Dr. Dufault recounts that during his years as medical student, house officer and practitioner he often had conversations about the practice of medicine with his father who was also a solo practitioner. Now, nearly 20 years after his father's death in 1963, Dr. Dufault reviews some topics they might currently discuss and which aspects of medicine might be found unchanged and which might be very different.
Human nature stands out as little changed and our profession still affords us the privilege of interacting with and observing fellow man.
Major advances have occurred in the technology of medicine while the sense of inability to keep abreast of the changes remains the same. Besides technological changes, there have been attitudinal changes. Office patients demand more information and hospital patients are sicker. Hospitals are buffeted by federal and state regulatory forces. Entire units such as the obstetrical unit at Athol hospital of which Dr. Dufault's father was at one time the chief have been closed because of increasing regulatory constraints.
Dr. Dufault's father would have found the changes in health insurance incredible. Blue Shield, founded in 1939 by the Massachusetts Medical Society as an insurance plan for the underserved, was hailed by the profession and helped physicians prosper. But, beginning in the late fifties the failure of Blue Shield fees to keep up with economic trends led to physician disaffection and by 1979 Blue Shield and the Medical Society formally separated.
His father, Dr. Dufault relates, would occasionally bemoan the fact that he had not pursued the training to become a prestigious specialist. He would be shocked to see that he was actually a model of one of the fastest growing specialties, with the American Board of Family Practice having been established in 1969. The future of Family Practice is not, however, assured. One of its linchpins, that of health maintenance, seems beyond the scope of physicians who cannot change human behavior as evidenced by failure to control obesity, smoking, alcohol, and drug abuse. Even counseling may not sustain the specialty since there are better counselors than physicians and economic reimbursements are much greater for "doing things to' patients than for' patients." More physicians will train in other specialties and these would also do a great deal of primary care themselves. Increased competition to offer primary care will also come from expanding numbers of physician extenders or nurse practitioners. On the whole, Dr. Dufault is pessimistic about the future of family practice.
The success of Medicare would have shocked his father. Physicians of his era lived in mortal fear of federal intervention. As Medicare became inevitable, physicians advocated for a "means test" to restrict its benefits to the elderly poor but, in retrospect, Dr. Dufault contends, such efforts were quite wrong. All elderly are benefitting from Medicare and a means test would have led to a morass of restrictions and regulations making it as inefficient as Medicaid. Physicians were not enslaved by federal intervention but were freed to treat the elderly "completely, compassionately, and well" and were also generously compensated for their efforts.
The future will have to address other major changes such as the societal effects of emptying mental institutions; the increasing number of brain damaged resulting from our resuscitation skills; the increasing sick and abandoned elderly resulting from the emphasis on small families.
It is hoped that the advice we provide will be as helpful as that provided by our parents and professional predecessors.