The New Health Dialogue

This is a story I loved writing: a family with three generations of doctors (It appeared in the Washingtonian print edition over the summer, it’s now on the magazine web site.) It’s narrative, not Policy with a capital P, but the family story encompasses so much of what's happened in American medicine over the last half-century, good and bad, and a lot of what we need to keep in mind as we redesign our health care system for the future..

Joseph Ricotta was an old fashioned family doctor. He saw patients in an examining room in the back of his home right up until the day he died. His wife kept the books. His teenage kids did the filing. When his patients couldn’t pay cash, they offered him a chicken, or came over to mow the lawn.

His son, John Ricotta, is a vascular surgeon and chairman of surgery at Washington Hospital Center here in DC. His granddaughter Lise is an anesthesiologist, specializing in regional nerve blocks for orthopedic surgery. Grandson Joseph performs unbelievably intricate endovascular surgery at Mayo.

Their family’s story embodies the arc of modern American medicine over the last half century. It’s a tale of astonishing technical breakthroughs—from organ transplants to CT scans, antibiotics, chemotherapy, statins, and other treatments that save lives. The explosion of knowledge has been so rapid that, as the physicians in the Ricotta family say, the challenge now is to manage that knowledge, not memorize it.

American medicine since the mid-20th century has also become so specialized that care can be fragmented, adding to the costs and complications of chronic diseases. There are so many new treatments and drugs and protocols that doctors don’t always know which to use, when to use them, or whether to use them at all.

Patients have become “health-care consumers” and doctors are “providers,” a change in terminology that the Ricottas say reflects new assumptions about doctor omniscience and patient autonomy. Mom-and-pop businesses—with Pop practicing medicine and Mom keeping the books—have morphed into a $2.3-trillion health-care system. Today Mom is just as likely as Pop to be the doctor.

And while one in six Americans is uninsured, it’s hard to envision many patients in 2010 paying off a doctor’s bill with a bushel of tomatoes.

It took me a very very long time to find a family to profile (I needed at least some of them to be in and around DC). I heard about a family of dermatologists, but frankly I couldn't get that excited about three generations of skin. The Ricottas, in addition to being willing to talk quite openly with me, just touched on so many thought-provoking ideas. The trend toward generalist to specialists (to subspecialist), the fear of litigation, the role of women, the fragmentation of care, the technology,  changing expectations of doctors and patients, the uninsured. And while I didn't intentionally hold out for a Mayo affiliation, it was terrific that it turned out that way, because the integrated care at Mayo, and the relative cost-effectiveness for some of the country's best care, is one of the models for health reform. Plus, I lucked out when Joseph told me a story about his little boy, aged five, walking around carrying Daddy's black bag and talking about aortas. Maybe the fourth generation.