Narrative
In 1955 he moved his family to form with two other physicians a group practice that in time would expand to five partners. Wedded to obstetrics, he soon earned the reputation of being a meticulous and hard-working clinician. He delivered all his patients. Resolved to remain current as the specialty broke new ground, he was among the first in his location to perform laparoscopic tubal ligations. He introduced fetal monitoring. His boys remember going with him to the family farm to practice the fetal monitor on pregnant cows.
During years of social upheaval, he quietly but consistently participated in his hospital’s obstetric service for indigent patients and provided coverage for a nearby home for unwed mothers. Residents rotating with him saw the same high standards of care and the same respect for patients, whether the patients were socially advantaged or not.
Yet by 1971 -- the midpoint in his career -- he could identify with the question raised in an Ob/Gyn editorial -- “What happened to the old-fashioned physician and the old-fashioned patient?” He was at a critical juncture. Would he limit his practice to the shrinking number of ‘old-fashioned patients’? Would he shift his practice away from obstetrics by focusing on the gynecologic needs of the women he had delivered in previous years? Or would he pay the personal and professional price to remain in the middle rather than on the periphery of his specialty?
Commentary
1971. When your own kids are leaving for college and you start delivering the babies of babies you delivered, it is time to look up from the exhausting day-to-day work and take a deep existential breath. The task and the profession to respect the patient -- to observe and listen closely -- remained central to being a trustworthy physician. But patients and physicians had changed. Hospitals had changed. Medicine had changed. Society had changed. Maternal and infant mortality and morbidity had dramatically declined. Ironically, so had patient and physician satisfaction. Respect and trust could no longer be taken for granted. Harm? Strangers do not notice and adversaries do not hesitate.
What had happened? What centrifugal forces were pulling patients and physicians apart? Social mobility? A more educated population? The move to protect individual rights? A sexual revolution? All these and still other factors contributed. But the most plausible interpretation points centrally to the tension between two honorable goals -- i.e., on the one hand, doing what is best for each patient and, on the other hand, insuring adequate care for the greatest number of patients. One strategy -- some might say, the traditional strategy -- would have a physician care for as many patients as possible without compromising the standard of care for each patient. Many physicians followed this strategy. Of course, moneymaking motivated some. And ethnic or economic prejudices could still go unchallenged. But many physicians genuinely struggled with the tension between individual and societal responsibilities.
However, all around them medicine was being reshaped by developments that drew attention away from individual patients. Such serious public health concerns as population control and indigent patient care had to be addressed. Research and experimentation -- propelled by wartime successes -- changed public expectation as ‘miracles’ moved from kidney dialysis to transplanted hearts, from polio vaccines to ‘the pill’. Statistical significance and randomized controlled trials reshaped medical education, medical literature, and clinical decision-making patterns. Government legislation and programs so defined the issues that Dr. Roy Parker, in his 1975 presidential looking forward to the year 2000, predicted, “The future of [obstetrics and gynecology] resides in the government”. The trend toward utilizing nurse midwives and other non-physician ‘extenders’ for routine tasks promised to increase the reach of obstetric care.
Obstetrics and gynecology had enjoyed startling advances -- as does a rapidly growing tree according to one observer. By the mid-‘60s, academicians estimated that the best medical education became obsolete in five years. The specialty expanded in fetal medicine, geriatric gynecology, endocrinology, gynecologic oncology, . . . . A chronology of editorial opinions highlights the gradual reformation taking place:
1959: In attempting to stay near the front of the [knowledge] race, there has been a tendency to forget or neglect some qualities of man as desirable as knowledge -- i.e., wisdom, dignity, and faith. Specialization is an evil, but an unavoidable one. We know more and more about less and less. We must avoid the easier method of treating the disease and neglecting the patient.
1963: All efforts not ultimately directed toward more competent and compassionate patient care are valueless.
1965: Programmed learning is in sharp contrast to the traditional pattern of education in medicine that utilizes a close association between student and preceptor for the transmission of skills from one generation to the next.
1966: Devoted to the concept of the responsibility of a particular physician for an individual patient, we are initially repelled by the impersonal, even amoral, nature of statistics and the collective approach. . . . [We should] try to comprehend the ways of the ‘monster’ and, by becoming to a degree part of it, attempt to guide its progress and so preserve some of what seems essential in the traditional ideals of medicine.
1969: Individuals want, need, and trust their physicians; at the same time, the patient generally favors and supports social reforms adverse to the physician and his ability to function as a personal doctor.
1971: Is this to be a point in time when we are expected to acknowledge our responsibility to the community in which we live – and, as a result, perhaps find ourselves doing what needs most to be done -- even though it may not be what we individually would have liked most to be doing?
By 1971 the curtain had been pulled back on female and fetal health. Medicine was in public view. But the public -- suspicious of social institutions and traditions -- had seen a darker side to their medical ‘gods’. The 1962 thalidomide scandal sparked congressional hearings over regulating drug companies and monitoring informed consent. Then came the 1966 exposé of twenty-two research projects authored by Dr. Henry Beecher (a University of Kansas graduate). And finally, news broke of the US Public Health Service’s Tuskegee research on syphilis.
Hospitals began displaying copies of ‘The Patient Bill of Rights’. The 1972 Canterbury Case shifted the focus of informed consent from what a physician should disclose to what a patient needs to know to make an informed choice. The widely-read Our bodies, Our Selves advised women to be wary consumers of health care. Another title put it more bluntly -- Rid Yourself of Your Gynecologist. 1973 saw the formation of a President’s Commission to address the perplexing questions modern medicine had created but alone could not manage. As Dr. William Bartholome of the University of Kansas School of Medicine explained in a 1971 letter – “There is need to involve not only the medical profession, but lawyers, sociologists, moralists, and society at large to resolve complicated medical issues”. Dr. Bartholome had just released a film that recreated a 1969 Johns Hopkins case in which he had been the resident who was told to pull the feeding tubes on a baby with Down syndrome and an intestinal blockage.
In 1955 he moved his family to form with two other physicians a group practice that in time would expand to five partners. Wedded to obstetrics, he soon earned the reputation of being a meticulous and hard-working clinician. He delivered all his patients. Resolved to remain current as the specialty broke new ground, he was among the first in his location to perform laparoscopic tubal ligations. He introduced fetal monitoring. His boys remember going with him to the family farm to practice the fetal monitor on pregnant cows.
During years of social upheaval, he quietly but consistently participated in his hospital’s obstetric service for indigent patients and provided coverage for a nearby home for unwed mothers. Residents rotating with him saw the same high standards of care and the same respect for patients, whether the patients were socially advantaged or not.
Yet by 1971 -- the midpoint in his career -- he could identify with the question raised in an Ob/Gyn editorial -- “What happened to the old-fashioned physician and the old-fashioned patient?” He was at a critical juncture. Would he limit his practice to the shrinking number of ‘old-fashioned patients’? Would he shift his practice away from obstetrics by focusing on the gynecologic needs of the women he had delivered in previous years? Or would he pay the personal and professional price to remain in the middle rather than on the periphery of his specialty?
Commentary
1971. When your own kids are leaving for college and you start delivering the babies of babies you delivered, it is time to look up from the exhausting day-to-day work and take a deep existential breath. The task and the profession to respect the patient -- to observe and listen closely -- remained central to being a trustworthy physician. But patients and physicians had changed. Hospitals had changed. Medicine had changed. Society had changed. Maternal and infant mortality and morbidity had dramatically declined. Ironically, so had patient and physician satisfaction. Respect and trust could no longer be taken for granted. Harm? Strangers do not notice and adversaries do not hesitate.
What had happened? What centrifugal forces were pulling patients and physicians apart? Social mobility? A more educated population? The move to protect individual rights? A sexual revolution? All these and still other factors contributed. But the most plausible interpretation points centrally to the tension between two honorable goals -- i.e., on the one hand, doing what is best for each patient and, on the other hand, insuring adequate care for the greatest number of patients. One strategy -- some might say, the traditional strategy -- would have a physician care for as many patients as possible without compromising the standard of care for each patient. Many physicians followed this strategy. Of course, moneymaking motivated some. And ethnic or economic prejudices could still go unchallenged. But many physicians genuinely struggled with the tension between individual and societal responsibilities.
However, all around them medicine was being reshaped by developments that drew attention away from individual patients. Such serious public health concerns as population control and indigent patient care had to be addressed. Research and experimentation -- propelled by wartime successes -- changed public expectation as ‘miracles’ moved from kidney dialysis to transplanted hearts, from polio vaccines to ‘the pill’. Statistical significance and randomized controlled trials reshaped medical education, medical literature, and clinical decision-making patterns. Government legislation and programs so defined the issues that Dr. Roy Parker, in his 1975 presidential looking forward to the year 2000, predicted, “The future of [obstetrics and gynecology] resides in the government”. The trend toward utilizing nurse midwives and other non-physician ‘extenders’ for routine tasks promised to increase the reach of obstetric care.
Obstetrics and gynecology had enjoyed startling advances -- as does a rapidly growing tree according to one observer. By the mid-‘60s, academicians estimated that the best medical education became obsolete in five years. The specialty expanded in fetal medicine, geriatric gynecology, endocrinology, gynecologic oncology, . . . . A chronology of editorial opinions highlights the gradual reformation taking place:
1959: In attempting to stay near the front of the [knowledge] race, there has been a tendency to forget or neglect some qualities of man as desirable as knowledge -- i.e., wisdom, dignity, and faith. Specialization is an evil, but an unavoidable one. We know more and more about less and less. We must avoid the easier method of treating the disease and neglecting the patient.
1963: All efforts not ultimately directed toward more competent and compassionate patient care are valueless.
1965: Programmed learning is in sharp contrast to the traditional pattern of education in medicine that utilizes a close association between student and preceptor for the transmission of skills from one generation to the next.
1966: Devoted to the concept of the responsibility of a particular physician for an individual patient, we are initially repelled by the impersonal, even amoral, nature of statistics and the collective approach. . . . [We should] try to comprehend the ways of the ‘monster’ and, by becoming to a degree part of it, attempt to guide its progress and so preserve some of what seems essential in the traditional ideals of medicine.
1969: Individuals want, need, and trust their physicians; at the same time, the patient generally favors and supports social reforms adverse to the physician and his ability to function as a personal doctor.
1971: Is this to be a point in time when we are expected to acknowledge our responsibility to the community in which we live – and, as a result, perhaps find ourselves doing what needs most to be done -- even though it may not be what we individually would have liked most to be doing?
By 1971 the curtain had been pulled back on female and fetal health. Medicine was in public view. But the public -- suspicious of social institutions and traditions -- had seen a darker side to their medical ‘gods’. The 1962 thalidomide scandal sparked congressional hearings over regulating drug companies and monitoring informed consent. Then came the 1966 exposé of twenty-two research projects authored by Dr. Henry Beecher (a University of Kansas graduate). And finally, news broke of the US Public Health Service’s Tuskegee research on syphilis.
Hospitals began displaying copies of ‘The Patient Bill of Rights’. The 1972 Canterbury Case shifted the focus of informed consent from what a physician should disclose to what a patient needs to know to make an informed choice. The widely-read Our bodies, Our Selves advised women to be wary consumers of health care. Another title put it more bluntly -- Rid Yourself of Your Gynecologist. 1973 saw the formation of a President’s Commission to address the perplexing questions modern medicine had created but alone could not manage. As Dr. William Bartholome of the University of Kansas School of Medicine explained in a 1971 letter – “There is need to involve not only the medical profession, but lawyers, sociologists, moralists, and society at large to resolve complicated medical issues”. Dr. Bartholome had just released a film that recreated a 1969 Johns Hopkins case in which he had been the resident who was told to pull the feeding tubes on a baby with Down syndrome and an intestinal blockage.
