COMMENTARY

Looking Back on 40 Years of Medicine: Reflections of a Retired Endocrinologist

Richard M. Plotzker, MD

Disclosures

December 18, 2018

Most things have a beginning, a middle, and an end.

In the clinic, every visit starts with a chief complaint, then has a set of assessments in the middle and a decision about what to do for each problem at its conclusion.

Similarly, the physician's career has a reasonably predictable trajectory, from that precious acceptance letter to the diploma that gets a special frame, to the Match and board certification. Then, most of us encounter a constant stream of patients until—just as our experience becomes difficult to replace—we exit the pageant by retiring.

Diseases Come and Gone

My own clinical tenure was recently concluded. In the course of 40 years, diseases have come and gone. During my last week, a relatively new disease popped up. Someone had an impressive elevation of thyroid-stimulating hormone (TSH), very low free T4, some mental impairment, and a record that showed normal thyroid function within the previous few months, traceable through the record over a few years.

This disease of medical progress was an increasingly described endocrinopathy from a PD-1 inhibitor, a new type of immunotherapy for a cancer that was once rapidly fatal and which was introduced to our patient just after the previous round of thyroid testing. And because there are other endocrinopathies associated with this drug that were totally unknown to the residents and only partly known to me, some literature search, ordering of tests, and teaching had to take place.

Some things are better left as part of medicine's past.

There was no AIDS when I finished my residency. I am old enough to have seen a septic abortion admitted to the obstetrics service on my clinical rotation, scrub in on an antrectomy/vagotomy for intractable peptic ulcer pain, and serve as a third-year student transcriptionist when a psychiatrist opted to expand a patient's stream of consciousness by infusing thiopental, which was once used as a form of truth serum.

The patient spoke in long, flowing paragraphs about her childhood and teen years for the next 45 minutes, yielding 17 pages of new history. Some things are better left as part of medicine's past—diseases and interventions that make the emerging cadre of experts wonder what the geezers of that generation, now mine, were thinking.

In those days, when CT and ultrasonography were in their infancy, adrenal and thyroid incidentalomas were not a part of ordinary endocrine office practice. Pituitary incidentalomas had to wait until the MRI became available.

The modern TSH and parathyroid hormone assays and percutaneous aspirations of thyroid nodules were all developed during my professional lifetime, resulting in a blend of early detection of the serious and excessive care of the innocuous, a challenge that continues to this day.

On the other hand, parathyroid surgery, which at one time had enough uncertainty that patients would decline surgical consent, has now become routinely successful, with far less surgical morbidity due to better reliability of the laboratory assay and more reliable methods of localizing the adenoma preoperatively.

Shifting Populations

Diseases from elsewhere in the world started appearing in United States. My classmates and I attended second-year pharmacology lectures on roundworms, flatworms, malaria, and tsetse flies—none of which any of us ever expected to see.

What my class did not anticipate was global migration on a massive scale as transportation improved and commerce became more international. My town now has large population centers of people from West Africa, Indochina, and Bangladesh.

In addition, the emergence of global travel has exposed Americans doing mercy missions or combat in various places to Ebola, SARS, or for the big game hunters, trypanosomiasis.

Endemic infections appeared infrequently, but common diseases such as diabetes or thyroid disorders were managed somewhat differently in other places, and we were asked to make these transitions.

Changes and Advances in Treatment

Use of the medical workforce has also changed during that interval. I've seen the treatment of depression move from the psychiatry office (where use of high-dose tricyclics needed professional caution) to the primary care offices and sometimes to my office, as the medicines became safer and access to psychiatric consultation became less available in many areas.

Options for treating diabetes expanded since 1994, with the introduction of metformin in the United States followed by thiazolidinediones, GLP-1 receptor agonists, DPP-4 inhibitors, SGLT2 inhibitors, and designer insulins that don't exist in nature.

Referral patterns from primary care to endocrinology or diabetes centers expanded in parallel, augmented by the increased acceptance of insulin pumps and continuous glucose monitors. And the most difficult cases of diabetes, once almost a lost cause, became amenable to intricate stabilization.

Along with the coming and going of diseases, the shifting of populations who have those diseases, and the enhancement of interventions, the life of the physician has also experienced a measure of professional cycling over that same 40-year span.

Professional Crises, Debates, and New Expectations

As a student, the news of the mid-1970s was the emergence of a malpractice crisis, with an acceleration in the number of lawsuits filed, a growth in the size of judgments and settlements, and a dramatic rise in the price of professional liability insurance beyond what many practices had budgeted.

In the background was a debate about whether MD and DO degree recipients should have parity, which seems to have been attained with benefit to the practitioners and the public, but with the disappearance of many dedicated osteopathic hospitals and related institutions.

Physicians were mostly in individual practices when I completed residency. Medicines were expensive and patients complained about their brand name prescriptions, but they did not have to exhaust a savings account.

I arrived as a physician, I retire as a provider. While the work has become more expert, the categories have become more generic. The expectations of the residents have changed—no more being on call every third night and having to work the next day.

It has created mixed results. A lot of experience was created during those nights, with the accountability that was required the next day at morning report, though at the expense of a physical battering and maybe some judgment impairment when admission No. 11 arrived (which is also no longer allowed).

The Next Beginning

As I exit this profession, I do not think that medicine as a professional experience is in a tailspin, as many colleagues of my era assess. Our laboratories are productive and new conditions and challenges are being met. We all want quality, and yesterday's travails become today's anecdotes.

As I step aside and my two children—both physicians—and my residents replace my generation, they retain a little of what we imprinted upon them. They may make a few quips about some of our folly and hubris as we did with our teachers and medical ancestors, but they will move the medical profession along into its next historical chapter, one that has been predictable over 4 years but notoriously unpredictable over forty.

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