The Practice of Medicine: Past, Present, and Future

THE PRACTICE OF MEDICINE: PAST, PRESENT, AND FUTURE* WILLIAM S. MIDDLETON1: The present era, marked by many crises in human affairs, will doubtless take its place in history as a singularly parlous period. The world has witnessed two major wars and many minor conflicts in the first two-thirds of the twentieth century. Their violence with the attendant toll in life and suffering has not only dislocated the economic and physical welfare of virtually all nations, but has left a heritage of suspicion and deep-rooted hostility that ranges from continued cold warfare to actual combat in a number of quarters of the globe. The population explosion has lent added substance to nationalistic fears and protective designs. To compound the sense of insecurity in a period of unheralded affluence, this country is faced by a ground swell of unrest that has invaded even the sanctuary of our institutions of higher learning. These conditions obtain in the face of scientific advances that transcend the wildest dreams of a generation past. Man has explored the depths of the fathomless seas and the vast reaches of the boundless skies. The astronauts have extended the frontiers of man by landing on the moon. More recently, unmanned satellites have surveyed Mars and the sun. Perhaps even more awe inspiring than these actual scientific achievements have been the sustained communications of the crews of the Apollo flights with their earthbound associates and well-wishers the world over during their epochal journeys . By telemetry, their likenesses, voices, and vital signs were regularly relayed to earth—a quarter of a million miles removed. In such a period, the practice of so vital a profession as medicine will perforce undergo radical changes. Particularly does this circumstance obtain when the inevitable incorporation of scientific advances in physics, chemistry, biology, genetics, and the host of other basic • Presented before John Shaw Billings History of Medicine Society, Indiana University School of Medicine, September 17, 1969. t Veterans Administration Hospital, 2500 Overlook Terrace, Madison, Wisconsin 53705. 334 I William S. Middleton · Practice of Medicine disciplines into medical thought and practice is considered. Indeed, at times the direction of reciprocal reaction is reversed, when medicine initiates the movement. Almost imperceptibly, medicine has assumed the broader aspect of a biologically-oriented discipline. With molecular biology an emerging science, René Sand's position has even greater force: "The place of medicine is in the stream of life, not on its banks." Hence the time is ripe to consider the recent order of the practice of medicine, its present status, and its probable future course. Until well into the twentieth century empiricism still dominated science in medicine. The experimental method had not radically displaced the time-honored patterns of description that had blossomed in the French school of Bichat, Corvisart, Laennec, and Louis (late eighteenth and early nineteenth centuries). Accordingly, the art of its practice held sway. In such an atmosphere, rugged individualism thrived and characterized the practitioners of the last generation. True a dependent public placed the physician on a pedestal with or without his overt encouragement. Certainly the natural psychology of the sick and disabled exaggerated the supportive function of the medical attendant. Moreover, it was the rare exception for the physician to cultivate the godlike role. Indeed, he reluctantly assumed the heavy responsibility of the arbitration of life and death. Unquestionably the intimacy of the patient-physician relationship of this period created a bond of trust and confidence that played an important role in cooperative therapy. Significantly, patients were usually attended in the physician's office or at home, since hospitals were meagerly equipped and afforded little, if any, advantages over the home except in unusual situations. So it came to pass that the image of the practitioner of the last generation was exalted not only in the popular mind but in literature and art. Robert Louis Stevenson pictured the physician as a devoted patient saw him: "There are men and classes of men that stand above the common herd, the soldier, the sailor and the shepherd not infrequently , the artist rarely, rarelier still the clergyman, the physician almost as a rule. He is the flower of our civilization (such as it is) and...