The 'Art' Of Medicine An Old-fashioned Doctor Examines A Health System In Need Of A Cure.

Posted: January 27, 1997

Back in 1929, Norman Rockwell did a painting of a snowy-haired doctor seated in his office, a spark of fun in his eyes, thoughtfully holding a stethoscope to the heart of a little girl's doll.

It is a classic Rockwell image, capturing the warmth and good humor of a man many Americans then, and for generations afterward, knew well: the family doctor.

On many occasions, it has struck me that my own doctor, who for more than 50 years has tended to thousands of patients in a folksy, unhurried way, could have climbed right out of that Rockwell painting and come to life.

And it came as distressing news late last year when he sent out a letter announcing his retirement.

It was more distressing to learn why.

Wally McCune, as he refers to himself (or Dr. Wallace G. McCune, chairman emeritus of the department of medicine at Germantown Hospital & Medical Center), is pushing 80, but age isn't the reason he is quitting.

Indeed, this wry, amiable man seems ageless. His hair, a tenacious hue of golden-yellow, has never quite managed to turn white. And in his slightly owlish visage, there is an impish twinkle. He has been practicing medicine since 1943, most of the time in affiliation with Germantown Hospital.

It is obvious that he loves being a doc.

I never thought he would quit.

But Dr. McCune is fed up with what's happening in medicine. And he's a little insulted. Medicine has become a business. And that is not his game.

A proposed 250 percent increase in his catastrophic insurance fund premium - one element of the malpractice insurance doctors in Pennsylvania must carry - was his official reason for shutting his practice.

But there were many other reasons - and all of them have to do with the tidal changes in modern health care that are rolling across America.

On a final visit to his office for a checkup last month, I lamented his decision to retire.

He had a brusque reply.

``Well, there aren't going to be any Dr. McCunes anymore,'' he said. ``And if things keep going the way they have been, pretty soon it's going to be dangerous to get sick.''

Dangerous to get sick?

I asked him to explain.

We're not there yet, he said, but we're heading there.

``What's wrong with medicine,'' Dr. McCune said, ``is we've lost sight of Number One.''

Number One is taking care of sick people. Curing their ills. Easing their pain. Making those who cannot be cured comfortable. Treating those who are helpless with dignity.

Those things, he said, should be the business of medicine.

But instead, ``Everybody's out making money. It's the buck that counts. The bucks are what motivates everybody.

``I didn't get into this business to make money,'' he said. ``I got into it because I enjoy practicing medicine.''

* He came from a small town in Western Pennsylvania, went to the University of Chicago School of Medicine, and came to Philadelphia to do his internship and residency at Thomas Jefferson Hospital. In 1949, he joined the staff at Germantown Hospital.

``When I came to Germantown Hospital, they had open wards. People in the ward beds were taken care of for free. Nobody ever sent them a bill.''

Now places like Germantown Hospital, with a 130-year history of charity and service to the community, are under pressure to merge into huge hospital ``systems'' to survive.

With the advent of HMOs, the practice of medicine as Dr. McCune has known it is becoming history.

Once, he alone would make the decisions on his patients' care. Now, he said, HMO gatekeepers are looking over his shoulder, always second-guessing.

``Everybody is telling you how to practice medicine. You get 800 advices on how to treat hypertension, as if you didn't go to medical school, do an internship and a residency. . . . If you want to put a person in the hospital, you have to call some telephone number to get approval, and you have to talk to some high school graduate who doesn't know what you're talking about. So then you have to talk to the medical director, but he's not available until tomorrow.

``It just takes hours and hours to get permission for these things, and the patients are lying around suffering and you're blowing your stack. . . . It's getting a little intolerable.''

To achieve profits, he said, HMOs ``ratchet down'' the number of days they pay for hospitalization. The limit for women having babies was squeezed to one day. It took laws to force HMOs to give birthing mothers at least two days in the hospital.

``Now we have the legislature practicing medicine! The legislature is passing laws telling the HMOs what they have to do. This is ridiculous.

``I don't think there's any possibility of reversing the HMO trend. I have resisted going along with it. Now, if you don't go along with it, you're not going to be practicing.

``When I began in 1943, the practice of medicine was a cottage industry. A doctor opened an office and got some patients. There was no third party to interfere with anything. If you needed something and couldn't afford it, you didn't have it done, or if you needed it real bad, the doctor found some way to see you got it done. Doctors charged their paying patients enough to cover the costs of those who couldn't pay. It was a pretty good system.''

* A routine visit to Dr. McCune typically would take an hour. He would walk into the examining room, issue a hearty greeting, tell you how well you looked, sit down, thumb through the pages of the file, ponder a bit, ask about past ailments, then discuss current ones. He would chat about current events, philosophize a bit, tell a joke. He would study the file again. He would conduct an examination. Eventually, he would offer an explanation for whatever was wrong that had prompted the visit, and prescribe a remedy. With a shake of his head, he would shut the file and declare: ``Well, I'm sorry, but I can't seem to find anything very seriously wrong with you.''

In the emerging age, the one in which Dr. McCune's advice is to avoid getting sick, there will be no such office visits. Doctors will not have the time.

``It's going to be impossible for doctors to practice medicine the way I practiced. They won't be able to make a living.

``The doctor is going to stick his head in the door and say, `Hi, glad to see you're doing so well,' and sign your prescriptions.

Doctors will spend more time ``oiling the machinery'' that runs the health-care industry and less time on Number One, the patients.

``The ideal is going to be to have a bunch of healthy young patients in your HMO. If you have a bunch of old, sick patients, you'll be in trouble. Seeing those patients takes time.''

HMOs aside, there are plenty of other things that need fixing in the health-care industry. Here, in abbreviated form, is Dr. McCune's prescription:

* Everyone should be required to contribute to the cost of his or her own care. Those with 100 percent insurance coverage lack incentive to keep costs down. If people had to pay something - 10 or 20 percent - for tests and examinations, there would be fewer tests and examinations, particularly unnecessary ones.

* Costly medical procedures should be reduced for elderly people with end-stage diseases. The emphasis should be on giving them dignified care, and keeping them comfortable.

* Malpractice mania should be curbed. Doctors spend a fortune on malpractice insurance. The pervasive threat of lawsuits often prompts them to order unnecessary tests, strictly as a defensive measure.

* Hospitals should give bad doctors the boot. And doctors who get the boot should not be able to sue so easily to get their jobs back. Even when hospitals prevail, such litigation eats up huge amounts of time and money.

It is a point of pride with Dr. McCune that during his years of practice, in the fast-fading ``golden era'' of medicine, there have been enormous advances in medicine. Endoscopic surgery. Joint replacement. Lens implants. Organ transplants. Heart bypass surgery. New drug treatments for heart disease, mental illness and hypertension.

While keeping abreast of all these things, Dr. McCune continued to relate to patients in simple, down-to-earth terms.

* ``This is Wally McCune,'' he announces, returning a telephone call. ``Are you sick? . . . Well, how sick are you? Would you say you're dying sick, or just miserable sick?''

Usually, I was just miserable sick. Whatever the problem, Dr. McCune always plugged me into the hospital, or the right drugs or the right specialists to get me back on my feet.

I was home, miserable sick, one weekend, and the telephone rang. ``This is Wally McCune. I was feeling a little sorry for you. I thought I'd call up and see how you're doing.''

Just tending to business.

Dr. McCune's last day was Dec. 31. This month, he's cleaning out his office, sorting through 50 years of accumulated files, books and journals.

``From now on, I'll be happy to hear about your problems,'' he said, turning in his chair and stretching his legs. ``But all I can do is sympathize.''

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