HEALTH CARE/Joan Retsinas

The Doctor: A Vanishing Icon

Think of Officer Friendly, walking a beat. He is mythic; research suggests that he was never real, always was mythic, reflecting our need for an avuncular police presence on our streets. Think of Sesame Street’s “people in your neighborhood”: the postman, fireman, librarian. Thanks to a reorganized, cost-efficient world on the one hand, and exurban sprawl on the other, most children don’t know those people first-hand; in fact, their stranger-phobic parents have cautioned them not to talk to people they don’t already know.

So the vanishing “doctor” is emblematic of the times.

In a long ago world of Marcus Welby, M.D. (a television show that is hard to find anymore, even on oldies cable), people had doctors. Their doctors knew them, and they knew their doctors. When a patient entered the examining room, the doctor knew something about the family, remembered past ailments, and used the chart as a refresher. The two talked. And the doctor examined the patient — a physical examination, before talking some more, maybe writing out prescriptions and orders for tests. The doctor would see the patient again and again, even in the hospital. If the prognosis was bleak, the patient (the doctor too) assumed the two would see each other until the end. That was an MGM script for The Doctor.

Of course, many of those Dr. Welbys knew little about medicine, had no access to super duper diagnostic technology, and rarely referred to the specialists with the expertise to save lives. So nostalgia for a mythic past is generally misplaced.

Yet I miss “the Doctor.”

He/She vanished in stages.

First came the name-change. “Doctor” gave way to “health care provider,” where the doctor, like a host of white-coated others, dispensed a “product,” in this case, “health care.” He/She “provided” referrals, tests, prescriptions, treatments. You took your car to a garage, your financial records to an account, and your body to a health care provider.

That gave way to “primary care physician.” This doctor was the nub of a network — the way-station to a specialist. Health care maintenance organizations — another modern moniker — put the doctor in charge of the paperwork necessary for you to see somebody else. This gatekeeper was beholden not just to you, but to the organization that employed him. Too many referrals, and the primary care physician risked being dropped from the insurer’s “network.”

“Hospitalists” entered the network: your primary care doctor would no longer follow you in the hospital; instead, a hospitalist would visit.

The single-practitioner went by the boards. Doctors formed large group practices. A patient might or might not see “his doctor;” instead, the patient would see a member of the group. Groups are of course more efficient, allow for easier consultations; but Dr. Welby didn’t run by efficiency.

More recently have come the demands – all reasonable, all warranted — that physicians disclose their possible conflicts: the consultant contracts with drug companies for promoting their products, the speakers’ bureau fees for speeches explaining products, the presence on corporate panels. Maybe, just maybe, your doctor isn’t thinking primarily about your best interest. The erosion of trust continues.

Now electronic medical records are replacing those illegible paper charts. Every organization concerned with quality, efficiency, and cost-effectiveness touts them. In another decade every physician will be tapping away while seeing patients. The physician often looks away from the patient, the better to tap. If you have ever had a conversation with somebody who isn’t looking at you, you get the feeling of a patient.

So the renaissance of humanism in medical education deserves praise. In “Bringing Doctors to the Dying Patient’s Bedside” by Pauline W. Chen, M.D. (New York Times, June 3), Dr. Chen highlights the program at the University of Medicine and Dentistry of New Jersey-New Jersey Medical School in Newark. Students elect to stay with dying patients, listening to them, sometimes just being a presence. Other medical schools are trying to revive students’ initial zeal to heal people — a zeal often worn away by today’s technological organization of medicine and training. Fueled by the Arnold P. Gold Foundation, schools are adopting “white coat” ceremonies and developing programs that promote the human link between patients and their doctors.

Not every patient will want this kind of doctor, but for those of us who do, I hope to welcome back Dr. Welby, retooled, and retrofitted for the 21st century.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.

From The Progressive Populist, August 1, 2010