DR. SAPHIR: If you were currently asked by a member of your family whether they should go into medicine, whether they should go into the field of pediatrics, or medicine in general, how would you answer them today, and why?
DR. EISENBERG: I'd tell them enthusiastically to go ahead. It's the most marvelous field you can enter, because you do well for yourself by doing good for others.
I don't think medicine has ever been more exciting, in terms of the developments in the field. Now, of course, I made a big point of how dreadful I think the new intrusions of administration and the like are being, but I think the battle can be won. I think there are signs that we're getting support from the public. “Drive in” deliveries were such a crass invasion of women's rights that, in a number of states, legislation has halted the “24 hours and get out” rule that applied.
I don't think that's the way to manage medical care, but I use that as a sign of the fact that the public is becoming disenchanted. So I think medicine is great and will remain great. Three of our four children are in medicine. And if we had another three, I'd send them on the same path.
DR. NATHAN: I just want to say I'm a late convert to pediatrics, so that I think I know why one goes into this field. I didn't go into this field as a young, starry-eyed medical student. I went in because I was absolutely fascinated, and I think that's where the joy of pediatrics is—that's where the action is.
It's in pediatrics that you learn what the human condition is. You learn how to apply genetics, as well as decent care principles, and you can get somewhere scientifically; it's a remarkable field. I don't know why anybody wouldn't go into pediatrics today. That's where biology is. That's where care principles are.
DR. HENDREN: I share the enthusiasm of my friend, Leon. We had five children; the first became a nurse but she died. Three are surgeons. I told them I didn't care what they went into, as long as it was some branch of surgery. The last one is a lawyer, but he's one of the good guys. He takes care of the rest of the family.
Let me just add that I tell all our young people, who seem distressed about managed care and all these things that there are always going to be sick patients. There will always be a need for somebody to take care of them. I don't know any of my friends who do something else beside medicine who look forward to going to work on Monday morning.
Because there's something interesting, something vital, where they'll have a feeling that they've accomplished something at the end of the day. I don't think people who are in business and law and all those other occupations have that thrill. It was very interesting for me to go back to my 50th high school reunion to find that there were four members of my class who weren't bragging about being out on the golf links. And all four of us are in medicine and are continuing to enjoy the practice of medicine. Everybody else is retired.
DR. AVERY: Well, I think if you can maneuver yourself into a situation where you do exactly what you most want to do and somebody even pays you to do it, you've got it made.
Moving back and forth from the bench to the bedside has been an exhilarating experience for me because I was given time to follow leads that came from observations at the bedside and to work in the laboratories. Returning and living in those two worlds has been what I would have designed as the way I most wanted to spend my life. I can't imagine anything any better except occasionally I feel a little guilty about being paid for it.
DR. DWORKIN: We heard about a number of conditions this morning—infectious diseases, surgical conditions, congenital anomalies, genetic abnormalities, and others, for which either a cure or certainly effective treatment has been implemented. In listening to the chronology, there have really been remarkable accomplishments, as recently as the past decade.
I wonder if anyone would care to speculate then, if we were to look ahead 10 years, to identify one or two common conditions, diseases that currently really do contribute to morbidity or mortality, with which we will no longer have to cope?
DR. WELLER: Well, when one sees one of the major infectious disease problems, AIDS, HIV, and thinks of what has been learned in the past 2 years about it, I have every confidence that 10 years from now AIDS, HIV will no longer be a major problem. But there will be something to replace it.
DR. SAPHIR: How do any of you think that the short stays that are now mandated in health care, whether it be surgery, or medicine, are going to affect the house staff, the doctors of the future, and what is the best way to cope with this?
DR. EISENBERG: At the moment, I think it's shortchanging training. However, if it's better care, and that's an issue that has to be resolved, then we've got to modify our training, so that it takes place in settings compatible with the best care. That means organizing outpatient and inpatient services, so that there is continuity so that the house officer does get to see the prospective surgical patient before surgery, during it, and after on a follow-up basis.
That's a complicated organizational arrangement. Life was much easier before, but one wouldn't want to double or triple the length of a hospital stay just for the convenience of the medical student or the teacher.
One of the problems is that so many of the things that we do as doctors are based on what we were taught and don't have much of a basis of evidence. I recently had occasion to review some of the literature on the treatment of myocardial infarction. When I was a medical student and a house officer, the treatment was 4 to 6 weeks of solid bed rest. It was 1954 before Sam Levine wrote the first paper about what he called chair treatment with coronaries. It frightened the hell out of everybody to get the patient out of bed and into the chair, even though we had good physiological reasoning as to why the patient was actually better off and the heart more rested.
Then gradually, ambulation went on from that. Well, look at all of the periods in time during which we swore by long hospitalizations. I think each one of these things merits examination. We simply have to redesign our education to match optimal care.
DR. GELLIS: When I first became a chief and in charge of scheduling calls on/calls off, I insisted that the same system be used that had been used all through my training. That schedule was every other night and every other weekend unless you fell so ill you couldn't move anymore.
When I first became a chief, I took over a service where people had been on just every third night. I thought that was scandalous, and I immediately revoked that and ordered every other night. Nobody fought it, but nobody did it either. They very quietly set up their own schedules and continued on every third night. Now I guess it's about every fourth night, or even sometimes every fifth night.
I don't see that it has affected the skills of the people who are being trained today for going out into practice one bit. They're a damned sight better than the every other night persons. So, I think you adapt to teaching and training the way you have to.
I certainly don't like this rapid admission and discharge because no one really gets to know the family. But then that's the problem of the primary care physician. This is why I urge that the primary care person take over and insist on being given all the information and help he needs.
DR. HENDREN: I would add a different perspective. Some of our surgical residents recently said that the problem with being on every other night is that you miss half the cases on the nights you're not there. So, we still have it every other night and every other weekend.
As I was listening to Tom Weller, who is one of my teachers, I thought, how insignificant is the work of the surgeon, when you compare it with the work of those that have wiped out polio, smallpox and all those things?
A busy surgeon in his lifetime operates on 20 to 25 000 patients, and that's all. As you look back over your lifetime you can say that probably 90% of those cases could have been handled by just about anybody that you know has any surgical skill at all. So your lifetime boils down to looking at relatively few people whose lives you have truly saved who wouldn't have been saved by somebody else. So I take my hat off to our medical colleagues who make these advances that save millions of children.
DR. WELLER: On the other hand, if you have a child who has a surgical repairable default, and only Hardy Hendren or Joe Murray can do it, you're making a contribution that's unmatched.
DR. HENDREN: By comparison, it's a small one. I have been in the position of appreciating the skills of the surgeon. I've had the experience of being on the receiving end, and I'm grateful for having good surgeons. But at the same time, the scope of what the surgeon can do pales in comparison to the advances that have been presented to us today by Dr Nathan and Dr Markowitz. My father had severe rheumatic valve disease, and my own aortic valve is going to need replacement sometime as a result of streptococcus. What you all do saves thousands. What we can do doesn't even come close.
DR. WELLER: This discussion brings up the basic difference between public health and medicine. The health worker deals with the community of people. It's always pregnant. The physician deals with the individual and is duty-bound because of the best medical or surgical care available. Each has its own role; each is important. I don't think one can judge relative values.