Reflections on Medicine - February 2009
Tex Med . 2009;105(2):13-14.
By John D. Bonnet, MD
When I joined Scott & White Clinic in September of 1958, internal medicine had few subspecialties. Most of us trained as general internists with a special interest in a given area.
Mine was in hematology, which had just started being interested in the treatment of solid tumors in addition to the hematological malignancies. There was no specific subspecialty for cancer or cancer treatment. My special interests had to do with clotting, the morphology of the blood and marrow smears, and the treatment of chronic leukemia, lymphoma, and myeloma.
By 1962 we were called the Hematology-Chemotherapy Service. We met with the pediatricians who were starting to treat childhood acute leukemia and joined Grant Taylor's Southwest Cancer Chemotherapy Study Group out of The University of Texas M.D. Anderson Cancer Center. We soon became the Southwest Oncology Group. We joined the just-formed American Society of Clinical Oncology. I became an oncologist.
You can't imagine what a thrill it was for this young internist to become a part of the wonderful advances in cancer treatment and the interface with the fantastic investigators who were spread all over Texas and the Southwest. Others joined my division at Scott and White. We received National Cancer Institute funding. We were part of the team. There was a cure for Hodgkin's disease with M ustargen, Oncovin, procarbazine, prednisone (MOPP). But we had to use nitrogen mustard (ugh), and later we found there were second malignancies, so we changed to Adriamycin, bleomycin, vinblastine, dacarbazine (ABVD).
The toughest job was pediatric leukemia treatment. Full drug dose had to be given on Day 14 with an empty marrow. We only had white cell, red blood cell, and platelet transfusions. No Epogen or Neupogen. It gave me white hair before I was 40! Fortunately, we got a pediatric oncologist. And we got a high rate of cures. That helped most.
Cancer treatment became more of a team effort. We proceeded with the surgeon and the pathologist to staging with lab and radiology. A treatment plan may include surgery, radiotherapy, and/or chemotherapy. I won't dwell on the bumps in the road. The successes cover up the toxicities, failures, and difficulties of the treatments.
However, I can't forget the beautiful 38-year-old mother of two who sat two rows in front of me in church. She had a complete remission of metastatic breast carcinoma to bone, lung, liver, and skin. It was a miracle; however, she died slowly from myocardiopathy from the Adriamycin. Her kids now have children - her grandchildren. A hug from them helps me know I did my best. But we'll do better. Targeted therapy such as herceptin promises me that the future holds better treatments with better results and less toxicity.
Two other major changes must be mentioned. One is the medical student population. The other is the reimbursement mess.
First, let's take the medical student population. Fifty percent are female. There is more ethnic diversity. The attitude is nicer.
I have two sons (orthopedics and family medicine) and a daughter-in-law (pediatrics) who work 50-plus-hour weeks. But many want to work fewer hours, or maybe 10 hours x 4, or something else. I think that is just fine. It is the attitude that counts.
Elgin Ware, MD, in his essay, " The Greatest Generation ?" (August 2008 Texas Medicine , pages 20-21), quotes Osler saying the most important maxim in medicine: A physician's duty is to "cure sometime, to relieve often, and to comfort always." I have found reference to it being said in the 14th century. Some claim it was above the door of the oldest hospital in continual use, the Hotel Dieu in Paris. "It is the physician's role to cure rarely, to relieve often, but to comfort always." Who first said it isn't important. But that it has been a principle of medicine for centuries is. These kids today have it. I hope we don't train them out of it. As long as they have it, medicine will do just fine.
Second, the greatest change: the reimbursement system. Medicare was signed into law in 1965. I wasn't in the American Medical Association House of Delegates until a year later, but I remained in the house for 20-plus years and saw the control of payment and the cost of drugs and services become the function of government. Then more recently, all sorts of variations of HMOs and health care payment plans. Drug costs are skyrocketing. Special tests and procedures rule the system. I think the only thing that we can agree on is that it is a mess.
How should it be changed? I have no idea. I see many of the doctors are coming with BAs in finance. This much I know: We are spending more on health care than any nation without showing that there is a benefit. More important, I don't think we can continue at this cost.
I did note that Dr. Ware worked in a free clinic. I was lucky to be the medical director of the Temple Community Free Clinic for 15 years. We keep hearing that millions aren't insured. Dr. Ware and I can tell you that we saw many uninsured and a lot of the insured with copayments so high they couldn't use it. The free clinic is going to have to be part of the system. We started that way. We should not forget it.
Therefore, Dr. Ware, I think this has been the Greatest Generation. The next will be even better if we just can get the patients and the system together. There's no telling how much we can achieve.
Dr. Bonnet is president of the TMA 50-Year Club. He was at Scott and White for 35 years.
Editor's Note: This is the latest in a series of essays by members of the TMA 50-Year Club .
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