, actual cures for their ailments. Patients were flocking to the great medical centers around the country, places like the Mayo Clinic, Johns Hopkins Medical Center, or the Cleveland Clinic. And those with means were willing to pay more. Physicians took notice and began to charge more. Insurance companies also took notice.
In the next installment, I’ll discuss how insurance companies responded.
This newsletter does not constitute medical advice. Make sure to contact your healthcare provider if you experience any of these conditions. Do not make any changes to your medications before consulting your physician.