Since Ancient Greece, western medicine has been associated with snakes,[i] so perhaps Medusa’s snake covered head, which when seen, turns people to stone, or ossifies them, is an apt metaphor for medicine today.
The unstated question for physicians is:
“ If Medicine is sick why don’t you heal it yourselves!’ The answer seems to be:
“Sorry. We can’t. Medicine is not a uniform or coherent profession, but many competing and isolated professions; each has looked at Medusa and become stone.
Government, in the role of a modern Perseus may:
1) Cut off the whole Gorgon head (immediate universal government single pay); or
2) Strangle one or several intertwined serpents at a time.
One toxic serpent is the failure of Primary Care. Even though a majority of physicians plan to enter that specialty at the start of training,far too few do so upon graduation. Their disillusionment is the result of ossified training favoring other specialties, and a realization that there is a mismatch between the demands and the value placed on primary care. To kill that snake we must attract and retain the best and the most idealistic students to primary care; and make their training more attractive, and more rational by:
I More rapid and practical medical training
II Inducements to practice Family Medicine
III Restoration of the Humanities in Medical training
IV Control of the Political Industrial Medical Cabal that drives outrageous costs
I Faster and more practical medical training:
This is not a new idea of course; in the Guild system a young apprentice learned by ‘see one do one’; the ‘master’ determines when the student was ready. The Hippocratic Oath reflects that guild system, requiring teachers and colleagues to hold professional secrets, and one another, sacred. In the USA today training for primary care is almost as long as many other specialties. It could easily be shortened. In the last century many accelerated physician training programs sprung up, most outside the US. I myself was in a U Minnesota accelerated 7 year college MD program devised in WWII– 3 pre med, 3 medicine, 1 internship.
In any event, 6 years of college before seeing a patient, and 9 years to complete a basic MD degree, is not necessary; neither is 12 or more post high school years before finishing Family Practice training. For any qualified student, we can provide for an MD degree 7 years after high school graduation: 3 college, med school, 3, internship 1, by:
1. Admitting students to med school who satisfactorily complete essential basic science in pre med: biology, bacteriology, medical anatomy and physiology, psychology, and biostatistics.(Thank god for software!) Students who had to recover from a poor high school experience, or pursued an interest in unrelated fields, might be given precede, in consideration of life lessons learned.
2. Beginning to evaluate and treat patients, under supervision, on the first day of med school.
3. Requiring that the last year of training be a general rotating internship (all specialties included);
4. Requiring this path be followed for all all medical students
II Inducements to Family Practice: We can:
- Offer to, but not require of all beginning med students, a fully subsidized path in Family Practice. This would be by way of a loan, cancelled after:
- 3 years Family Practice, in selected places, with tax free stipend equivalent to three times the average FP residency pay.
- For another 3 years thereafter, continuing that stipend, but also allowing private practice at the selected site. At any time after the first obligatory 3 year period, a subsidized Family Practice physician could elect to practice elsewhere, or apply for any specialty training.
III Resuscitation of the Humanities
What is subjective is generally foreign to medical training, but is elemental in life; one result is that too many physicians are deficient in the Humanities, and to a degree, dehumanized. Too often we:
Cannot or do not write or read well.
With the exception of medical literature, may not read at all.
Are unfamiliar with much of history, literature, music, and art.
Are too detached from patients and community.
Are ignorant of basic logic, philosophy, debate, and public speaking.
Finish training with little interest outside self interest.
While physicians are not alone in being dehumanized in a 21st century world, communication is more critical to medicine than most professions because:
# a deficiency in the humanities greatly reduces one’s ability to put the human condition in perspective;
# it leaves one less able to reject specious reasoning or ad hominem argument;
# it lessens our ability to appreciate the beauty and to hear the voice of every era, including our own;
# it limits our options as healers, listeners, advisors, parents, friends and lovers.
Therefore, I suggest at least four required upper division college humanities courses during the last 18 months of premed:
English literature; English Composition
World History; Philosophy or world Religion.
Suggested but optional: Speech, Music, Spanish
Adding these Humanities requirements for entry to medical school can both make graduates better physicians, and make a medical career more attractive and practical for students already well grounded in the humanities. More didactic material like Calculus, Physics, or Physical Chemistry, exists in the e.universe, where acquisition and sorting of material is a given; those skills can be added any time a specific medical career requires it because physicians, we hope, do not stop learning at graduation.
III Controlling the PIMC—Political Industrial Medical Cabal
Physicians, politicians, and the average voter,–none altogether ignorant and none altogether innocent–are groomed and seduced by the PIMC. (I use the term Cabal instead of Power because to use Power creates a problematic acronym.) Yet I do mean Power– the power of money, which is best considered an addictive drug. Physicians tend to practice in prescribed ways because the Cabal controls this drug: Money. We see it. We complain. We call for change. We want to be free, but wait for someone else to free us, fearing the pain of withdrawal. In short, we go about business as usual. What could be done?
The penultimate power in a democracy –while it survives–is the informed voter who actively participates in intense and intestine public debate. An encouraging fact is that this debate about medicine is now growing more active and informative every day. The most significant contribution that physicians can make is to participate actively, while listening carefully, as well as speaking carefully.
By contrast, the PIMC–the Cabal– exercises its right to plant sophisticated misleading or biased self serving material throughout the media: TV, magazines–both public and professional–, the net, and direct advertising. Physicians must call foul whenever media presentations are mired in self-interest. They must call out clearly, and determinedly, but with a civil tone. Screaming, playing The ‘Doctor’ card, or making demeaning remarks loses any debate.
There is a saying that ‘all politics is local’. A local medical society magazine is the members’ soapbox; their Hyde Park and Trafalgar Square. It is often their only ready forum. Physicians, to be effective must join the public debate both independently and within the profession. Essays and posit discussions in the medical society magazine generally reflect opinions of local docs; as such, they are far more interesting and believable,and more genuine, than collective or organizational voices alone. When physicians speak as individuals, even if what is said may be unwise, prove embarrassing, or be off the official text, it is still that individual’s opinion. Physicians must be involved, and Speak up. So must we all!
The names of far places can magnetize the human mind, inducing a lifelong attraction. The Atacama Desert & Antofagasta are found at the North end of Chile, the country with the farthest north-south range of any on earth, a very narrow slip of volcanic land clinging to the western edge of south America and the Andes mountain range. It is a land of chaotic climatic and topographic contrast, from the arid North to the glaciated South; in an East-West direction it rises from sea level to the Andean heights like Ojos del Salado, a few meters lower than the highest in the western hemisphere, Aconcagua. It is of necessity a nation of engineers who design earthquake tolerant roads and buildings, and operate many mines, including the largest underground and open pit mines on earth. The people are defined by the sea, the mountains, and small fertile valleys-In the words of an epic Chiean poet- una loca geografía – a crazy geography.
Sodium nitrate (Calicihe, or saltpeter) is abundant in the desert North, once the world’s best source of raw material for both guns and butter-fertilizer and gunpowder. But that changed overnight after WWI when Germany found that nitrogen could be harvested from the air as ammonia. During the following half century of severe economic and social decay, the nitrate mines were confiscated and operated at great cost to the government, even though the situation of hard bitten and proud miners remained dismal.
By the 1970s two government saltpeter mines remained, some distance inland from Antofogasta, each home to about 10,000 people: miner families. The State, goaded by very strong and aggressive left wing Unions, tried very hard to comply with demands. A hospital was built to provide OB and basic surgical care. To partially repay for free training, medical school graduates without any prior experience were assigned to the hospital- essentially alone – for two year terms- sentences, in the view of some. One can imagine the outcomes.
Low numbers of patients made even marginal care very costly. Conditions for miners remained deadly, as the average miner had to be ‘retired’ before age 35 due to silicosis. The ambient dust was so bad they had to be moved away. Elsewhere in the Atacama only ghost towns remained where empty opera halls and neglected elegant mansions told of a long gone opulence.
During the 1970’s privatization of most state owned industry began, including the two Salitreras of the Atacama. The new owners consisted of a curious amalgam of investors and union organized mine workers. The disparate groups of owners had a designed-in mutual interest, however: a concern for costs, survival, and profit; they needed to agree on a way forward because they were prohibited from selling their shares for seven years. The question of what to do with an inefficient and prohibitively expensive hospital came up.
A friend of ours had visited here during his illness, co incidentally hearing of the Kaiser- Permaente health system. So when he called about assessing the hospital situation at Pedro de Atacama, I immediately agreed. My old mental magnetization for Antofagasta was operational. What follows is a very abbreviated outline of what we came up with. It is outdated to a degree, and has, I expect, inaccuracies. Yet I offer it for consideration in view of our situation today in the U S. Perhaps, if the reader prefers, it can be considered creative non fiction, like the daily news and media mouthing.
In the Chile of those times the social security system was changed. A person could elect either to continue the existing national system, or to switch to managed investments among 12 competing brokerages, operating something like restricted IRAs; the contributions to this plan remains the property of contributor and hiers. With that as an example we discussed an option for health care to be made available to larger employee groups, like the salitrera miners; they would elect, by majority vote, to retain their government mandated health care contribution themselves, and manage their own health care for their own group care (in this case about 20,000 including the other nearby sister mine.); they would define benefits, elect co-pays if required (at the outset this would be rather easy because benefits were scant and marginal at best.); they could elect to contract with health providers or employ them; at the end of each year they would review and revise their plan for the next year; as they gained experience and resources, they could invest more in health diagnosis or treatment; they could acquire, lease, and operate clinics or hospitals; they could contract to provide defined benefit health care to people who were ineligible for a large group plan; last, the most significant and important feature of the proposal, I think, was that if a surplus were available at the end of any year, it could be either used to expand services, or to distribute a dividend to members.
Obviously this proposal was influenced by the Kaiser-Permanente model. It was not fully accepted or implemented, but many aspects of the plan were adopted. The hospital at the Salitrera was abandoned in favor of a clinic, with the loss partly assuaged by free daily bus travel to Antofagasta and the proffered group health care there.
It would be interesting if something similar could be considered here; and yet, that seems unlikely. Would it work? Would it be possible given our republicrat/media/industrial complex? I leave those questions to the reader to consider. ¡Salud!