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- March 29, 1999
- Vol. 51
- No. 11
A Pioneering Pediatric Surgeon Recalls His Early Days in Medicine, When Doctors Were Gods Among Men
In the world of medicine, few working physicians have witnessed more changes than C. Everett Koop, U.S. Surgeon General from 1981 to '89. The Brooklyn-born son of a banker, Koop graduated from Dartmouth College and Cornell University Medical College. When he began practicing pediatric surgery in 1946 (he was the first surgeon in the U.S. to devote his practice exclusively to children), a polio vaccine was a dream and penicillin was only rarely available. As surgeon-in-chief at the Children's Hospital of Philadelphia, Koop gained a worldwide reputation by performing innovative operations on newborns. In 1981, President Reagan tapped him for the Surgeon General post.
Now 82, Koop hasn't slowed. A professor of surgery at Dartmouth Medical School and the senior scholar at the college's C. Everett Koop Institute, an organization founded in 1992 to improve medical education, he lives in Hanover, N.H., with Betty, his wife of 60 years and mother of their four children. "I'm not like most people my age," he boasts. "I can bend everything, and I can pick things up off the floors." Nor has he stopped dispensing information to help Americans stay healthy: His Web site, drkoop.com, has had some 6 million visitors since it was started last August. "No prescription, " Koop says, "is more valuable than knowledge." The doctor discussed medicine past and present with New York bureau chief Maria Eftimiades.
When I was a young surgeon in the 1940s, whenever a magazine had a poll asking readers, "What profession do you admire most?" the No. 1 answer was always medicine. Now, I don't think we'll ever crawl back to the top spot. I don't know when the difference came. During my childhood, physicians were held in awe. I wanted to be a doctor from the age of 6, so I paid a great deal of attention to physicians—they were gods among men to me. When the family doctor drove up to your house for a house call, you knew the healing had begun.
Many times he would sit down at the kitchen table and have a cup of coffee. These doctors were interested in the whole person. They knew that if someone was having psychosomatic troubles, it could be because of the alcoholic spouse or the child who was delinquent. I have often told my medical students that you learn more in one house call with a patient's family than you can in 10 office visits.
Years ago, doctors listened more. We didn't have the myriad tests we have now. The art of diagnosis was to listen to the patient's history and put it together as a detective would. A recent study found that when patients come to a doctor with a complaint, male physicians interrupt them within 17 seconds, female physicians within 45 seconds. Only 1 in 52 patients leave that kind of encounter feeling, "I told my story and the doctor listened to me." Managed care has made the relationship no better, because companies limit the time doctors can spend with patients.
There has also been a loss of formality within the profession. When I was in the first years of my medical career, nurses always wore uniforms. They looked beautiful—stiff, starched uniforms, and those hats. There was a greater sense of protocol in the hospitals.
In other ways, of course, medicine has made great strides. When I first arrived at Children's Hospital of Philadelphia, I was horrified by what passed for anesthesia. A nurse-anesthetist would hook a tonsillectomy patient to a machine that delivered open-drop ether vapor through a curved tube into the side of his or her mouth, then leave the child alone to start another anesthesia. It was only a little short of miraculous that there were not more misadventures.
Before pediatric surgeons developed techniques for surgery and postoperative care, the way children suffered under surgery was almost criminal. When I was a resident, a simple inguinal hernia operation on a 4-year-old would start out with an incision three to four inches long, when 1¼ inches would do. The old procedure produced a large, heavily sutured scar that made the poor child look like a toy football with thick laces. After the operation, the youngster would be confined to a hospital bed for 7 to 10 days and sent home with instructions that he could not laugh, sneeze, cough or lift anything for six weeks. Nowadays, youngsters come home from a hernia operation after only a matter of hours—with no stitches and no restriction on activity.
From the summer of 1934 until now, I have been in a medical setting. I was there when penicillin came along. We saw patients die of problems I have never seen since penicillin. We used to see Ludwig's angina, an infection from streptococcus on the floor of the mouth. You couldn't get your finger in the patient's mouth, and the patient couldn't breathe. Penicillin came along and whoosh, it goes down in 36 hours. Thanks to penicillin, rupturing an appendix while removing it is not the tragic situation it was when I first started in surgery. In those days, rupturing an appendix could bring on peritonitis, which could ravage, even kill the patient.
When I was a youngster, our parents dreaded the arrival of summer because of polio. It would come in August, and no one knew how it came—no one knew what a virus was. Swimming pools were closed; kids were kept from each other. The Salk vaccine, which came in 1954, changed all that. I look back on those years, from about 1948 to 1960, as the golden era of medicine, because two things were happening: We were doing more for our patients, and patients were able to get more and more health insurance. In those days, insurance paid the doctor or hospital for whatever they did for patients.
Another thing people don't think about is what a difference it made when plastics became readily available. In my early days in medicine, we had glass syringes. We treasured those syringes because they were expensive. And the needles were steel needles. If you used them a while, they got dull. The first thing I would do in the morning was sharpen my needles on an emery wheel, polish them down, sterilize them. Now everything is disposable. If you go into an operating room today, you'll find things we treasured and paid $300 for and kept locked up that are made out of plastic—you use them once and throw them away. No patients complain about dull needles today.
Working long hours is not new, though. When I started out, I was the only pediatric surgeon south of Boston, east of Chicago. There were times I had an assignment, 14 hours off, 34 hours on. I was tired all the time. As for the training, it was more leisurely than it is now. We thought the mass of information to be learned was unlearnable, but 95 percent of what a medical student is taught today was learned since I graduated. Now students know all that I learned, plus all this other stuff.
Social life has changed for medical students, too. In my day, medical students didn't marry. I was married the week before second year began, and everybody told me I would flunk out. The first two internships I applied for, I was turned down solely because I was married. The first surgical residency I applied for, they said, "Dear Koop: You didn't mention whether you were married. If you are, don't answer this letter."
I was different from my peers in another way: I didn't smoke. No one had a clue that the use of tobacco products would be deleterious to your health. Smoking became the frontispiece of my terms as Surgeon General. It was the single most preventable cause of death. Now every kid who smokes knows what the risks are—he just thinks he's not exposed to them.
People often don't act on what they know. When I left my job as Surgeon General in 1989, one-third of Americans were obese; now half are. You get a nice baby who's thin and people say, "Feed him up!" They forget that fat babies become fat kids, and fat kids become fat adults. It's abetted by no activities. Nobody goes out to play anymore. They sit and watch television, or their family has bought them a computer. When I was a boy, I never heard of a kid going on a diet. Now I wish half of them were dieting.
All my life I have said to patients, "If you want success, take charge of your health." When I was growing up, that was hard to do. No one talked about preventing health problems. You just lived along, got an illness and got the doctor to bring you back to where you were. The average person today is so much more knowledgeable than his father was, and the Internet is making people more knowledgeable all the time. It's possible to empower the patient to be more responsive to his illness and to make decisions in tandem with the physician. The Internet will change the way medicine is practiced.
It needs to change. In 1941 my first malpractice insurance policy was $15 a year; now the average premium for surgeons costs tens of thousands of dollars. Former colleagues recently told me, "When a patient comes in, you look at him as someone you are possibly going to see in court." I was glad I was out.
I'm one of those rare doctors who was never sued during the years I practiced. I can tell you why: because I listened to patients and families and made them allies with me against the disease affecting the child. If I usually saw a patient three times a day, when he was in critical condition I saw him eight or nine times a day. The dividend was that the parent said, "This guy is doing the best he can do."
The hallmark of medical professionalism is putting the needs of patients above one's own. Work until the job is done, not by the hour. But more and more in managed-care settings, doctors work on a time clock. Either managed care will succeed in burying the hallmark of professionalism, or doctors will wake up and we may get changes that are better for the patient.
I'm discouraged about what has happened in the profession, but not about what's going to happen. We're dealing with a new breed of medical students, youngsters who once again feel called to the profession, who aren't looking at it as the best way to their financial goals. You hear students say, "I was raised in such and such a town. My family had nothing, my friends' families had nothing. I want to go back there and practice medicine." It used to be, "I'm planning to go to Park Avenue." That's a wonderful trend.
- Maria Eftimiades.
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