Flashback in Medical Economics

25 years ago: Oct. 13, 1975

It’s hard to pin down who coined the pejorative, "assembly-line medicine," or when. By the mid-1970s, though, it had become the standard, sour description of high-volume, low-rapport office practices. Doctors who ran such medical mills caught flak (and still do) from slower-paced colleagues.

That’s why "So What’s Wrong with Assembly-Line Medicine?" came as something of a surprise. In his article, Milton R. Curry, a solo pediatrician in the Midwest, not only defended his average of 220 patients during 22 hours in the office each week, he bragged that patients and their parents loved it. His proof: the "Christmas cookie" test. "Each year, my nurse goes around to the other eight physicians in our building to see how many cookies, fruitcakes, and other remembrances they’ve received from grateful patients," Curry wrote. "Last December [his practice] had accumulated five times as many goodies as any of the others!"

He explained some of the timesavers that made his system work:

• Parents who’d scheduled their kids for complete physicals were sent postcards asking them to arrive with a urine specimen, which "can be difficult to induce in the office," Curry noted.

• Only one adult was allowed to accompany the patient in the exam room. "That keeps Mommy from bringing Daddy or female relatives to get underfoot."

• To the maximum extent possible, routine clinical tasks were delegated to assistants. In his few minutes with the patient, Curry focused on doing the physical exam, interpreting test results, and prescribing treatment.

• Long-acting antibiotics were used "liberally." In fact, Curry conceded, he overused them, "by ivory-tower standards." The drugs cured 90 percent of his patients after a single visit, he claimed. Furthermore, "in 18 years, no patient of mine has had a serious allergic reaction to antibiotics."

• All incoming phone calls were handled by an LPN, with backup by an RN and by Curry himself–but only if absolutely necessary. "I almost never talk on the phones myself," he said. "That would be taking time from my paying patients to give free service."

By streamlining office procedures, wrote Curry, he could make time to see almost one-third more patients per week than the typical pediatrician. And his high visit rate "allows me to charge one-fourth less than the median fees in pediatrics without sacrificing too much income."

Still, the doctor chafed at the "assembly-line" label given his practice by other physicians in his community. One sign that the criticism hurt: A note with the article acknowledged that "Milton R. Curry" was a pen name, used "to keep those who might oppose his somewhat unorthodox style of practice off his back."

50 years ago: October 1950

A quarter-century earlier, the furor over assembly-line medicine centered on Great Britain. After two years of existence, Medical Economics reported, the National Health Service was a herd-’em-through, high-prescribing, overutilizing, wasteful mess.

A team of AMA investigators crossed the Atlantic, spent six weeks assessing the situation, and came home with virtually nothing good to say about the NHS. "Among physicians," they despaired, "the emphasis is on numbers rather than service" … "The patient is in a position to demand what he wants. If he is not granted what he demands–whether it is an ambulance ride, a drug, reference to a hospital–he can remove himself, his family, and his friends from the doctor’s list" … "The physician has completely lost his independence, since he can no longer gain economic freedom outside the medical monopoly established and controlled by the state."

And this gloomy prediction: "Abuses of the service are evident everywhere. They must lead to more and more regulations, tighter enforcement, greater penalties for violation, further limitation on freedom, and further deterioration of the quality of medicine."

Pretty much what you’d have expected from the AMA, which was also sounding louder and louder alarms about the threat of socialized medicine in this country. More telling were the laments of physicians in the trenches of British health care.

"I used to pride myself on being a conservative prescription writer," a London GP told a visiting editor from the States. "Wouldn’t give the patient a script unless I’d looked him over pretty carefully and found out exactly what would help him. Never wrote more than 4,000 prescriptions a year.

"Now the lid’s off. Patients come through my surgery in an unmanageable stream. I listen to their troubles, dash off the scripts, and buzz for the next patient. Last year I wrote about 10,000 prescriptions."

From another GP, in Glasgow: "In the old days, a person who wanted some aspirin or a roll of bandage simply went out and bought it. Under the NHS, he asks his doctor for a prescription. And the doctor knows that if he refuses, he’s quite likely to end up with one less name on his list."

The editor returned to the States to write in this magazine: "Nearly all appliances are being dealt out hand over fist. During the first two years, patients got more than 11 million pairs of eyeglasses, more than 4 million sets of false teeth, more than 100,000 hearing aids. So many wigs, corsets, and surgical appliances were distributed that even the Health Ministry can give no accurate count.

"The drugs-and-appliances program neatly illustrates the basic defect of the NHS: It is a shotgun remedy. Some of it hits the target and helps, but much of it misses the mark and is wasted."

75 years ago: October 1925

"The business magazine of the medical profession" began Year 3 of publication by looking at the accomplishments of Years 1 and 2.

"Two years as measured by the ages is as naught," our first editors reflected, "yet in that brief space of time there has been aroused in the minds of the physicians of this country an economic consciousness quite unknown to the profession in the centuries of its existence. This fact has been accomplished–we can say with becoming modesty [sic]–very largely through the preachments of Medical Economics.

"Many physicians have been frank to say that by carrying out the precepts laid down in these pages they have added very materially to their incomes," our "modest" editors of the Twenties continued. "Others have expressed the belief that they are better practitioners and are able to carry on more work with less effort as a result of following suggestions we have published."

Then, as now, the goals of the magazine were evident in its article mix. Consider these titles from October ’25:

• "The Doctor and His Investments"

• "The Evils of a Fixed Consultation Fee"

• "The Other Side of the Case History"

• "The Rural Medical Crisis Diagnosed"

• "Current Literature for Investors"

And then, as now, the editors steered a wide path around the bone-dry prose style of more-scholarly journals. Take, for example, this passage from their part-reportorial, part-analytical, part-battle cry treatment of the "crisis" in rural care:

"The spirit of fair play so common among the American people will not permit us to stand by idly and see one part of our citizens obtain a higher degree of medical service than another, merely because they happen to be nearer the great centers of population. Such a condition would be poor sportsmanship as well as poor business."

Man, could those guys tickle the typewriter keys!

–James D. Hendricks
Executive Editor

Medical mirth, 1925 style

A few jokes scattered through our October issue of three-quarters of a century ago:

Patient: Can this operation be performed safely, Doctor?

Doctor: That, my dear sir, is just what we are about to discover.

Doctor: Ah, my little man, I knew the pills would help you. What did you put them in–water or jam?

Little Boy: In my peashooter!

"Oh, Doctor, do you think the scar will show?" asked the fair young appendicitis patient.

"Can’t say, Miss," her surgeon replied. "I’m not setting the styles this year."

A little drum riff, please.–The Editors, circa 2000

James Hendricks. Flashback in Medical Economics.

Medical Economics

2000;21.