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Denebola » Article » Plain Doctoring: The Future of Health Care An Interview with John D. Stoeckle, MD (MGH)
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Plain Doctoring: The Future of Health Care An Interview with John D. Stoeckle, MD (MGH)

By Denebola
Published: February 2010

Junior Jenny Wong, Denebola editor David Han, and former Denebola editor Nina Gold interviewed Dr. John D. Stoeckle, who was a director of The Clinics at Massachusetts General Hospital and was a professor at Harvard Medical School for many years, about the issues of primary care, its progress, and its relation to today’s health care debate.

The Stoeckle Center for Primary Care Medicine at MGH now carries on his work.

Denebola: What influences someone to practice primary care or Family Medicine?

John D. Stoeckle: Small town practice, like where I grew up, was the GP but the medical school was another kind of culture. It’s that culture that really influences the kind of medical work you will do.

[Currently] most schools have the same agenda; they want you to be scientifically knowledgeable and clinically apt in terms of the area of patients, and if you want to specialize¦ they certainly will encourage that kind of contribution [as well as going] into research.

More and more are thinking of a public health orientation, but primary care and general medicine is down on the rocks.

Denebola: Is there still interest in becoming a doctor?

JDS: Yes, I think it remains a tremendous force. It remains, for all the difficulties and contradictions, a very good job. It has public respect for the task and involves skill, responsibility, and judgment. It is a hard job but there remains an ethical sense that you are doing good, not just for yourself but for people. The idea of service remains profound.

Denebola: How will the medical training be different than yours?

JDS: It will be different, [and] the two things encompassed will be working with more people around you in the care of the patient and ¦ dealing with a patient who has more information’€whether it’s accurate or not’€coming into the medical system. You will be dealing not only with patient-doctor communication, but [also] much more patient-staff communication.

The space will also change. It will not only be smaller but also more impersonal because it’s shared. Part of the relationship was worked up in that space, whereas now many doctors will share the same room to either examine patients or discuss their situations.

Gone will be the photographs, degrees on the wall, mementos that, good or bad, were part of what younger doctors might now call “bonding.

Denebola: How will the teaching/learning process be affected?

JDS: It’s always been apprenticeship: watch me talk and watch me do. And now it has shifted with these changes and newer technologies.

Now it’s “let me watch you, then you give me your judgment and I will give you mine, and we can go from there. It’s now more interactive [and includes] participatory kinds of exchanges and more like tutorials as well as individualistic, where young doctors get their learning from their peers and patients’€as in the past’€but also shared online, from across the city or across the country.

You get feedback from one another, the group, your supervisor, someone across the world.

The old apprenticeship model will still be there and remain strong, but the learning process [will be affected by] lectures on the web, video, and audio lectures on line, simulations, other kinds of didactic learning.

Denebola: How long was the average primary care visit when you began practice in the late 1940s?

JDS: When I began, we were in the clinics here. I wasn’t in private practice. I arrived early and would see an average of eight patients from eight until 12. That became a standard time, half an hour. But if you consider the statistics, the American doctors have always seen patients for longer periods of time than European doctors, and much longer than Asian doctors.

Denebola: Mentioning other nations, are there elements from their health care systems that America should adopt in the reformed health care system?

JDS: We’ve discussed finances and ways our payment situation might be helped by looking abroad. Practice will become more collective, the idea of a solo office or an office building, the simple way of putting people together while still maintaining our fee-for-service may well give way to a more collective way not only of practice but financing practice in health centers. Even in this town, medicine remains highly privatized.

Denebola: How can we characterize support for medicine over the years?

JDS: During the 1960s and 1970s, there was considerable support for primary care, which followed from something called the Millis Report. It was given a sort of social, political, professional boost from government, foundations and the medical schools. The old idea of the GP disappeared and you had this mix of primary care, family medicine, and pediatricians blended together into a kind of movement.

What happened in the 1980s [was that] the market economy emerged in medicine changing the character of medicine because you were paid to get people out of the hospital using tests and medications, and [there was] more emphasis upon turning numbers rather than caring for individuals.

You can see this by the remark that hospitals are the most expensive “hotel in any town, and notice we do not characterize a hospital by particularities of its care but by the number of “beds or its capacity.

Denebola: How have information sources outside the hospital affected patients and doctors?

JDS: The TV ads, the journal and newspaper articles, the radio discussions about this or that illness or treatment are increasing, and increasing in detail. [While] none of this has been deeply studied¦ this information obviously affects both patients and doctors in their expectations of the experience and the distortions, errors, misunderstood information certainly makes or will make things harder in terms of treatment.

You may think you get a more informed patient, but informed about what? Younger doctors will have to be prepared to correct misinformation, but that was always the case to some extent.

The other aspect all new doctors need to consider is where they’re working, [which is] bigger organizations. You will be dealing with corporations, which means many rules and procedures, office managers, lawyers, and public relations people supervising your doctoring.

It’s like running the Pentagon, a huge task. If you think the directors themselves must have economic training, you’re not following what’s happening in our medical schools’€a number of students have that economic training, just as any number of engineers and scientists at MIT.

Denebola: If the Health Care bill is passed and millions of new patients come into our current system, what will that mean for communication and services?

JDS: America will need more providers, whether that’s nurses or doctors or those supporting them. The nursing schools are now pressing to expand their schools. The question will be how to divide that care up.

The primary care doctor will not be seeing all those patients, and it’s another example of the new teamwork’€the nurse, the doctor, so the time elements will be different, and the continuity of care elements also different.

The other issue will be the make up of this population. They are, for example, on the lower age side, so there will be much more need in the pediatric group and then you have all these Americans getting older and living longer, so they will be competing for care and services as well.

Denebola: Yet, isn’t that what the new Health Care bill is all about, more preventive medicine and more access to entry level medicine?

JDS: In terms of serving the public or serving the profession¦ the profession is faced with de-skilling the job all the time, so you have this movement, which we began at Massachusetts General Hospital in the 1960s of nurse practitioners, but now places like Columbia want to go beyond that and make the title, Dr/Nurses. So they will take over general practice organizations and there will be, perhaps, another level of a primary care doctor who manages all those different kinds of people under her or him.

So, it’s an ambivalent situation at the time for physicians and their training, and it’s hard to see how this provides the patient with the kind of care  [that] advocates of current health reform intend, or wish.

Some, like John McKinley, the sociologist, believe this goal is unreachable give[n] the contradictory forces of the drug, hospital and insurance industries, doctors, and patients, and then you have all these technological changes.

So it’s not a total experience with the doctor, but one split between many elements of care, only marginally integrated for the patient. The idea of personal care has gotten divided up because the information the patient receives now originates from so many different sources, with no guarantee any one or all of them are in direct, accurate, timely contact with the other.

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