THE WAY WE WERE

ENTERING AN ERA AT ITS CLOSE

The changes in medicine and its practice during the past half century are well beyond anything that would have been imagined at the halfway mark of that century. The situation and the role of the physician have altered considerably. The status then enjoyed by the physician has been eclipsed by technical progress in medicine. In addition, there are many interesting and compelling scientific and technological careers available that did not exist in midcentury. They have served as magnets for younger people with high aspirations. These are the types of people who would have entered into medicine when it was the acme of careers. They have within them varying mixtures of the entrepreneur, the curious, the intellectual, the scientist, the humanist, and a touch of the pragmatist.

The science and technology that developed over these past fifty years have made it possible to have careers in information technology, astrophysics, space exploration, undersea exploration, and new sources of energy, among others. The technology of war even played a role, and an important one. Paramount in all this was the computer. It changed society and then the world, and, as it changed the world, it changed medicine. But it changed it for the better. It brought diagnostic power undreamed of and made efficient an inefficient process. It brought the recognition that medicine, unbeknownst to itself, controlled a large segment of the economy. This was a phenomenon that occurred almost by accident: As more people were born—and kept alive by sanitation and vaccination—more medicine was needed to care for them in their adult years. The costs became significant, and many people could not afford them. Physicians engrossed in the practice of a consuming art—the Magnificent Obsession of movie fame and many novels—noted but did not assimilate the societal reaction to what physicians saw only as improved methods to care for people. Soon enough, business recognized it and began to organize and manage medical care and, relatively quickly, began to profit handsomely from it.

Those of us born in the late thirties or very early forties entered medical school in the later fifties or early sixties. It was a time that I have heard described as a "Golden Age of Medicine." In surveys taken at the time, physicians were ranked second only to Supreme Court justices in public esteem. A golden age, of course, is relative to the observer. Physicians were at the top of a revered profession dedicated to the care of others, and they were almost solely responsible for the management and delivery of that care. The fact that care was very unevenly distributed and closely related to ability to pay was not a consideration. The physician wore the garb of a priest and seer; his opinions were respected, given great credence, and sought in areas outside of medicine. He was the educated person, in the broad, liberal arts sense of the term. In addition, he knew a certain amount of science, and he knew the workings of the human body and psyche as well. He was a shaman at what would be the end of the age of shamans. There is some hyperbole here, used to crystallize the image, but not too much. It was like that. Younger people thinking about careers aspired to enter medicine for reasons intellectual, altruistic, compassionate, and aspirational. The career provided a good living, but although that may have been subsumed in the career choice, it was not a driving force. The concept of helping one's fellow man had not yet become a cliché, and "My son the doctor" was a humorous descriptor but still one that many parents wished to be able to use.

Consider that medical care at midcentury truly was not too far from the time when infectious diseases ravaged populations and certain age groups—the very young and the very old. With the exception of some specific vaccinations and early antibiotic research, there had been very few real advances in medical care and therapeutics since the time of Galen. There were very real benefits to health from better sanitation, improved nutrition, and less crowded living conditions, and life expectancy was beginning to increase. But the nineteen centuries leading to our own twentieth all were about the same in terms of medical therapeutic results. There had been incremental gains in the understanding of some physiological processes and certainly a growing appreciation of the importance of public health, but the upstroke in therapeutics and disease prevention really would not take place until just before the mid-twentieth century. That was not very long ago.

Consider that we have had societies of some sophistication for about the past five thousand years; we are talking about just 1 percent of that time span. Perhaps it should not be a surprise that medical care has undergone such a metamorphosis in the past half century. What we call modern medicine moved into its adolescence at midcentury, and we know how quickly adolescents change.

There were three advances in medicine that were present at the beginning of the twentieth century and marked an inflection point that separated the century from the fifty centuries that had gone before. These were: vaccination, the beginnings of what was termed the "germ theory," and the importance of sanitation and public health in the control of disease. A second inflection point came about midcentury with the expansion of biochemistry and immunology that brought modern science into medicine. The emergence of molecular biology and the rapid expansion of technology and computers midway in the second half of the century were a third inflection point, and it is that upstroke that we are riding yet today. Note that the last two of these changes in the sophistication of medicine and medical care occurred in or around the mid-twentieth century and largely over a span of about forty years.

These changes in medicine and medical science did not develop in isolation; they were a parallel to advances in other areas. The nineteenth century had brought electricity and power grids, steel, the telephone, the telegraph, the automobile, and, as early as midcentury, the first oil well. The Industrial Revolution, building upon all of these, brought the enormous expansion of the railroads and steamships. The advent of the railroad was the first real change in locomotion since the time of the Romans. Think about that! The momentum of new ideas and the savoir faire to bring them into commercial reality provided the momentum for an enthusiastic start to the twentieth century. Much of this was on view at the Chicago World's Fair (Columbian Exposition) in 1893 and both summarized the astounding scientific and technical advances of the nineteenth century and presaged what might be anticipated from the twentieth. Despite the heroic efforts of its organizers and planners, it did not come even close to what the...