For me, thinking about where health care has been means thinking about my father. Dad retired in the early 1990s, after a lifetime as a general internist in a small Pennsylvania town. By then, bitter about what was going on in health care, he was tentatively hopeful that the president's task force might change things for the better.

Hope was something he learned early. Fifty years before my evening at the White House, he was with the Twenty-Ninth Infantry Division, preparing for the Normandy invasion. Six weeks after landing with the second wave at Omaha Beach, he was wounded in heavy fighting near Brest. In one of the most efficient medical triage operations ever devised, he was flown back to Britain and operated on the next day. After three months in a rehab unit, he was sent home with a Purple Heart. One leg was a little shorter than the other, and he'd never play college basketball, but it could have been worse.

He went back to Michigan on the GI bill and then to Jefferson Medical College in Philadelphia. In the heyday of postwar optimism, medicine had a transcendent sense of purpose. Just as we had beaten the Nazis, we would build hospitals in every town, triple the number of doctors. Heart disease and cancer would succumb to science, like syphilis and tuberculosis. Dad saw one of the first open-heart operations, the early experiments with renal dialysis. Penicillin changed infectious diseases from killers to routine, treatable illnesses. Laboratories started analyzing blood specimens for electrolytes, calcium, and phosphates. To the bewilderment of his father, who thought it time to get out and earn a living, Dad completed an internal-medicine residency. Specialization was the thing to do.

In 1955, as the first board-certified internist in the booming coal-and-steel town of Johnstown, Pa., Dad organized a multispecialty group practice, then a slightly heretical undertaking. No longer could the patient turn to a single doctor with absolute trust and faith. Doctors called consultants; patients had little choice about whom they might need to see; they told their stories again and again; new doctors ordered new tests; the price of care went up; continuity of care decreased. Yet Dad's practice, which attempted to combine specialists and continuity, thrived. He brought the technology of the tertiary-care center to Johnstown, introduced people to the diagnostic wonder of electrocardiograms, convinced the hospital board to build a new coronary-care unit, and worked tirelessly to maintain a residency program in internal medicine.

Like many veterans, Dad was entranced by John F. Kennedy's message of poetic optimism and mission. Kennedy made himself the candidate of the World War II foot soldiers. These men would figure out new ways to do things, would not acknowledge that the old rules applied. They were the best and the brightest, and failure was not an option.

But with Kennedy's assassination, Dad stopped asking what he could do for his country and began asking what was in it for him. Vietnam, the riots, and the assassinations of the '60s only confirmed his view that hope had died in Dallas.

Dad's multispecialty group practice lasted until the 1970s, when the cardiologist in the group got tired of subsidizing the cognitive specialists, and set out to claim the $350,000 annual income that he'd come to believe was his due. The gastroenterologist soon followed. A few years later, the practice was bought by the hospital, as part of its new preferred-provider organization.

I imagine Dad meeting with the PPO buyers in their pinstriped suits, trying to follow their talk about capitation payments, covered lives, and shared-risk arrangements. They were young, dark-haired, thin. He had nobody to call for advice, and didn't know how to ask. He was the person people asked for advice, not the one who needed it. He asked for a couple of days to think it over, but he knew that he would sign; that he was holding a worthless hand; and that the young men with their leather briefcases knew he was bluffing. There was nothing left to sell.

The splintering of Dad's medical group was symptomatic of a much larger problem. Doctors were no longer colleagues, all in it together. Instead of imagining how the profession as a whole might respond to the political, moral, and economic challenges of the day, physicians identified with a particular specialty, and imagined a profession that was infinitely divisible. They thought a lot about what was good for pediatricians, surgeons, or gastroenterologists, what was good for academic medical centers or rural family practices, but not about what they all had in common.

Continue reading, "Life Support."

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