American College of Physicians: Internal Medicine — Doctors for Adults ®

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Overcoming the irony of progress to find joy in medicine

From the April ACP Observer, copyright 2003 by the American College of Physicians.

By Munsey S. Wheby, FACP

I have witnessed immense changes in medicine in the nearly 48 years since I finished medical school at the University of Virginia School of Medicine. The training environment in the mid-1950s was so different from today, both in the level of supervision and the inpatient population that we treated.

I recall with twinges of both fear and exhilaration having near-complete autonomy over patient care as a house officer at New York Hospital. At that time, we kept myocardial infarction (MI) patients in the hospital on bed rest for three to four weeks.

As a trainee, I had ample opportunity to learn clinical medicine at these patients' bedsides as they spent weeks recuperating. We residents got to know our patients well—and they, us. Through the days and nights we spent with them, we learned something of the art of medicine.

Since then, that art has changed dramatically. On the plus side, we have substantially improved outcomes for MI patients. We now have greater understanding of cardiovascular disease and its prevention, as well as a large range of medical and surgical treatment options. We discharge MI patients in days instead of weeks. And after an MI, patients follow active rehabilitation regimens.

Perhaps the most vivid way for me to mark—and celebrate—the substantial progress we have made in diagnosis and therapy in this last half-century is to recall one of my patients during residency who had fatal thrombotic thrombocytopenic purpura.

Nancy was just 42 years old and had previously been healthy. Her illness began with subtle neurological changes that progressed relentlessly, along with purpura and intestinal bleeding. No effective treatment was available, and she died after three days in the hospital. Today, a patient like Nancy would almost certainly be treated with plasmapheresis with great success.

Research, teaching and practice

Following residency, I spent six years with the U.S. Army Research and Development Command, doing research and seeing the world. I studied iron metabolism in Washington, tropical sprue in Puerto Rico and cholera in the Philippines.

After a year at Rutgers University's then-developing medical school, I returned to the University of Virginia, where I've remained. My entire career as a clinician, teacher and administrator has been based here.

Practicing medicine while educating medical students and housestaff has been my most gratifying work. It pushes me to study as my field advances and changes. It keeps me ethically and professionally alert so that I can serve as a model for students and residents. And it keeps me engaged in—and optimistic about—life as I see patients demonstrate hope, courage and endurance in the face of illness. (I wrote about this aspect of my practice in the March 19, 2002, Annals of Internal Medicine, which is online.)

In more than 35 years of practice, I have primarily cared for patients with serious hematologic disorders, but I have always considered myself an internist first and a hematologist second. The skills required to give good care to a patient with a hematologic malignancy are the same fundamental competencies that expert general internists have. Those include a wealth of medical knowledge, superb physical examination and interpretation skills, refined diagnostic acumen, finely honed clinical judgment and dedication to patients' well-being through and beyond illness.

The irony of progress

As I reflect on my career so far, I find it ironic that while we have witnessed amazing progress in medicine, we experience so little satisfaction and joy as a result.

Stunning advances in science and clinical practice have made it possible for us to help more patients and effect more cures than we ever dreamed in the early days of my practice. One would expect physicians to be ecstatic with the new medicine. On one level, of course, we are. We sometimes even take for granted our present astonishing clinical prowess.

But much of the joy we should experience has been dampened by practice hassles, which stem largely from our country's failure to develop a coherent health care system that keeps pace with medical and societal changes. Our current fragmented "system" makes it hard to be a doctor today, especially the kind we all vowed to be.

Whenever I talk with internists, I hear a similar lament: "I feel excitement and satisfaction when I am in the examining room with my patients, but these feelings are sobered when I have to deal with the complexities of compliance, coding and insurance."

The sad reality is that for American internists, these hindrances steal time we could spend with patients and cause tremendous professional dissatisfaction.

Improving internal medicine

In the coming year and beyond, the College will focus its energy and resources on working toward a key goal: making internal medicine the interesting, exciting and profoundly satisfying career that originally attracted all of us. In the February ACP-ASIM Observer, Immediate Past President Sara E. Walker, MACP, described some of the College's efforts in this cause. (Her column is available online.)

The College is pursuing this goal for two reasons. First, we worry about the declining numbers of medical students and residents choosing general internal medicine as a career. Second, we want to ensure access to care for all patients, particularly the elderly and those with multiple illnesses.

These two concerns—physician supply and patients' access to care—dovetail. General internists are essential if all patients are going to have optimal access to care.

These concerns have also prompted us to intensify our advocacy efforts to diminish or eliminate bureaucratic hassles. These distractions impede patient care and dilute the satisfaction we should all find in doctoring done well.

Starting the conversation

I'm thrilled and honored to serve as the new President of ACP, an organization dedicated to fostering excellence and professionalism in medical practice. I see this office as a wonderful opportunity to do all I can to work toward meeting this lofty ideal.

As I begin my term as President, I've shared a little about myself in this column in hopes of fostering a year-long conversation with you about the things that really matter in medicine. Throughout the year, I'll introduce important and even urgent issues for College members in my columns.

I hope that in turn, you will respond and make your views known to me (msw4x@virginia.edu). In addition to your local Governor, you can also contact Mary T. Herald, Chair of the Board of Regents, at mth1@columbia.edu, or Jeffrey P. Harris, FACP, Chair of the Board of Governors, at jharris@shentel.net. All of us at the College want to hear from you.

If my columns can stimulate a candid discussion of issues that are crucial to our lives and work in internal medicine, I will have had a most satisfying year as President.

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