Physicians International   6/95

The international registrants at the national meetings of my specialty, the American Thoracic Society, approach 40% of the 10,000 attendees per year. One of the high points of this yearly experience has always been to interface with these international members. It has been an interest of mine to observe what is the common bond of physicians working in all sorts of practice environments, from government employees, to HMOs, and indemnity insurance, and now a number of variations in between. But despite the different working environments, many of which we are unable to change, doctors worldwide seem to have a uniform point of reference as regards caring for the sick and dying, relieving human suffering, and searching for cures. We have a common language, purpose, and bond. Even at an international meeting in Amsterdam in 1967, I was able to have excellent clinical discussions with pulmonologists from the communist world.

I was fortunate to be able do my psychiatric Junior medical student clerkship at Topeka State, a Menninger hospital. Karl Menninger, founder of the Menninger School of Psychiatry in Topeka, was on the faculty of Kansas University Medical School. In one of the 15 books during his professional career from 1918 until he died several years ago, he did a treatise on the physician and his world. This book is now out of print. As I recall, he related the many physician specialties to the numerous trades and professions. Internists had the psychological make up similar to architects. They had the overview. He compared other specialties to people from many different walks of life. The point I remember him making was that physicians and surgeons were not a homogeneous group. They were as disparate as the rest of humankind. They would not have a uniform or predictable point of view. However, when physicians are involved in their primary purpose in life, they were very focused and reasonably uniform in their approach to patient care.

An example of this disparate point of view was recently noted by National Public Radio in reviewing the nominee for the Surgeon General. NPR pointed out that most of duties of the Office of the Surgeon General were transferred by President Johnson to the Secretary of Health, Education, & Welfare. The reason given was that Johnson could control the Secretary of HEW, a bureaucrat, but he was unable to control a Surgeon General, who was always a physician.

A more recent example occurred when Mrs. Clinton designed a national health plan for our country. She did not invite any physician group to participate in the planning phase. It is hard for bureaucrats to predict how physicians will act or react even when setting up the environment in which physicians will see patients or practice.

Although physicians have difficulty in designing or controlling the environment in which they practice, they are never at a loss to give their evaluation of it. Some two decades ago my wife and I were having lunch in a restaurant in Brussels with a Scandinavian internist and his wife. He extolled his system of government medicine but recognized its shortcomings. His government salary was $30,000 and his take home pay was $9,000. He didn't have to worry about filing taxes or paying health insurance. The $9,000 was the entire family income. They enjoyed life and the security of health, welfare, and retirement at no further expense. However, he also recognized that his country was so homogeneous that they would probably never again produce a Nobel Prize scholar.

I was once invited as a guest consultant to the Zentral Deutsches Krankenhaus in Munich. After touring the hospital with its 400 pulmonary beds and 400 TB beds, I discussed a patient they presented to me who had a right heart cath in the evaluation of dyspnea. When I asked for the PA and wedge pressures, they said that they had to interrupt the procedure at 4:30, because the nursing/technician shift ended. They would have like to have gotten the information I asked for in my discussion, but their practice environment precluded it. Later on in the evening at a Rathskeller, after discussion of cases and practice problems seemed to ebb, I was able to gain a perspective of our foreign policy. These German pulmonologist began asking why the USA was providing the military protection for their country. This certainly saved them a lot of taxes, but why were we willing to pay for their national security?

Trinity Hospital in Kansas City had a complement of seven Danish interns for many years. I worked there one summer as an extern after I had completed my clerkships. This was my first exposure to international physicians. They could not understand why American doctors worked so hard making hospital rounds before 8 AM, then rushed off to their office for a full eight hour day and later returning to see their sicker patients, and then available all night. They questioned why American doctors worked so hard to please patients. In Denmark, they said, the doctors would show up at their office at 8 AM and see patients until 4:30. There was no night work in Denmark unless they had the day off. This was my first exposure to physicians who considered medicine a job rather than a profession. The physicians in Denmark had all the protection of their labor code, just like any other worker.

Although practice environments are so varied throughout the world, the actual practice of medicine has a very similar focus that transcends all language and political barriers. We, along with nurses, may be the best hope in international politics as long as we remain outside the realm of politics.