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Rolling with the changes

by Daniel on July 16th, 2015

My last article looked at some issues about medical education inspired by my upcoming 50th anniversary class reunion. It was at just such a reunion weekend that the revered Dr. W. T. Connell reminded his audience of the old physician who said proudly “I’ve been around this hospital for 50 years and I’ve seen a million changes and I’ve been against every damn one of them.” Well I’ve been around the practice of medicine for 50 years and I want to examine some of the changes that have occurred and how I have reacted to them. I haven’t been against every damn one of them but perhaps I’ve come too close to this degree of rigidity. In my reaction to change there may be some lessons to be learned – lessons about how health-care professionals might adapt to those many changes which will surely occur in the next half-century. Historically physicians do not have a particularly good track record adapting to change. We had to be beaten about the head and ears for instance to get us to wash our hands after doing autopsies and before delivering babies. The 50 years during which I have been involved with the practice of medicine say from 1940 to 1990 have seen more changes than occurred for a couple of millennia previously. There is no reason to believe the rate of change will slow down. When I began the study of medicine we had precious little to offer patients that was really effective. We had quinine for malaria digitalis to help the failing heart morphia for pain and ether for the blessing of anesthesia. There were also the sulphonamides and penicillin was on the horizon. Now we have a list of effective medications that fills volumes and overfills our heads. It seems as though a new name is coined every day and I must admit I sometimes get confused as to whether Adalat is a new drug or a new car from General Motors. How did I react to all these changes? Sometimes well sometimes poorly. I hopped on the penicillin bandwagon fairly quickly although my soul-searching over whether to increase the dose from 10000 units to 20000 units in a difficult patient now seems silly. I used a lot of streptomycin as “pen-strep” probably too soon. I was very slow to use chloramphenicol for the minor infections I saw in general practice though it did cure the one case of typhoid fever that I saw. I was also slow to begin prescribing oral contraceptives on the grounds of not wishing to upset the delicate hormonal balance of young women. In retrospect another silly precaution. On the other hand I was slow to start inserting IUDs and am glad I was. And I’m certainly glad I stuck to coils loops and Ts and didn’t get involved with shields. The book Feminine Forever which advocated the life-long use of estrogen replacement for menopausal women was published in the 1960s. In the late ’80s this slow learner was still struggling to figure out whether this was really a good idea. Is the last word yet in on the subject? Upon my retirement I found in my desk drawer a vial of pills called Thalidomide. A drug rep had given them to me and I had passed them on casually to a pregnant patient suffering from nausea. She returned them to me at her first postnatal visit by which time the horrible side effect of the drug was known. Now that was a lesson. I did deliver a baby with phocomelia and was relieved to find that I had prescribed Bendectin rather than Thalidomide. But I’m still not sure about that one. I do know that vomiting of pregnancy as an entity requiring medication practically disappeared after Thalidomide. I did home deliveries as a GP in the late ’40s and was scared spitless for my efforts. I have trouble understanding why they are coming back into fashion. I sat in staff meetings where we berated ourselves because our “section rate” was getting up to 4%. We even had “mandatory second consultations” prior to C-sections for a while. Despite this the C-section rate got up to 20% didn’t it? I don’t know that there’s much evidence it improved fetal outcome all that much. Maybe it cut down on lawsuits. In any case the C-section pendulum appears now to be swinging back. Perhaps it was nurses that got us on the fetal monitoring kick so quickly. It gave them – all right and us – a feeling of comfort to slap a monitor on the belly of every laboring woman. And then because of an equivocal or unreadable tracing the patient needed a scalp clip which was soon followed by an intrauterine catheter which led so often to a section. Though not directly involved I was very slow to learn to advise women that something less than a “modified radical mastectomy” might produce as good results in breast cancer. I remember reading about a Scottish surgeon in the ’50s who said just that. Nobody seemed to hear him until the ’80s. And speaking of “prophets without honor” I remember as a resident sitting up one night with Dr. Shute waiting for a delivery. He told me of his pain over the rejection by the profession of his claims for vitamin E. Well I pop a couple of vitamin E capsules nightly now. My internist seems to think it “may have some value.” Perhaps the most fundamental change I have faced is the manner in which I’m paid for my services. Like most of the physicians of my time I was dragged kicking and screaming from an era when the patient paid you two bucks and maybe a chicken for an office visit. For 30 years now I have been well paid for my services by my kindly government. Now I kick scream and struggle if that government wants to change by one iota their method of reimbursing me. But the most difficult change I have had to face is the abortion question. One day I was told that the act I had believed was illegal immoral and only to be contemplated after intense soul searching had overnight become legal moral licit and to be undertaken on an ad lib basis. That change and the rapidity with which it occurred was extremely difficult for me. In the end I did my share of therapeutic abortions. I often felt it was more than my share. I always hated the procedure both ethically and technically. It was perhaps the best solution to a bad problem but it still remained a bad solution. It also left me with some questions. If those of us who ended up doing abortions really believed they should be done why were we not on the ramparts leading the fight for legal abortions before the legislation was changed? Why did we leave it all to lay people and Dr. Henry Morgentaler? Why was there that period where we tried to get our psychiatric confrres (via the second consultation route) to make decisions that we should have been making – a decision we now in fact do make? Finally we were warned by those opposed to the procedure that if we accepted abortion on demand we would end up discussing euthanasia. We scoffed. But people are now debating the morality of euthanasia. Is this another change physicians will soon have to face? So what is to be done about the inevitable changes of the next 50 years? Well I hope we will continue to adopt change slowly as we have done in the past. By going slowly we shall at least be applying the old medical adage primum non nocere “first do no harm.” We should learn I think not to apply powerful new medications to minor diseases e.g. Thalidomide. We should remain open to the possibility that any therapeutic modality may benefit sick patients e.g. vitamin E. Our success rate is never so high that we can afford to scoff at alternative solutions to patients’ problems. At the same time we should remain alert to the possibility that any treatment new or old may harm the patient. Of this we should never lose sight. In the final analysis we should be consoled by the old adage that “if our foresight was as good as our hindsight we’d be a lot better off by a damn sight.”

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