Diagnosis for Democracy
Insights into the State of Our Union
A Blog by Rob Tenery, MD


September 10, 2013: Even the Lexicographers Have Noticed the Change

By Rob Tenery, MD on September 10, 2013

The 1955 edition of my Grandfather’s Oxford Universal Dictionary defines a physician as one who practices the healing art. The dictionary program that comes with my Mac computer defines that person as one who is qualified to practice medicine. The difference between the two definitions, fifty-five years apart, clearly demonstrates that the lexicographers realized that this profession has evolved from the art of healing to the science of practicing medicine.

Reflecting on my over 38 years of practice, there are very encouraging signs that our profession will be in even better hands. The diagnostics and therapeutics available to these new physicians dwarf what we had to offer.  The ability to share the latest breakthroughs and advances make our ‘snail mail’ systems archaic. Many problems that were insurmountable just years ago, are relegated to day surgery or a prescription for oral medications. There is no question that the science of medicine is infinitely better. But the art, the personal side of that relationship, has been compromised, and in some ways, so have the physicians.

Although third party payers and federal dictates distance physicians from their patients, so do the advances in the diagnostics and therapeutics. The example is submitting a vial of the patient’s blood for evaluation and a short while later a profile of his/her blood chemistry appears on the closest CT screen. If the answer is still unclear, often instead of delving into the history further or going back to the patient for a more thorough examination, another battery of tests are ordered.

When my grandfather started his practice in the early 1900s, he relied on his stethoscope, probing hands and a highly trained ear to arrive at a diagnosis. Today’s physicians rely increasingly on a battery screening panels and digital imaging. My physician father would reach out to take the pulse on virtually every patient on which he rounded. Today’s physician is often seated at the nurses’ station bringing-up the patient’s particulars on the CT instead of further query at the bedside.

The term clinical acumen is a way of judging the ability to cipher out the correct diagnosis and proceed with the best therapy. With advances in the diagnostics, the physical examinations, and to a lesser extent, the histories are moving into the background. The physician’s role as an examiner, listener and caregiver is evolving into one of an interpreter and prescriber.

In the past, what has set physicians apart from the other disciplines in the medical field is their more thorough understanding of the basics of the anatomy, physiology and pathology that they acquired in the long hours of medical school and their early years of training. Today that is changing for several reasons.

Most of the other disciplines have raised the standards of their educational requirements, bringing them closer to those of the medical schools. Second, there are the advances in the science that bypass the need for this more in-depth understanding. The example being the wide utilization of blood panels and digital imaging for even the most minor problems. Even though these advances more often lead to a correct diagnosis sooner, there is the potential to ‘dumb-down’ the practitioners that rely on them.  The often-quoted adage that if you don’t use it, you lose it may apply when referring to the basics of the science that physicians learned in their early years of training. Also as the other disciplines work to expand their scope-of-practice through the state legislatures, these improved diagnostics tend to make-up for many of the shortfalls in their training.

The other factor that pushes physicians further away from direct care is their delegation of services. The practice of medicine has never been exclusive to physicians.  The many disciplines rendering health care services are not new. What is relatively new is physicians allowing or encouraging others to practice with their imprimatur.

Nurses have always stood alongside the physicians, rendering whatever care that was ordered. That role is changing too. Not only are nurses drifting away from the physician’s side, they are going out on their own. As the administrative and regulatory demands of health care increase, nurses are moving into teaching, up to the ‘front desk’ or as primary care givers themselves.

Frontline care, such as physical exams, the treatment of ‘lumps and bumps’ and post-operative routine rounding are increasingly being relegated to others. Physicians’ assistants act as physician extenders, allowing ‘their’ physicians to devote their attention to the more complex problems. It was only a matter of time until the discipline of a nurse practitioner would move away from the direct connection with a physician. Several of the national pharmaceutical chains have joined this movement by establishing drop-by clinics, mostly staffed by nurse practitioners, for the evaluation and treatment of the so-called minor maladies.

Certain specialties, such as ophthalmology are essentially giving away frontline care to optometry. Refractions and contact lens fitting, considered too mundane by many new ophthalmologists, have long been delegated to their staff. With the move toward increased specialization, many ophthalmologists don’t even offer refractions and many are all to glad to turn over the minor infections, abrasions, refractive complaints and management of their postoperative patients that complicate their already busy practices. Unfortunately, when it comes time for the state legislatures to address any expanded scope of practice legislation put forward by the optometric associations, the ophthalmologists’ retorts get less sympathy and public support.

Psychiatry has long jostled with the scope of practice issues raised by the psychologists. Anesthesiologists with the nurse anesthetists. Orthopedists with the chiropractors and the podiatrists. These examples, either by advances in the training of the other disciplines, delegation or lack of interest, as in ophthalmology, are changing the face of health care.

There is a real threat that the advances in the science, the expanding presence of the other health care disciplines and the reimbursement differential between primary care services and procedures are changing the physician who practices the healing art into a doctor who practices the science of medicine.

It seems ironic that all one has to do is look up the definition of a physician in the dictionary to see what was has changed in medical profession.




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