A Medical Economics Web Exclusive

Note from The Editors: The following article appeared in Medical Economics more than 30 years ago, in our Jan. 19, 1970 issue. Richard C. Bates, an internist in Lansing, MI, and one of our foremost Contributing Editors, took Arthur Clarke-like pen in hand and outlined his vision of 2001 in what we called a "satirical prophecy." Bates, who is now retired, looks back at the article and says with a chuckle, "At least I got the last paragraph right." We think you’ll find that he had uncanny insights, long before the advent of managed care, telemedicine, same-day surgery, the Internet revolution, and other phenomena.

2001: The heyday of the non-MD doctor

By Richard C. Bates
Internist/Lansing, MI

It's Jan. 5, 2001, and a proud day in the life of Eleanor Goodfellow, a family doctor who's been in practice for 10 years. She's just opened a message informing her that she's the recipient of a shiny new MB (Bachelor of Medicine) degree. At age 30, she can look forward to many more years of pleasant productivity. Her new degree, earned by continuing study following graduation from paramed school at the age of 20, grants her an immediate 10 percent jump in salary. Studying televised lessons and taking examinations on her home video computer have become so much a part of her life that she plans to go on for an MM (Master of Medicine) degree. This will mean an additional 15 percent jump in her income.

Goodfellow doesn't in the least regret her decision to go into primary medicine instead of taking the longer course to an MD degree, which would have required her to work as a specialist in some regional medical center. As a small-town girl, she enjoys her role as the leading source of medical care for the 12,000 families of Lewiston, ID. And in the long run, considering her earlier start at earning, she'll come out almost as well financially as if she had become an MD.

Not bad, she reflects, for a woman with only two years of formal college education. Things have really improved since the old days when Father was one of Lewiston's frustrated and frantic GPs. How could the old boy and his colleagues have stood the pace all those years! He'd be astonished if he could know that, in half his customary 60 hour workweek, his daughter takes care of a city grown four times as large. But, of course, he practiced in the days of cottage-industry medicine.

"Enough daydreaming!" Goodfellow scolds herself. "Time to check on my hospital patients." (She thinks of them as her patients, though they're 100 miles away at the regional center in Spokane.) She punches a series of code numbers on one of the machines in her trusty communications center, and one by one patients begin to appear on the screen even as her image is projected into their rooms. Jones, the accident case, is walking nicely. Thanks to that new osteoblastic stimulating hormone, his multiple fractures have healed in less than two weeks. As a result of such successes, the old technique of open gluing of fractures has now been largely abandoned.

The Smith girl, Goodfellow notes, is positively blooming from antigenic adjustment therapy. In the old days she'd probably have gone into rheumatoid arthritis or lupus.

The Carter boy is still on continuous milieu interieur monitor, but he's as alert and cheerful as one could expect a 4-year-old to be with tubes in both arms. "Lucky boy to be alive at all after eating a whole can of insecticide," Goodfellow muses. "I do wish we could teach parents to keep poisons out of reach." However, with an intravenous blood-composition monitor on one arm and with the other arm hooked to a unit that adjusts any abnormality through computerized dialysis-infusion, he can be kept well indefinitely.

Mrs. Schaeffer is having her gallbladder out, and Goodfellow watches for a few moments. It's always a thrill for her to observe the surgical technicians. It used to take Father an hour and a half to do a gallbladder, she recalls. Now it takes 20 minutes. What with the new electrical anesthesia, bloodless surgery, and tissue glues, the operation isn't much more complicated than dressing a chicken. Without the need for pre-op and post-op medication, patients walk to the operating room and back and are usually discharged the same evening.

Rogers is in the recreation room, but the screen reports that his chemical profile, based on 50 analyses of his blood and 150 ultraviolet spectrophotometer urine tests, indicates his problems are due to a type 25B myeloma protein. No wonder his local screening tests confused the diagnostic center! Anyway, as soon as some anti-25B protein arrives from the international center in Zurich, he'll be started on a course of therapy that Goodfellow's technicians will complete at home in three months.

Old Mrs. Hartlove is coming home without treatment. Some slight irritation is expressed in the notes on the lower half of the screen. The staff thinks Goodfellow should have seen that the patient's overall health score of 20 makes her ineligible for more than minimal care. Since 1980, when the cost of health care approached 20 percent of the Gross National Product, the Government has had to be quite severe in restricting the spending of large sums on aged and hopeless cases. Goodfellow understands that, but she's gotten emotionally involved with the dear old soul and has allowed feminine compassion to overwhelm good judgment.

It's 10 am now and time for Goodfellow to feed her baby. While she does, she checks in with the clinics on her video console. There are 10 general and five specialized clinics that, as a Government inspector, she must check daily. Of course, she doesn't have any direct hand in managing the clinics, but since she carries the inspection responsibility, she likes the employees to see her face on the screen once a day, just so they'll know she cares.

The general clinics are all operating on schedule for once. Every citizen has to go through a clinic check twice yearly (except pregnant women, who go monthly), so Goodfellow receives angry letters forwarded from the mayor's office when there are delays, as happens when the equipment breaks down. It always seems to be that trouble occurs in the three clinics for ages 25 to 40, which deal with the busiest people. The 50-and-over clinic for the retired never seems to get fouled up.

The five specialized clinics (Physical Disease, Chemical Disease, Mental Disease, Behavioral Disease, and Triage) take Goodfellow a little longer to check than the general clinics. She therefore usually looks in on the first four before lunch and saves Triage, where the knotty problems end up, until after she has had her nap. The red light signaling an emergency in the Physical Disease Clinic goes on just as she is about to dial in. It's an industrial accident; a midthigh amputation, complicated by cardiac arrest while the patient was being transferred from the helicopter to the clinic. Goodfellow notes with approval that the technicians already have him on pacemaker and are pumping oxygenated nonantigenic synthetic blood (ONASB) into the severed femoral vein. She knows the heart should start directly.

It's a clean amputation, so the leg is also on ONASB. When the technicians get a heartbeat, they'll dip all the open surfaces into universal antiseptic and fibroblast stimulant, apply bone glue to the femur fragments, and then begin the meticulous job of gluing the arteries, nerves, muscles, and skin together. The patient will require a brace to lock his knee and lift his foot until nerve function returns in three months, but he can go home tonight and be back at work on Monday. Actually, Goodfellow doesn't need to look in on such routine matters as a severed limb, but Federal regulations require her to be notified of cardiac arrest in any individual with a health factor of 30 or over.

In the Chemical Clinic, they're administering antianti-insulin antibody to a young man. A General Clinic computer comparison of his genetic history with his last 10 blood-sugar determinations has flagged him as being prediabetic. There's a slowdown in the line of 6-month infants awaiting oral universal vaccine–an unusual number of mothers have come in all at once. It's not getting the vaccine into them that takes time; it's the painless tattooing of microscopic Federal identification symbols under the nails of their right forefingers.

Families are always eager to get this done six months to the day from birth, when by law that invisible life-long identification mark officially makes the baby a citizen. This means that families can then transfer Grandpa's gift into the baby's own account, start collecting a family income increase, and get in on all the other benefits. From now on, any financial, medical, or legal transactions involving the baby will require him to place his finger under a scanner that's sensitive only to the special inks used in his tattoo.

Every financial transaction a person makes, in fact, is recorded in an income center where his income tax is automatically computed on a daily basis and the correct amount of taxes immediately transferred from his account to the Government's. He'll never need to touch money, hire an accountant, sign his name, have his signature notarized, carry identification, be fingerprinted, or visit a bank. The mere placement of his right forefinger beside any document under a scanner will record that information in his permanent file. The same finger placed under the proper scanner in any health center instantly makes available any facet of his past medical history.

Next, Goodfellow looks in on the Mental Disease Clinic. It's being phased out, now that schizophrenia is no more, but there are still some brain-damaged and many senile individuals to be seen on a regular basis. With health factors below 10, these people aren't entitled to surgery or regular clinic exams, of course. Older female volunteers make up a large part of the staff here, so Goodfellow is particularly careful to show appreciation and encouragement.

The Behavioral Clinic is just starting to administer parent licensure exams to 25 couples applying for permission to have a family. The exams are stiffer this year because, due to the increased proportion of well-adjusted people in the younger generation, there was a slight rise in population last year. As usual, several applicants are taking the exam for the second time; they failed last year and have been in group therapy since then in an attempt to raise their maturity index to a level acceptable for parenthood.

All pregnancies are initiated at the insemination center, using frozen sperm from certified donors. The donors have no history of hereditary disease, are physically superb, and have an IQ of 130 or above. Though it's a strictly kept secret, Goodfellow's husband is one of only 20 certified sperm donors in Lewiston. His sperm is pooled with that of hundreds of other donors, ionized to separate XX from XY sperm, and then shipped around the country. Those couples who pass the parent licensure exam are sent to the insemination clinic to which they must return for two more pregnancies at intervals of three and one-half years. Each couple must agree to a family of exactly three properly spaced children, but they may choose whether they'll have two boys and one girl or the other way around. They can have the males and females in any order they wish. Accordingly, no one would dream of having unplanned children, and, thanks to abortion pills, it doesn't happen.

The various group therapy sessions–for obese adolescents, for the parents of rebellious, anxious, or immature kindergartners, for sexual perverts, for gluttonous, mood-altered, or extremist adults–all pass under Goodfellow's inspection. Now she takes time to fix lunch. Her husband, an air-pollution-control engineer, has been working at his video console in the next room. The two older children, 4 and 7, have been at their school consoles all morning. Most families are finished work by noon, but Goodfellow's family understands that doctors work long hours. So after lunch, she sends the two kids off to the park with her husband and, leaving the baby asleep, walks across the street to the Triage Clinic for an hour.

The first business at hand is a breech extraction. The patient was brought in at midnight and then placed on delivery-hold for Goodfellow's convenience; a midwife had been unable to perform the usual home delivery. (Had the case been too complicated for Goodfellow, the woman could have been transported to Spokane for more expert obstetrical care. Jet ambulances regularly make the trip in 20 minutes.) Five patients have been fingered through regular clinic exams for elective major surgery, so Goodfellow sees them together, explaining details of the trip to and from Spokane and answering questions.

The next is a man with a benign brain tumor. It’s a complicated case, and she presents him via video console to the neurosurgeon in Spokane. The specialist agrees that expense will be saved if he’s sent directly to the Federal Neurosurgical Center in Kansas. Since a chemical cure for malignancies was found in 1985, brain operations for tumor have become quite rare, and there’s a trend toward sending them all to Kansas.

The Triage Clinic staff doesn’t have any other pressing problems, so Goodfellow stops for coffee. She’s scarcely had the first sip when her baby-watch monitor notifies her that the baby is awake and sneezing. "Drat it," she thinks to herself as she crosses the street for home, "you don’t suppose he’s coming down with a cold? I do think medical science with all its modern know-how could come up with a cure for the common cold. I’ll probably have to walk the floor all night."

Originally published in Medical Economics magazine, Jan. 10, 1970

Let us know what you think! Send an e-mail to meletters@medec.com.

Want to talk to the author? You can reach Richard C. Bates, MD, at signe24@aol.com.

Richard Bates. 2001: The heyday of the non-MD doctor.

Medical Economics

2001;8.