While 50,000 dissatisfied corpsmen leave the Services each year, a rising flood of dissatisfied patients threatens to engulf the clinics, dispensaries, and emergency rooms as more and more conditions become treatable on an outpatient basis. It may be that the solution to the former problem will prove to be the solution to the latter.
In the last 100 years, American medicine has made a forced march out of the medical dark ages. Quantum leaps have been made in basic medical education, internship and residency training, antisepsis, antibiotics, drugs, research, and acute care, to name but a few. In general, these have been scientific and technological changes, which have coincided nicely with the American belief in scientific progress. These accelerating changes, abetted by mass communications and increasing public awareness, have laid the foundation for a revolution in medicine. This is made even more acute by the widespread realization that significant segments of the American population receive little or no benefit from all this progress. On a social and ethical level, much of American medicine is still in the dark ages. The whole matter has been brought to a head by the political action of those deprived, aided by socially-conscious public officials, to acquire by legislative action what they had been denied by medical tradition. Health care is now a right, not a privilege, and social change has been imposed upon American medicine. The significance of this change cannot be overemphasized, but it is odd that so few within the medical profession realize that the change has already occurred and is no longer subject to debate. How shall we adapt to this change?
At the very heart of medical practice is the special, almost sacred, relationship between the doctor and his patient, which has the weight of centuries of practice behind it. Within its confines has been practiced the best of the art and science of medicine, but it has benefited too few. Now that medicine has developed new tools and society has acquired new expectations traditional medical approaches are no longer adequate. The invaluable moral tradition of the special doctor-patient relationship must be retained, but it clearly needs a new implementing ethic geared to altered modem circumstances. Too many feel that the move towards “socialized” medicine will necessarily destroy the sanctity of this relationship, but this is not so.
The Navy has been a bold innovator in attempting to find a new ethic to implement medical care for that segment of society for which it is responsible. Yet, the Service is roundly criticized for its effort, both by the providers and the recipients of the care. Considering all that the Navy has accomplished, this attitude represents one of the real ironies of the current medical scene. To be an innovator means that one will be among the first to encounter difficulties in new ways of doing things and, unfortunately, the worthiness of a goal is no guarantee against these difficulties. Too many look upon problems as evidence of failure or barriers to more progress; rather they should be looked upon as milestones in the achievement of a goal. This is no time to be fainthearted or to retreat to the inadequacies of the past; continued progress is essential.
It would be well, at this time, to examine the complex set of relationships presently existing between the various partners to Navy medicine. It will rapidly become apparent why it is presently so difficult to make everyone happy. There is a tangled, often contradictory, skein of expectations threaded through the entire system which can be satisfied only by the most skillful management of people and resources.
What does the patient expect of the doctor? He expects to have free and immediate access to doctors of high professional competence. He expects to have the full, undivided, and sympathetic attention of the doctor and his associates. He expects the doctor to listen to what he has to say and then to be examined adequately. He expects the necessary tests and x-rays to be taken and reported promptly, a diagnosis to be made where possible, and then to have the doctor explain to him, in language that he can understand, his condition and treatment. He expects the cost of care to be reasonable.
What does the doctor expect of the patient? He expects the patient to be courteous in return, to make intelligent use of his services, keeping unnecessary visits to a minimum. The doctor expects the patient to cooperate fully in his treatment, following instructions implicitly, to be patient when unexpected delays occur and to be appreciative of the care he is given, whether it is paid for directly or not.
What does the medical department expect of its doctors? It expects the doctor to see everyone who asks to see him and to give that patient the exact amount of care he requires as rapidly and as economically as possible. It expects him to be professional in behavior and appearance and to be gracious to all who seek his services and serve with him. It expects him to accept and support the policies, procedures, and dictums of the medical command and to be tolerant, if not enthusiastic, of the military apparatus. He is expected to be loyal to his parent service and to its line and medical leadership.
What does the Navy doctor expect in return from the medical command? He expects that full and wise use will be made of his skills and capacities. He expects to be free to practice medicine in his field of training with adequate support in the way of experienced paramedical personnel—corpsmen, technicians, pharmacists—laboratory, and hospital facilities, equipment and drugs to adequately treat his patients by modern medical standards. He expects to have the time to perform his job adequately, not to have to see too many patients too rapidly, and not to be distracted by more than the absolute minimum of non-medical duties. He expects to be compensated adequately for his services and to be supported by his command. He expects to be treated with respect and, in turn, to have leaders whom he can trust and respect.
What does the medical command expect of the patient? Nothing! And, therein, in the eyes of the doctor, lies perhaps the greatest evil of the entire medical system of the Navy, since it effectively asserts that the doctor has no rights.
At the next level what does the Navy expect of its Medical Department? It expects the Medical Department to provide all of the necessary curative and preventative medicine to maintain the health and effectiveness of every person for whom the Navy is medically responsible: the man on active duty, the retiree, and their dependents. It expects the special medical requirements of forces afloat and ashore will be met in both Peacetime and wartime situations and the Medical Department will be ready for any possible medical contingency, foreign or domestic.
In return, the Medical Department expects the Navy to provide sufficient funds, men, material and general support to carry out its mission.
It is obvious that the practice of Navy medicine has become a vastly complicated process and it is no wonder, then, that there are problems. Similar considerations are beginning to intrude on civilian medicine as the impact of Medicare, medical insurance, and governmental regulations are increasingly felt. However, the Navy doctor is being asked to be all things to all men and, like all mortals, he has his limits. The conscientious doctor in trying to satisfy all the expectations of his patients, the medical command, and the Navy ends up satisfying few and becomes intensely frustrated in the process. A failure at any level of the doctor-patient relationship will affect it adversely. And, no matter what the other achievements of the system may be, if the doctor-patient relationship is poor, then there will be dissatisfaction with the system. Put in its simplest terms, the press of expectations presently exceeds the capacity of the system to satisfy them.
Obviously something needs to be done, but what? Before answering this question, some further comparisons are in order if we are to clarify exactly where the Navy stands in relationship to the health-care problems of the rest of the country.
That the Navy has advanced as far as it has, and can expect to progress even further in the future in dealing with health care, derives from certain unique advantages it possesses in confronting its medical problems—advantages almost totally lacking in the civilian medical world. In fact, civilian medicine is particularly ill-equipped to meet change on a broad scale. It has been accurately accused of being a “cottage industry” and a “non-system.” Further, reflexive resistance to change has been exhibited by substantial and influential numbers of American doctors, who vainly hope that the verities of an earlier medical age will be sufficient to deal with the present.
The Navy has concrete goals. By virtue of the Constitution and Public Laws, the Navy has been given the clear responsibility to provide medical care to a specific and well-defined group of people. Even more importantly, the Navy has been given the necessary authority to act to fulfill these goals, and has created the necessary organization to implement the authority. Civilian medicine lacks all of these and, as a result, much of the present civilian medical turmoil centers about the determination of goals and a decision about how they are to be reached and by whom. Organized medicine is inevitably more complex (and unquestionably more difficult to manage) but, in the final analysis, it is organization alone that permits successful movement against large-scale problems.
A shortage of personnel is a burden to both civilian and military medicine. The military, temporarily at least, enjoys the advantage of the draft in obtaining the people it needs. Like the civilian sector, it must train the great majority, but it loses too many at the end of their obligated service. Even in this dismal situation the Navy enjoys an advantage. Not only is civilian medicine short of people, but it is also doubly burdened by a severe maldistribution of the people it does have. By using a uniform, Navy-wide system of medical statistical reporting and analysis to define work load and projected need and by using its authority to transfer personnel the Medical Department puts its medical people where they are needed most, as accurately as possible in a large system which must operate at the mercy of world events and political decisions.
The cost of civilian medical care is nearly out of control, and beyond the ability of most to pay for it directly. The cost of Navy medicine is rising also, but not nearly so fast. As the Medical Department competes with the rest of the naval establishment—and the Navy, in turn, with the other branches of the armed forces—for available funds, economy of operation becomes a key word as everyone strives to get the maximum from funds that are ever in short supply. Further, the use of resources is coordinated and controlled uniformly throughout the system, eliminating needless duplication that is one of the major causes of rising civilian medical costs.
Before moving ahead with any concrete suggestions, certain assumptions are necessary. First, it is assumed that the organization of the Medical Department will remain essentially the same and there will be no change in the present medical benefits. In other words, the Navy Medical Department will continue to provide comprehensive medical care to all eligible individuals as completely within its own resources as possible. Conversely, the Navy will not turn to the civilian medical sector for direct medical care, since this would be an additional burden on an area that has been unable fully to meet its own responsibilities. As an aside, we cannot over-emphasize the extent of the benefits the average Navy man enjoys in his present medical care, even with its admitted problems.
Second, it is assumed that the nationwide doctor shortage will not be substantially alleviated in the years immediately ahead. Even if the much-needed Federal Medical School bill is enacted and the government infuses massive amounts of money into the nation’s medical schools, it will be years before the results—an actual increase in practicing physicians, civilian or military— will be evident. Of those presently graduating from medical school, 96% are fulfilling their military obligation. This cannot be increased and, in actuality, can be expected to decrease with changing draft laws and exemption for service in areas of critical civilian medical need. Further, even though the total number of doctors being graduated now is increasing faster than the population growth, it doesn’t nearly meet the increasing demand for their services, so the competition for the presently available doctors is becoming much more intense. Therefore, the Navy does not, and will not in the immediate future, have all of the doctors it would like.
Finally, the Navy will not resort to any sort of a fee-for-service as a gate for entry into the health-care system. Hand-in-glove with this, the doctors will have to face and finally admit that it is, and really always has been, the patient who makes the initial determination of the need for medical attention, whatever his reasons. However, this is no reason to permit the patient to completely control entry, in the manner that has presently occurred in the open access system. As long as the fee-for-service and petition-for-care systems existed, the doctor could deceive himself that he was in control of the system. He was, to an extent, but the control was not geared to need, and, much too often, excluded the wrong people. Further, it was subject to abuse by those who could afford it, the fee then serving merely to soothe the doctor’s injured pride.
Now that the fee is gone, it has not been replaced by anything, and the doctor’s skills are truly being abused. It is true that removal of the fee has exposed fully for the first time the magnitude of need for medical care in this country, but it is just as true that unrestrained entry into the system is as great a barrier to rational medical care as was the fee-for-service. The doctors should not direct their animosity toward the patients who bear no fault for the present state of disarray in the health care field, but rather at the system that does not respond rationally to the patients’ levels of need. The doctors should address themselves to seeing that the system responds in proportion to need; this would reduce their sense of frustration and would enable them to deal realistically with a situation that needs the very best they have to offer. It should not be forgotten that medicine is a service profession and the doctors should be trying to help the patients, nor merely control them.
A solution is needed which can be effected rapidly and economically to meet the real problems that presently degrade medical care. The widespread use of doctors’ assistants (DA) and screening personnel is just such a solution. Pilot programs are already in existence for this type of personnel. Figure 1 indicates how they might be used to improve patient care.
PATIENT
COUNSELING SERVICE SCREENING CLINIC SICK CALL EMERGENCY SERVICE
SPECIALTY CLINIC
DIAGNOSTIC SERVICES
OUTPATIENT
--------------------------------------------------------------------------------------------------------------------------------
INPATIENT LOCAL HOSPITAL
INTENSIVE
CARE UNIT
REGIONAL HOSPITAL
Figure 1
The diagram is largely self-explanatory, but certain aspects of it deserve special mention and emphasis. The changes will be greatest in the outpatient setting where the great majority of dissatisfaction occurs; it is a rare inpatient in a Navy Hospital who is unhappy with his care. Better than 90% of the complaints by both doctors and patients arise in the dispensaries, clinics, and emergency rooms where the uncontrolled flood of patients is presently greatest, and can be expected to increase in the future as medical advances permit more and more conditions to be treated on an outpatient basis.
The main point of the arrangement is to provide a screen of varying depth between the patient and the doctor. This is not to deny patients access to doctors but rather to ensure that access is on a planned and rational basis, permitting only those patients that actually need his services to see him. The logic of the proposal is straightforward enough, but will it work? I believe it will. A thorough survey and screening program, carefully organized and supervised, would do an excellent job of disclosing illnesses, some of which may be detected even before the patient is aware of them. Certainly, it would be an improvement over the absurdities of fee-for-service or unlimited access systems which have absolutely no plan behind them.
A specific diagnosis might not always be given but the fact of abnormality would rarely be missed. Because referral for special or additional treatment would be on a rational basis, the patient could be moved as rapidly as necessary, since the system is designed to get the patient to the right doctor at the right time and ensures that the doctor will have adequate time to devote to that patient. Provision is also made for the urgently or emergently-ill patient to have immediate access to a doctor who would have—to hammer across this essential point again—all of the time necessary to treat him fully, as befits the patient who needs his particular services. This, then, refutes the alleged depersonalization of socialized medicine; rather it will return the doctor-patient relationship to its most ideal state and it will be there for those who need it, not merely for those who can afford it or who can get to the doctor first.
The general plan is sufficiently broad that it can be readily modified to suit the needs of small or large facilities or groups of facilities, which hopefully will operate much closer together in the future. The Navy Regional Medical Plan holds great promise in this area as it will permit increasingly close coordination and cooperation among presently disparate medical entities with resultant improvement in the provision of medical care.
A very important part of the proposed system is the provision of services listed under counseling. The average military family is young, inexperienced, separated from home and family, and beset by frequent periods of night duty, deployments, and overseas duty. Friends may be few and are, themselves, usually just as inexperienced in dealing with the problems of military life, not to mention the problems of getting along in a new marriage or with a young family. Presently, too many of these people end up in clinics with minor or non-existent complaints asking for tranquilizers they do not need. What they do need is someone to talk to, someone older and experienced with qualities of compassion and common sense and a desire to help people. There is a real need for a formal counselling service based on a blend of the services presently offered by the chaplain, Red Cross, and Navy Relief. Again, this could be readily accomplished by non-medical and paramedical personnel, freeing the doctor for more critical pursuits. In a hospital setting, it would be possible to present related informational and educational topics such as well-baby care, family planning in its broadest sense, nutrition and general health information. This would have an additional benefit of creating a better informed patient population that would be able to make much more intelligent use of the available medical services. On the medical level, such integrated services are being provided in the new and expanding Navy medical program of Family Practice clinics, which are geared to the concept of a single doctor treating whole families as a unit. The formal counseling service, mentioned earlier, would be a perfect complement to this family unit concept. Here. again, we have encouraging evidence of the Navy system permitting a more ideal patient-doctor relationship.
Beyond the improvement in health care there is a second and almost equally valuable benefit in this proposal, and that has to do with the doctor’s assistant himself. It will permit a marked improvement in the career pattern of the hospital corpsman. Presently, more than 30,000 corpsmen leave the military Services each year taking their valuable medical training and experience with them, many of them to continue medical work in civilian life. At present, there is no long-term future for the corpsmen in the field of direct patient care and there are many who would like to serve and could serve well in this area. However, with the exception of a nursing program, which takes only limited numbers, the only paths of advancement presently available are in technical and administrative fields. The DA program would be a natural extension of their present duties in which they are already established and respected members of the Navy health team. The corpsmen have the potential to perform a real service to the Navy in this area of increased responsibility, and it will afford them opportunity for full professional status in the field of direct patient care. Further it will create a cadre of trained and experienced men who will he ideal candidates for independent duty. This will be particularly true in those billets where a doctor is assigned presently, but is grossly under-utilized, and is therefore bored and bitter, whose services would be of much greater use in areas of heavy patient-load.
The benefits to the doctors, in terms of improved and more rational use of their skills, cannot help but he beneficial, and should act as a positive career incentive. More than anyone else, the doctors presently bear the brunt of the inequities imposed by completely open access to medical care, and in turn the patients have suffered also. Some changes in attitude will also be necessary if the program is to be successful. The doctors will have to be willing to step back and relinquish some of their authority and the patients will have to be willing to accept a new health-professional. Since this represents quite a departure from the usual way of doing things it may be quite difficult for all to adjust to the new system, but it is absolutely necessary if health care is not to degenerate into complete chaos.
There are two final advantages to the proposal. First, it can be put into effect right away, since it is built upon people and training programs that the Medical department already has or is in the process of creating. As emphasized earlier, the problems cannot wait for long-term solutions. Secondly, it will be economical, since it is building on existing programs and the DA will be in the middle of the payscale.
A brief word about the cost of medical care is in order. No matter what economies are possible, this proposal will cost money, and it will require on the part of the Navy hard decisions concerning how much of its resources will be devoted to these ends. The demands for funds are limitless, but the funds are most decidedly limited. But there is also a limit to which people and resources can be stretched—doing ever more with less and less—beyond which there is inevitable deterioration of service. Civilian medicine faces the same hard choices, with the added disadvantage that they have so much further to go in achieving complete health care.
Last, but by no means least, it is time to announce that the Navy has really done a very good job in medically caring for its people. Undue concentration on the problems too often obscures this basic fact. It has been stated that military medicine cannot hold doctors because its goals, organization, and paths of advancement are not consistent with what the average doctor considers the proper use and development of a medical man. The statement, as such, is undeniably true, but there is much more to it than that. The original implication was that this was the fault of the military. Rather, it is the matter of doctors’ attitudes, based on traditional medical thinking for the last century, that are at fault. The old platitudes no longer suffice. Navy medicine’s problem is not that it is out of step with the times, but that it is marching to the tune of the future, and the rest of the world of medicine does not realize that it must catch up.
Navy medicine has made great progress in attaining its goal of providing complete health care and has shown the way in adapting the practice of medicine to modern technology and concepts of service. The problems that remain are capable of solution. The Navy and the Medical Department have every reason to be proud of what they have accomplished and the beneficiaries of the care provided should be appropriately grateful. We can well serve as a model for the rest of the nation. This is not to say that we will or should be copied exactly, but the Navy has shown what can be done in the field of health care.
__________
Commander Flynn attended Phillips Andover Academy, graduated from Yale University in 1954, and received his M.D. in 1958 from The Yale University School of Medicine. He served his internship at Philadelphia General Hospital in 1958-1959, and entered the Navy in July 1959. His first duty station was at the Key West, Naval Base Dispensary, where he augmented to the regular Navy. He then received his training in general surgery at the U. S. Naval Hospital, Portsmouth, Virginia, from 1960 to 1964. In October 1964, he began duty as a surgeon at the U. S. Naval Hospital, Beaufort, South Carolina. In May 1965, he served with the Augmented 2nd Medical Battalion, 4th MEB in the Dominican Republic. From July 1966 to September 1967, he served as surgeon in the USS America, returning thereafter to the Beaufort Naval Hospital where he is presently Chief of Surgery. Doctor Flynn is a diplomate of The National Board of Medical Examiners and The American Board of Surgery.