Primary Care in 1940

“Okay, Curmudge, who cares about health care in 1940, and what does it have to do with Lean?”

“In 1940, Jaded Julie, I cared a lot. And the Toyota Production System had not yet been invented, so we won’t talk about Lean until later.”

“Proceed with your ancient history, Curmudge. I’ll just sit here in wide-eyed amazement.”

“I grew up in a small town with a population of about 2,500. We had one law enforcement officer, Marshal Bill Arnold, and one physician, Dr. Russell Arnold (no relation). Bill Arnold was the first responder for everything. When one had a minor illness or injury, they would call Bill; he would jump on his motorcycle and ride over to apply first aid. If the patient had to be transported to the hospital 10 miles away, he would summon the local undertaker with his hearse. Bill also responded to all fire calls. If the fire were serious, Bill would call Ted Kekic, who would get the town’s fire truck out of his barn.”

“It sounds as if your town lived life in the slow lane.”

“Regrettably that’s true Julie, even if your house was burning down. Dr. Arnold’s medical practice was also typical of the age. His office was in the basement of his home, his wife was his nurse and bookkeeper, and office hours were from 2:00 to 4:00 every afternoon. He did not have appointments; everyone had to sit and wait their turn. The wait was not usually very long, because he asked people requiring minor surgery, like me with an ingrown toenail, to arrive around 4:00. Dr. Arnold had only one exam room; and as a kid, I always wondered what the stirrups were for at the end of the examination table.”

“It seems that in those days primary care medicine wasn’t very complex, Curmudge. No receptionist, no laboratory, no radiology, no Medicare, no insurance, almost no referrals to specialists, and one nurse who was rarely needed.”

“That’s it, Julie. I never saw Dr. Arnold write anything, so he must have kept everyone’s records in his head. I guess he knew everybody in town, literally outside and inside. His bills would show only two items, numbers of house calls and numbers of office visits. Years later in 1978, my mother died suddenly. It was Dr. Arnold who called at 2:00 a.m. to tell me. He had arrived at my parents’ house only moments after the 911 EMTs. That was the ultimate in personalized care.”

“It sounds as if Dr. Arnold was exceptional…an early model for Marcus Welby, MD.”

“Well sort of, but back then most doctors were family physicians in a solo practice and on call 24/7. It took an exceptional person to live that way. In 1940 primary care was, by far, the major part of the health care delivery system. If your physician was clinically competent and had a good so-called ‘bedside manner,’ you had a favorable patient experience. That was especially true if you were lucky enough to get well. As I recall, personalized care was the norm.”

‘Speaking of personalized care, did Dr. Arnold meet all of the attributes of personalized care in our Affinity Brand Promise (1)?”

“Some of the attributes would have been different back then, especially for me, a six-year-old child. Dr. Arnold could not have known me better. Except for the surgeon who took out my tonsils, he was my only doctor from the moment I was born until I left home to go to college. In that era, partnering with one’s physician in decision-making was rare because he was the only one with access to health care knowledge. He always spent enough time with me to handle my problems, but frankly, as a kid I couldn’t wait to get out of the office. Thinking back, our doctor’s outstanding attributes were his willingness to make house calls and the depth of our personal friendship. He was always there when we needed him.”

“You seem to be suggesting, Curmudge, that despite the complexity of modern medicine, primary care physicians should try to duplicate the feeling of personalized care that you experienced in 1940.”

“Actually, Julie, I suspect that because of the complexity of modern medicine, what I experienced will rarely be achieved today by a primary care physician in a solo practice with his wife as both nurse and bookkeeper.”

“So, senescent sage, how can physicians today achieve this elusive personalized care?”

“I’ll conjure up a vision, Julie, and share it with you in a week or two.”

Affinity’s Kaizen Curmudgeon

(1) Kaizen Curmudgeon. The 5P Pyramid. Posted April 2, 2009.