Monday, May 7, 2012

If it’s not fun, it’s not public health. If it’s not public health, it’s not fun.

Those were the days, my friend
We thought they'd never end
We'd sing and dance forever and a day
We'd live the life we choose
We'd fight and never lose
For we were young and sure to have our way...
Those were the days, oh, yes, those were the days.”
Lyrics by Gene Raskin popularized by Mary Hopkin in 1968.
Once I got beyond the range of the Twin Cities, “oldies” stations were the only ones that came in clearly on my car radio, as I drove to Madison for my 40thmedical school class reunion.  I thought that was quite appropriate, so for three hours the sound track of the 60s and 70s filled my ears and my mind and my soul as I reminisced about the “good old days.”  The nostalgia increased as I turned onto Madison’s East Washington Avenue and saw the Wisconsin State Capitol in the distance, drove by Ella’s Deli, and headed to the Madison Club on the shores of Lake Monona.  All the hopes and dreams I had as a medical student welled up in my consciousness and gave me pause as I considered how well I had taken advantage of the opportunities that were before me in 1972.  I had mixed emotions because my actions have been a mixed bag.
(As an aside, the first person I ran into upon entering the Madison Club was not one of my classmates but our gross anatomy professor, Jim Pettersen, who was one of our favorite faculty members and who has attended most of our reunions over the years.  When I told him what I was currently doing, he asked, “Do you know my uncle George who used to be the Minnesota Health Commissioner?”  George Pettersen was the health commissioner when I came to Minnesota and George and I worked together on several projects in the early 80s.  I discovered that he is doing well and living in the Crosby-Ironton area.  What a small world.)
It wasn’t long after entering the reception room and getting reintroduced to former classmates before we were sharing stories and catching up on 40 years of life.  However, among the laughter about the quirks of old professors and the silly things we did as students, there was a palpable sense of underlying dissatisfaction among many of my classmates.  Eighty percent had already retired and among those still practicing, most were looking forward to retirement.  Besides me, the only one who seemed to be still enjoying himself in his profession was Henry Anderson, who happens to be the state health officer in Wisconsin. 
Our class had started to practice right at the beginning of a major transition in medicine.  In our conversations it became evident that the advent of managed care and HMOs and the evolution of medicine as big business had negatively affected their enjoyment of medicine.  They articulated that what they ended up doing was not what they had anticipated.  They felt like the rules had changed in a way they didn’t like, yet they weren’t able to get out of the game.  Most enjoyed many parts of their practices but they did not have the passion they thought they would have had. 
In pursuing this discontent a bit further, I got a sense that the parts of their practices that they didn’t like were when they functioned as technicians or when they treated the same conditions over and over again with little impact or when the business of medicine overwhelmed the profession of medicine.  What gave them joy, however, was when they were making a true difference in the lives of families and their community.  They lit up when talking about their work with scouts or other community groups, their volunteer time with high need or underserved populations in their communities, their teaching and mentoring of future physicians and other health care workers, or their advocacy around policies that affected their practice or the health of their communities.  It struck me that they were most energized and most satisfied when their medical training and practice could be linked with public health outcomes.
Yesterday, I shared this story during the “Heritage Lecture” that I had been invited to give to a group of radiologist who were attending the annual meeting of the Minnesota Radiological Society.  After my presentation, several physicians of much younger vintage than I, approached me and shared that the disenchanted feelings are not unique to my 1972 classmates; they are prevalent even among today’s early and mid-career practitioners.  This made me think of a quotation of Rudolf Virchow, a noted physician of the 19th century and the father of pathology. 
“Medical education does not exist to teach individuals how to make a living, but to empower them to protect the health of the public.”
These experiences with my classmates and physicians in Minnesota have convinced me that our efforts to integrate medicine and public health and to use a public health as a framework for health reform are not just essential to improve population health and control healthcare costs; they are necessary to restore meaning and enjoyment to the provision of healthcare.  Public health is an integral part of the values of being a physician (and probably every other healthcare profession).  If that part is absent, meaning and satisfaction are easily lost.  Integrating medical care and public health are essential to truly reforming our healthcare system.
You have all heard me say that “If it’s not fun, it’s not public health.”  I still believe that but the experiences of the last week have also convinced me that in the field of healthcare “If it’s not public health, it’s not fun.”