Medicine’s next great challenge has less to do with knowledge and the patient experience, and more to do with a generational divide.
If you ever plan to motor west
Travel my way, take the highway that’s the best
Get your kicks on Route Sixty-Six.
It winds from Chicago to L.A.
More than two thousand miles all the way
Get your kicks on Route Sixty-Six.
I write with apologies to both Bobby Troup and the Mamas and the Papas, both of whom inspired various parts of this piece. Being an old musician, it is very easy for me to slip into thinking of the world in terms of musical eras.
My January disputation ended with me counseling a young physician about her lack of zeal and loss of purpose. As I sat quietly listening to the Nat King Cole version of Route 66, I realized something of the nature of this interaction. The problem here has less to do with medical knowledge or patient experience, and more to do with how we see the world. The physician and myself represent two different generations of Americans; when we look into the abyss that separates us a totally different abyss looks back. It’s not what we see; it’s what we were taught to perceive. The question is: Do our beliefs match any sort of reality?
Our journey this month is only partially metaphorical. There is a place in this journey. It’s California, which holds in the American psyche not only a land but also a mode of travel. The adventure is the journey. And at this moment in time, no other state has arisen to have the same place in our joint mentalities as California. No one is ever Oklahoma or Missouri dreamin’.
What represents my generation? If I had to take it down to one phrase to describe how we grew up and what we believed, it was relentless positivity. We grew up in the shadow of those people who had fought and won the War. There was nothing we thought we couldn’t do. The TV show “Route 66” was big in our formative years. The series followed two young hip guys seeking adventure between 1960 and 1964 as they motored throughout the United States – never doing drugs – righting wrongs along the way. Every week, good triumphed over less-than-good. In the 1950s and ‘60s, there were no bad people on TV. Probably the worst thing these villains did on the show was use the dessert fork for the salad course.
It was the time of can-do. Our immigrant parents had lived through the Depression, beat the Germans and the Japanese. Eisenhower was President and all was right with the world. If you tried hard, you achieved your dreams. There were no government programs for happiness. In fact, there were no government programs at all in medicine until Medicare in 1964. Doctors were kind and tried to respect the patient’s finances, as well as their family and lifestyle in making medical decisions. Dr. Kildare was our hero. It was American Graffiti on steroids.
We believed in certain things. When you got married, you stayed married. You raised your kids. You went to church on Sunday. If you were in trouble at school, it was nothing compared to what your father would do to you at home, especially after he’d had a few drinks. And then he’d hand you over to your mother who would finish the job. Was it a little rigid? Yes. Did it give us a managed life you could depend upon? Yes. Things seemed much clearer to us in black and white.
But things slipped away. In 1964, Route 66 went off the air and Tonkin Bay happened off the coast of Vietnam – a place none of us could even find on the map. Suddenly everything changed. California was still Valhalla but instead of orange groves and movie lots, it was the home of alternative lifestyles and unhappiness. The people migrating West were different. No longer settlers looking for a new life but upper middleclass kids looking for a reason to exist. They thought if they left Cleveland and went to San Francisco, chanted with the Hare Krishna and ate peyote buttons, the meaning of life would appear. They were wrong.
In 1967, the summer of love, while the rootless, aimless idle class was at Haight-Ashbury, I was working in the labor gang at Great Lakes Steel in Detroit. For a week I watched the City of Detroit burn while sitting on the iron ore docks on the Detroit River. The world was coming undone for me. I watched both the private and public worlds falling apart. I watched a sitting President for the first time say he would not run again because he could not explain the Asian War, which was going poorly, to say the least. A country which has its young hating its old is never a pleasant sight. Watching the Ohio National Guard shoot down students at Kent State was numbing. Where was the country that I knew about as a child? It was gone. The War made no sense. The flower children made no sense. My parents’ generation made only a little sense. Our work made sense. The chance that I might be a doctor made sense. Medicine at least held some traditions, some values and had a center of morality called, “the patient and the patient’s interests.”v That’s what made sense to me. That’s why I went there.
The meaning of California as the American safety valve was gone. The dry land and the bleached sky, the Great American Myth that everyone gets to start over with a clean slate in the Golden State had disappeared. I think it always was more of a myth than a fact but we believed it. We ran out of continent before we ran out of discontent. In 1967, if you took the country and stood it on edge and shook it, everything loose rolled into California. The old Californians, those who were there generations before the Second World War, didn’t understand the new transients, their lack of roots, both philosophically or physically. The Joads, the dustbowl crowd, they could understand them; for they were seekers of farmland and family. But what did disgruntled children of the 60’s want? They had never known hard times or real threats, let alone honest work. No one really understood what was happening. It was a transition with no purpose, no vector, no function.
I can remember the ‘60s so well, that as Robin Williams would have said, I was really not a part of them. It was the shift from the New Frontier, the Kennedy kids, to the ultimate “it’s about me” mentality. “Don’t trust anyone over 60” meant we weren’t even supposed to like those people who had raised us, saved the world, and sent feckless youth to university.
California dreamin’ was still happening by 1972. That year the University of Michigan Medical School was California’s fifth largest supplier of interns to fill the spots in California hospitals. But things changed there as well. Doctors were starting to shift values and goals. At the beginning of the ‘50s, over 80 percent of physicians were primary care doctors of some type. But by the end of the 1960s, those graduating from medical school, 80 percent wanted to be some type of subspecialist. That way they could protect their time and advance their incomes. In the maelstrom between old doctor and young specialist, the Hippocratic Oath, if not gone, was being badly corrupted. Getting NIH money was more important than taking care of people. Being on a staff at a major teaching institution meant the residents really did the work and this remained so until the Feds finally took a stand again in 1996 when I was the ACEP President. What a mess for all parties concerned. You are a young practitioner indeed if you don’t remember the attendings signing the resident’s ER chart each morning, while they had spent the evening at home in bed. Different people, different times, different dreams.
Debates about helping to cost effectively manage a patient’s problems left with the World War II generation of doctors. If the just-released data is correct, the unending rise of tests and X-ray ordering proceeds on, driving us into financial oblivion without really effecting either the length or the quality of patient lives. Between this, EHR — the electronic health record and the more and more ridiculous regulations, I think the gap between our science and our compassion grows.
I think there was a time when physicians actually liked the people they cared for. Neither their recordkeeping or their science was perfect but probably such care was given out with real compassion. Maybe there was a time when there were grateful patients and family who knew you’d tried to do the right thing. Now those same people just sit at home watching lawyer ads on daytime TV. I propose that the universal CPR – do it to everything lying on the ground – helped to kill our sense of purpose and bring more anger than life to patients. We move forward as individual generations, barely trying to understand the purpose of one another. We are each marooned on our own bank and shoal of time, always assuming our generation did it right.
Today our science is better. We can make it painless. We can keep you alive longer. And yet, the patients grow more and more to distrust us. Now that we have adopted the ethical standards of the Italian Train Union Workers, why should we expect any better? Our California (American dreams) are not what they used to be.
So where are we now? Route 66 is mostly gone. I had lunch at a favorite spot in Haight-Ashbury two months ago and the exact same burned-out drug addicts and schizophrenics who were asking for spare change 20 years ago were still there. The entire area is now gentrified and the rents are the highest in the nation. Microchips trumped meditation in a big way.
The art of medicine and government have gone the same way. In 1965, we as a country had the largest gold reserves in the world. Now we have the world’s largest sovereign debt. We were in the top three countries in patient longevity. Now we’re 17th. We spent about five percent of our gross domestic product on healthcare. This year we passed 20 percent, while Canada is half that. And the Germans, who we occupied when I was a kid, will produce better healthcare than us for one-third the money. When will we stop being a profession that sits only in observation and takes no action? “Can-do” no longer seems to exist. Everyone in medicine wants a job and nobody wants to work. Doing things for the greater good of the profession seems somehow like a quaint idea which most people will pass on. Their mantra: ‘By God, if you’re going to expect me to be there, you’re going to pay me.’ Everyone believes they are overworked and underpaid. What short memories doctors have concerning the great workload shift and payments.
This dissolution of the American ethos is probably best summed up by Joan Didion’s masterwork, Slouching Towards Bethlehem. As she gives us reflections on California, they parallel the country and in many ways the practice of medicine. Read this book, then decide if we have the courage to care about healthcare, as opposed to our own self-interest. Because courage is asking yourself the kinds of questions you really don’t want to know the answers to.
Won’t you get hip
To this timely tip
When you make the California trip?
Get your kicks on Route 66.
Salbo populi suprema lex esto.
—The welfare of the masses is the supreme law.