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December 2000
Volume 64 |
Number 12
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RESIDENTS' REVIEW
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| Our
Sphere of Influence – We Are the Final Push
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Gary D. Gonsalves, M.D.
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following is an excerpt from a graduation speech written by
Dr. Gonsalves, who is embarking on his career in anesthesiology. |
Finally, the time has come for us to claim our place in the history
of medicine. What mark will we leave as we transition through
the next 30 years? If the past offers any indications of the future,
then I believe we are entering a very exciting time. Just look
at some of the advances of the last 100-plus years. When was the
last time you discussed a medical paper without mention of (or
perhaps cursing) statistics? Credit this to Bradford Hill who
in 1937 published "Principles of Medical Statistics,"
where he clearly delineated, among other things, the essential
outlines of accurate clinical trials. How about Pavlov, who in
the late 1800s studied conditioned reflexes in dogs – studies
that were later used by Bayliss and Starling, who in 1902 developed
the concept of a chemical component that they called a hormone.
Does the name Rontgen sound familiar? In 1895, his paper gave
birth to the field of diagnostic radiology. Other contributors
include Sir Alexander Fleming, who accidentally discovered the
bactericidal effects of penicillin; Franklin, Watson and Crick
who discovered the double helical nature of DNA, and the list
goes on. What will be our contribution to medicine?
I will suggest that for us to have an impact on medicine, we
will have to serve our patients in very unique ways. The problems
plaguing the Tucson community and, for that matter, the nation
are not entirely new. December 7, 1939 – the lead article
in The New England Journal of Medicine is titled "Payment
for Medical Services." Now jump forward in time to the April
6, 2000, New England Journal of Medicine article titled
"California's Beleaguered Physician Groups – Will They
Survive?" Sixty years later, we are still grappling with
the same problems. Despite our nation's most significant post-war
economic expansion, Arizona physicians have gingerly tiptoed through
a battlefield scarred by a decade of declining income and the
death of several beloved institutions. I quote from Steve Nash,
M.D., the Executive Director of the Pima County Medical Society:
"As we call roll in December 1999, there are several
names missing: Thomas Davis Medical Centers, age 75; Group Health
Medical Associates, age 25; The Tucson Clinic, age 46; Tucson
General Hospital, age 50... It is beginning to feel like the
last two miles of a marathon. You know, the stragglers have
dropped out, the pack has fallen back. You gather energy to
look around, trying to see who’s left for the final push."
We are the final push! If medicine is to continue serving
patients and not industry, then we have to accept responsibility
for much more than patient care. Just as our primary education
teachers have taken on every imaginable role in addition to teaching,
we must enthusiastically embrace our profession in order to preserve
the sanctity of the doctor-patient relationship. Does it seem
ironic that in Latin the word "docto" means "to
teach?"
As teachers, we must lead the public debate on what value
we, as a society, place on medical care and what we are going
to do to ensure the best possible care for the greatest number
of people. Perhaps one of the most debated medical topics is Medicare
– the government's answer to health care for our elderly,
our most vulnerable patient population. The question I propose
is, "Should government be involved in the delivery of health
care, or should it rather establish a set of rules to help allocate
our medical resources fairly?" I find it very perplexing
that health maintenance organizations and pharmaceutical companies
are thriving, yet on September 2, 1999, the California Medical
Association released a report titled "The Coming Medical
Group Failure Epidemic." The report begins, “Mounting evidence
collected by the California Medical Association now points to
the imminent collapse of a key element in the state's health care
delivery system with as many as 90 percent of the physician organizations
in the state poised for bankruptcy or closure.
In a soon-to-be-related example, within our field of anesthesiology,
Medicare recently proposed that nurse anesthetists, one-third
of whom never graduated from college, can deliver anesthesia without
the supervision of a physician. This decision was made in the
face of a study conducted at the University of Pennsylvania involving
in excess of 65,000 patients at 219 hospitals, the end result
of which reported a 28-percent higher death rate and a 21-percent
higher failure-to-rescue rate when an anesthesiologist was not
supervising the nurse anesthetist. This is what happens when doctors
are not involved in public policy, while the legislatures turn
a deaf ear to all except those lining their pockets with dead
presidents.
With the last two references made, I make my final point. As
a budding anesthesiologist who matched at the University of California-Los
Angeles anesthesiology program, the California Medical Association
will be part of my sphere of influence. What will be yours? The
time has come for us to resume the unique paths that united us
four years ago. As we venture on, we must recognize that we have
the ability and responsibility to be influential within our own
fields and communities. If successful, we will one day unite again
and our collective experience will be used to effectively address
perhaps the greatest challenge facing medicine: the concept of
universal health care. Let this be the legacy that we leave medicine
and patient care.
Gary D. Gonsalves, M.D., is an anesthesiology resident at
Good Samaritan Regional Medical Center, Phoenix, Arizona.
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