The recent edition of Emory Medicine noted that Dr. William Fackler of LaGrange received $5 for a house call in 1950 as if it were truly remarkable as well as a mark of dedication and sacrifice. I was a family physician in Monroe, Georgia, a quarter-century later, from 1973 until 1979. At that time, Medicare reimbursed 20% less than that--($4) for a visit to my office! My expenses for caring for a patient in my office totalled $4.32, creating a lose-money situation. Altruism is noble, but the bank which held the mortgage on my home wanted cash the first of every month, not a recitation of all the good deeds that I had performed. Interestingly, Medicare reimbursed a physician in DeKalb County (about 30 miles west of Monroe) $12 for the exact same service during the same time frame. And the government, organized medicine, and the general public all wondered why there were no family physicians in rural areas! The current problems with the practice of medicine started when the government became involved with the advent of Medicare in 1964. Until then, the practice of medicine was a calling, as a calling to the ministry, and doctoring was an honorable profession. If people could pay for care, they did. If they couldn't pay for care, they received care anyway. With the coming of Medicare, the art of doctoring was reduced to maximum allowable charges, and 80% reimbursement, and ICD codes, and more effort to think about the business of medicine. And it has never been the same. J. Gordon Morrow III, MD Dr. Morrow is assistant professor of anesthesiology at the School of Medicine and clinical director of Grady Memorial Hospital.

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I have witnessed firsthand the evolution of "medicine through the generations." I became a physician in the so-called "golden age" of the 1960s and 1970s, when fees-for-service were at their highest levels and when doctors answered only to their patients. My father was a physician of the old school who made house calls and accepted whatever payment his patients were able to provide. Both of my sons are recent graduates of Emory School of Medicine [Eric, 94M, and Kevin, 97M]. They and their contemporaries are entering a profession that has changed dramatically, as different from my generation as mine was from my father's. During the past decade, the US health system has undergone what can only be described as a revolution, where autonomy has been taken from physicians and conferred on HMOs. Managed care has impacted all phases of the profession, including both undergraduate and graduate medical education and the practice of medicine in both academic and private settings. Today, doctors must answer not only to their patients, but also to the public good. As academicians, we must adapt our activities both in the teaching and practice of medicine to permit our students to work effectively in this new marketplace. We have a responsibility to educate them in this new health care atmosphere, but the challenges we face in doing so are formidable. The information explosion of the 1980s and 1990s has caused a rapid expansion of the medical school curriculum. With more to teach our students, our faculty must be life-long learners in order to be effective. Many medical schools, including Emory, are changing their curriculum to focus less on large general lectures and more on smaller group teaching in classrooms and in clinical settings. But this approach is more labor intensive for a faculty that is also under pressure to see and treat more patients to compensate for falling revenues. Simultaneously, the government is cutting its financial support to hospital residency programs. At Grady Hospital, for example, where we used to have 12 cardiology fellows, we now have seven, and under new federal guidelines, residents are limited to an 80-hour work week. These constraints have not affected the quality of care at Grady, but they haven't made it any easier for us to get our work done and done well. Ultimately, however, I think the challenges posed by managed care, the information explosion, and financial constraints are more problematic for people of my generation, who are being called upon to make significant adjustments to the way we practice and teach. In response to these changes, many of my colleagues tell me that they would no longer recommend medicine as a career to relatives or friends. I am not one of them, and, fortunately, high-quality young people are not listening to such advice. Most young people come into medical school these days driven by strong altruistic motives. They are intelligent, motivated by humanitarian interests, and accepting of a changed health care environment. They come into medical school with their eyes, their minds, and their hearts wide open. I believe the future of American medicine is in very good hands. Joel M. Felner, MD Dr. Felner is professor of medicine and associate dean for clinical education at the School of Medicine. He received the 1996 Emory Williams Distinguished Teaching Award, Emory University's highest teaching honor.