This is Archives Oral History interview number 31 with Dr. Brent M. Parker, member of the Washington University School of Medicine’s class of 1952. Dr. Parker is chief of staff at the University of Missouri-Columbia Medical Center. This interview was conducted on May 12th, 1977.
Dr. Parker, would you tell us a little bit about your childhood? I know your father [William B. Parker] was the Registrar for the medical school here at Washington University, but do you have any brothers or sisters?
I have one brother who is three years younger and he is Professor of Medicine at the Washington University School of Medicine at present. Some of my early recollections from when I was young are of visiting Dad in his office – I believe it’s now the Dean’s office or one of the administrative offices in the South Building of the medical school. I can recall going into the old area there which was near the current library. [ed. note: Dr. Parker probably is referring to the North Building.]
Was it because your father was associated with Washington University that you decided to attend here with the free tuition benefits?
The free tuition benefits were a very important incentive, I must say. On Dad’s salary it would have been a struggle to go anyplace else. And of course, we all knew that Washington University was an excellent institution, both for undergraduate and at the medical school level. So it worked out very well.
Were there any factors that you can recall that influenced you to go into medicine?
I think that Dad had always felt that his not having an M.D. degree was a real deficit in terms of working here. He saw the physicians and what they did and how interesting it was and how enthusiastic all of them were about what they were doing. I’m sure he influenced me somewhat. On the other hand, I was always interested in science; I had liked people and meeting people and felt that these factors would be very good in terms of medicine and a future career. In addition, I spent a time in the Navy Hospital Corps, doing work all the way from janitor to being an assistant nurse, I suppose you might say, and found the medical aspects of that very interesting. Since I was only eighteen when I did that – it was before medical school, of course – that also influenced me favorably toward going ahead with it.
Could you describe a little bit about your medical education as you recall it? Were there any professors that you feel, looking back, were really influential or top-notch professors?
There were certainly a number of professors who were top-notch. We had six lectures from Carl Cori, who won the Nobel Prize. Although he had somewhat of an accent and they were a little difficult to follow, they were very clear and very well-given. We did not see some of the really famous people a great deal. We did see Evarts Graham. I recall once when we were sitting in one of the old amphitheaters that had a pit down in the bottom and Graham had a patient down there and wanted a student to come down and examine the patient and picked my name, I guess at random, from the class list. So I had to go down – it almost looked like a stage – to examine this patient. I examined the abdomen and Graham made some comment when I finished to the effect that, “Parker you’re not examining your family,” as if I hadn’t done a very good job, which I’m sure I hadn’t.
Some of the people in Medicine that I recall very well and who gave brilliant lectures and brilliant rounds were Barry Wood and Carl Moore. John [R.] Smith was a cardiologist who later had a very important role in my career. John gave some lectures which were very famous in the classes then describing heart murmurs and heart sounds. He would imitate them, going “Lub-dub, lub-dub,” for the first and second heart sounds. John was dubbed as “Lub-dub Smith.” He really did a remarkable job in those lectures and in his Saturday noon clinics, which he rehearsed very, very carefully.
I think in many ways Barry Wood was the most stimulating teacher I ever saw. He had teaching rounds at the bedside which were unequaled and really was extremely good at bedside teaching and bringing out the pathophysiology of the disease and tying the patient’s symptoms to the aspects of the disease that were known about. I always felt it was somewhat of a tragedy when he left clinical medicine to go into administration full time some years later.
You mentioned John Smith and the impact that he had on your career. Could you describe that a little bit?
Well, later I was a fellow in Cardiology and did research with John.
Was that here?
That was here. And when I was on the faculty at Washington University for fourteen years he was my immediate boss, I suppose you might say. So I worked really very intimately with him for a number of years and became quite good friends with him.
Could you describe any differences that you see in medical education from, say, the late ’40s to early ’50s as opposed to the mid-’70s? This is twenty-five year [period] in which medical education [has changed] or [been] reformed.
It’s hard for me to say very much about the basic science years – the first two years – because I haven’t had any intimate contact with what’s being done in those years in recent years. But I think basically, in terms of the clinical teaching that it’s very similar. We continue – at least at Missouri and I think here also – continue to assign a student to a patient and the student then works that patient up and presents the patient to the house staff and to the attending physician at a conference or rounds, and basically it really hasn’t changed very much.
I think the broad aspects and what I consider perhaps the best of medical teaching haven’t changed, and that is the intimate patient contact, learning by doing, learning by reading about your patient. Because there’s just such a fantastic body of material that one has to master in medicine that nobody really can do it. You learn best when you have something to pin it to; a patient you can recall, or you’re stimulated to read about it. You really can’t possibly learn everything about all of the different aspects and specialties of medicine and retain it all.
How is it possible for professors to get across the developments in the last twenty-five years? Students today have to learn twenty-five years more information than you had available to you. How are the professors able to get that across?
I don’t think you can teach all the things that are known or have been learned in the last twenty-five years. I think you have to teach how the student can find that material, how he can use references, how he can find the articles or the textbooks or where he can find material when he’s confronted with something. It just isn’t possible to teach all of that. You really have to, I think, teach basic core material, which we’re trying to do, and then how to find the other material. I suppose you have to try to impart a feeling of the need to continue to learn, to look up problems but not try to memorize everything. What are facts now probably won’t be facts in ten years. Everything changes very rapidly.
I notice that some of the medical schools which are just starting out now are incorporating within their curriculum a lot more emphasis on the use of the social sciences and humanities. Do you think that this is positive trend, to expose the students not only to the biological aspect of man but also [to] his social and psychological aspect?
I think that makes sense. I’m not sure it’s really all that different than what was done when I was a student because there was a fair amount of emphasis on the humanities then, and we were encouraged to take as many courses as possible in the undergraduate years in those disciplines. But what you suggest is certainly true; that disease does not occur in a vacuum, that the patient’s background, the things that occur around him, the culture, all sorts of things impact on the disease and they’re all very important. I think that the better-rounded a physician is – the more he knows about people and society – the better citizen he is in general [and] the better physician.
You’ve gone from a private institution to a tax-supported institution. Do you see any difference in the quality of education there or do you think it’s basically the same? The fact that the tax-supported institution has to rely upon the people, their willingness to pay taxes, to support this institution whereas Washington University can rely more on its alumni or private foundations or _____(?).
We certainly don’t have the level of financial support that Washington University has and it affects what we do to some extent. It affects our physical facility which was built around 1956 and has not been altered to speak of in twenty-some odd years. It was probably only barely adequate when it was constructed; now it’s twenty-one years old and we have more patients in the hospital than it was designed for. Our support areas are certainly very short in space. So basically we have a physical facility that isn’t too good. And we also have problems in finances in terms of getting the equipment that we need.
Again we have a variety of problems at Missouri. Not all state schools may have them, but it started out as an indigent hospital where you sent indigent patients. That’s changed; we have some patients that pay but we still have a lot of patients who don’t pay and then the state doesn’t support those patients who don’t pay enough to really help us keep up with what we need. We’re tied in, of course, intimately with the University of Missouri system. We’re tied in at a period that higher education, in general at the state level and I think probably at the private level, too, is having increasing problems with funds to carry out the mission. Support for education seems to be considerably less popular than it was a decade ago. So we’re having some problems, no question about it.
What was your position when you were here on the faculty at Washington University?
I was in Cardiology; I was an associate professor of Medicine in Cardiology, director of the Adult Cardiac Catheterization Unit and consulted for the thoracic surgeons. I did a lot of clinical cardiology. I started out in 1959 when I came back here, trying to do research, and seeing patients and doing catheterizations. But as the clinical load grew, our staff didn’t grow to keep up with it and time for research became less and less. I suppose my reputation, if there was any, grew in the area of clinical medicine. I was busier and busier in that area and found I was spending ten hours or more a day seeing patients and that didn’t leave much time for useful research.
Did the move to the University of Missouri provide for additional time for research?
By that time I’d decided I really didn’t feel that I was going to be able to do significant research. I have done some research there, but not bench or basic research. I think you really have to do that about 50 or 60 or more percent of your time to be doing very significant work. The move to Missouri really was to go into an atmosphere where I felt teaching and patient care were first-class activities. I don’t mean to criticize Washington U., but in my department I always felt that research was the field or the activity which was considered most highly, and if you were really a first-class citizen you were doing good research. I was caught in a situation, I suppose you might say, where I was spending more and more time seeing patients and teaching, which I thought were very important. But I wasn’t sure that the rest of the faculty felt were very important.
At Missouri that activity is obviously more important. I’ve had two teaching awards since I’ve been up there and I suppose, because of my clinical activities, I was asked to be chief of staff just a few months ago.
Do think that the philosophy of the medical school here at Washington University is one that encourages research and passes that on to their students as opposed to passing on the idea of being the general practitioner or the family doctor?
I think there is some tendency to push research here, and probably, if one does medical practice, to push specialty practice and perhaps not primary care. And that’s not bad; I wouldn’t criticize that because I think research is terribly important and somebody needs to be doing it. Not everybody should or can, but I think some institutions need to have that as a very major emphasis. It’s interesting, though – even when I was in school – the research emphasis was there, and the specialty emphasis, but a fair number of my classmates ended up in primary care and in small towns in Missouri in private practice. So I think that you can have an emphasis in the school but what people do is still their own private decision. Most people do what they really want to do.
There was an article in the Post-Dispatch one Sunday a couple of months ago comparing St. Louis University’s medical school with this one. It was stated that St. Louis University’s philosophy is more of training the students to be the doctor, the one that goes to treat the patients, whereas Washington University is training the student to be the researcher.
That’s partly true, but I have to say, in all honesty, that I think the students that finished at Washington U. when I was in school and when I was on the faculty, had good training in clinical medicine and many of them turned out to be outstanding clinicians. I think probably one of the advantages we had at Washington [University] was that we had very good people – very good students, very bright and very capable, and if they wanted to do something they could do it very well.
Since you’re in the University [of Missouri] medical school now, do you think that students today are faced with any more problems, more difficult problems, in their medical education than you had faced during the early ’50s or do you think it’s about the same?
They clearly have more material to try to master. I suspect that in the basic science years – the first two years of medical school – that it may be even more difficult to relate some of the fancy new science that is coming along and which is very important to patients. That’s always, of course, been a problem in medical schools: the seeming lack of correlation of the first two years and taking care of patients. So there is a lot of material, and some of it doesn’t seem very relevant. I don’t think in the clinical years that there are very different problems; again, more material, perhaps, but other than that I’m not sure there’s any tremendous change. At least I don’t think of any. Clearly, what they face though, when they go out into practice, is some very striking change.
Thank you for talking about practice. I was wondering if you’d be able to describe any current problems of medical practice such as malpractice insurance, which seems to be a hot issue today, Medicare, euthanasia versus the life-supporting equipment – whether the person should be kept plugged into the machine or whether it’s ethical or legal to pull out the plug. Could you talk on some of these problems?
Let’s start on malpractice and try to talk a little bit about each of them. Malpractice is becoming an increasing problem and even Missouri, which hasn’t been a very litigious state, is having increasing numbers of suits. We’ve found at Missouri [University] that our commercial carrier is pulling out. They had been charging what we thought were exorbitant rates, and now are pulling out entirely and [we] are seriously considering going to self insurance, which I believe was done here a year or so ago. In other words, we will pay a certain amount of money, the physician part and the hospital part to insure ourselves with our own money.
I’m not sure why we’re having more malpractice problems. Part of it, I suppose, is the expectation that the result will always be good when clearly it just can’t be. Clearly there are diseases and processes and problems in medical treatment that will prevent the result from always being good. The expectation of many patients is that it will always be good and that leads to real problems.
I suppose our increasingly technically-oriented medical system may also be a problem. That is, some physicians [and] some ancillary personnel are very oriented toward computers and all the lab tests that are ordered and not very oriented toward talking to the patient and spending time with the patient. Many of the problems, I think, relate to that dissatisfaction. The patient feels, “The doctor doesn’t spend any time with me, he doesn’t talk to me, so I don’t think he’s giving me anything for my money.” Then when the result isn’t good they say, “Well that result is because the doctor didn’t care and he wasn’t supervising.” So these are problems. I notice that the Washington U. self-insurance program sent out a little blurb to the physicians which indicated that the physician should treat the patient as a friend. I think that is part of the key – to keep good rapport with the patients, let them know what’s going on, let them be a partner in the decision-making. And if the result is bad but they’ve been a partner in the decision and were informed when they helped make that decision, then they don’t have any real kick coming.
Although it might be rather dangerous, do you think that there is anything the government could do to intervene? Could the AMA and the Congress sit down and try to write a law that would try to protect doctors?
There have been a variety of laws which have been tried. There have been laws that attempted to put a cap on the total amount that could be sued for, [and] a variety of other laws which, I think, have shortened the period between an incident and the time the claim could be filed. Many of these laws have been ruled unconstitutional by state and the national Supreme Courts, so they haven’t been a very good solution. I don’t know what will come out of this in the long run, but I think it’s important for the public to realize that malpractice is costing every patient, anybody who is sick, money every time they see the doctor, every time they go into the hospital. So I figure that malpractice costs them in one hospital over $9.00 a day per patient. If the public says, “Hey, look at this. Doctors are running extra tests because they’re afraid of malpractice. They’re maybe not doing some tests that have some risk, that might have been beneficial. And look at the cost that the doctor has to put into his fee and look what the hospital is doing.” If the public comes to this realization, then I think the problem may scale down. Probably the eventual solution is some kind of impartial board which would award people who legitimately are wronged some moderate amount of money to cover their expenses and suffering, but to cut down [on] frivolous claims and cut down the tremendous overpayment on certain types of claims.
Do you think the rise in malpractice cases is going to affect the number of students who go into medical school as well as the number of doctors who are currently practicing to quit their practice?
I think it certainly is true that some doctors in practice have either gotten out of practice or done something different – gone into salaried positions where the risk was less. I don’t know whether this is going to influence people going into medicine or not. There are a number of potential clouds on the horizon as far as I’m concerned in terms of medical practice in the next ten or twenty years that should give people some pause for thought, at least. Some cause for thought. But we still see large numbers of students applying to medical school. We see large numbers of Americans who go to Guadalajara and places like that because they can’t get into American schools. So the profession still seems to be very attractive to the young people. Perhaps they don’t see some of the clouds on the horizon that I see and perhaps other people see.
You’ve mentioned Medicare. I don’t think that Medicare, per se, is particularly bad. It’s true that the government usually doesn’t reimburse the physician and hospital for their total costs, or at least what they think their total costs or fees should be, but it has provided a large group of patients with better medical care, perhaps, for certainly considerably less out-of-pocket expense for the older, aged patients. But Medicare, I think, is symptomatic of an increasing problem that’s coming into the profession, that is, increasing control by outside agencies. The amount of red tape that’s already present in terms of papers to fill out, restrictions on the hospitals and what they can do and on the physician – perhaps to a lesser extent – on what he can do, are really becoming very large. I think this will almost surely continue.
We’re now being told, for instance, in hospitals that probably we’re not going to be able to increase our income next year more than 9 or 10 percent. We’re told that we have to check patients for the length of stay in the hospital and make sure the admission is justified and the PSRO-type activities. This takes physicians’ time; it’s a fairly difficult, onerous task, at least many physicians consider it such. I think these are symptomatic of the sorts of things that are coming, and if we get national health insurance I think we can almost surely predict there will be more of this. The government will be making efforts to hold down costs; there will be a number of restrictions in what can be done in terms of medical practice, charges, length of stay in the hospital. We have medical audits now. Now all of these things sound good, of course – you should audit yourselves; make sure that everybody is getting good care.
With hypertension – let’s say a patient has hypertension and he’s admitted to the hospital. Then there are certain things that you can do. The government spells it out and you audit to see if this is done. This is really cookbook medicine; I don’t personally think it necessarily will be very good medicine. I think the physician will become more and more of a technician and less and less of a thinker as the increasing government controls come in.
Talking about government control, just recently President Carter recommended, I think, that hospitals not be allowed to increase their prices within a year more than 9 percent. Do you think that will pass? Do you think the AMA is going to be out lobbying?
The AMA is already lobbying against it, and the hospital associations. I read in the paper last night that they’re now talking about 10.2 percent. I think Califano [ed. note: Joseph A. Califano, secretary of Health, Education, and Welfare under President Jimmy Carter] mentioned that. It’s really frightened our hospital administrator. Probably what’s going to happen at the University of Missouri, at least, is that we already probably have a 7 percent salary increase which was mandated by the University. The [increase in] cost of supplies and other things that we have to buy is more than 7 percent and basically if the 9 percent or 10 percent gap goes through we’ll have no money to do anything different or new. We’ll just be able to pay the increased salaries and increased cost of the supplies and won’t be able to expand programs. I suppose this wouldn’t be so bad if you were at Barnes Hospital where you had most of the things you need and fancy new equipment. But if you’re trying to catch up and trying to get new, fancy equipment than it’s not nearly as good. I think that’s probably the state where we are at Missouri. So he’s very, very unhappy about the prospects. And I think practically all hospital administrators, as best I can read, are unhappy about the prospect.
Now for the question on euthanasia versus life-supporting equipment.
This sort of problem is really posing terrible quandaries for physicians. I’ve never felt that the profession should do everything it knows how to do for every patient. That sounds callous. What I mean is that clearly when a patient comes in with advanced carcinoma there are many times when you’re better off to give them something to make them comfortable and not do all sorts of expensive, painful tests to keep things going for another week or two and run up a hospital bill by another several thousand dollars. I feel very strongly that a patient who is dead – who has brain death on the electroencephalogram – should not be maintained and that life should be allowed to end. As far as I’m concerned, it’s already ended, and I personally would not feel that pulling out a plug on such a patient is euthanasia. If the patient is essentially dead for all intents and purposes, has no chance for having a useful life in the future, then pulling out the plug is not euthanasia. That’s my personal bias. We have, of course, enthusiastic young residents and students who, I think perhaps, order too many tests on old people, patients who are really very elderly. And they’re put through difficult tests; I think sometimes the benefits gained are rather minimal. This is an area that, I think, requires a lot of maturity, a lot of decision-making ability. You need to work in conjunction with the family, frequently. I think about the Karen Quinlan case, when the family did not want that to go on and physicians refused to accede. I think that was clearly very unwise on the part of the physicians.
I don’t know if you read about the incident that was in the Post-Dispatch last Wednesday, but a young man from Boston was being accused of murder and it’s his defense that if the guy had still been hooked up to the machine, the guy – the victim – would not have died and therefore the defense would not have been brought to court for murder. How do you resolve something like that? Because that is getting into the legal problems of saying, “I’m going to pull the plug and it may result in someone going to jail for thirty-forty years,” or, “I’m going to keep the patient hooked up to the machine just so this guy doesn’t go to jail.”
You mean somebody had done something to this patient?
I think the young man had shot the patient – the victim. I think the only way this victim was kept alive was by being hooked up to a machine. Someone [the doctor?] pulled the plug, because for all practical purposes he was dead; there was no sign on the EEG machine that there was any life left. And so they felt that he was dead. Now the defense is coming back and saying, “If he had been kept hooked up to the machine he would be still living and therefore I would not be brought to court.”
It’s a stupid defense.
You don’t think he has anything to stand on?
No, because basically he had already killed that person. That person was finished in terms of useful life and was really not functioning at all as a human being. And basically, that person was dead. If they buy that, if the jury or the judge buys that, I’ll be very disappointed. That’s a very frivolous sort of argument.
I have one more question and that is: what is your philosophy as a physician and has it changed over the years? In other words, did you start out with, say, a lot of high-powered goals or goals that you see now that were unrealistic and were quickly shattered, or do you think that your philosophy basically has stayed the same?
I don’t think it’s changed very much and I hope – it’s hard remembering back twenty-five years – but I hope my philosophy was that I always wanted to do the best job I possibly could for this human being who was asking me to help him. And basically I think that has to always be the philosophy of the physician. We are physicians, we have a profession only for one reason and that’s to take care of sick patients. That’s really true in the medical school, where you have a medical school only for one reason and that is to turn out doctors who will take care of sick patients. So everything has to focus back on the patient. My philosophy is now, and I think it always has been, that my job is to try to do the best possible job I can to make the patient well, or as much better as possible. To treat the patient kindly, to treat the patient in the way I myself would wish to be treated if I were in the position of the patient. I think that is to me the key of being a physician, a successful physician.
Do you have anything else to add that you think would important or that you would just like to put on tape?
I guess a few comments about memorable experiences while I was in medical school. I recall, for instance, eating hamburgers after working in the anatomy lab. We’d go over to the Phi Beta house. Shirley Ruggieri would have interesting, nice hamburgers, but our hands just reeked of the formaldehyde that we had gotten on them in the laboratory, and it was really quite difficult. And I recall going on the bus some evenings – I had to take the bus back and forth to medical school a fair amount of the time – and wondering how people thought I smelled with all the formaldehyde on me.
I recall George Oliver and I went to see our first patient – this was in sophomore Physical Diagnosis. We went down to City Hospital and the patient must have been engaging in a feces fight with another patient because there was feces all over the patient and all over the place. It was a rather interesting start in clinical medicine for us.
Then I recall George, my brother [Charles] and I delivering a baby together. I was a senior student and he was a junior student. I was thinking to myself, “This is a pretty inept team for delivering a baby.” Fortunately, it was accomplished all right and nothing particular happened.
Then, when we were freshmen, there was the Rutledge case. You probably haven’t ever heard of the Rutledge case, but poor Dr. Rutledge was a brilliant student here and was, I guess, the first winner of the Student Research Award. But he had problems – it’s a complicated story. His wife left him. He was a very emotional person and he found his wife with another man and attacked the man and castrated him, literally. This was then brought to court. It was right while we were all freshmen and it was just all over the papers and very, very messy and difficult. And we had long conversations about what should be done in such a situation. Dr. Rutledge later committed suicide after some time in jail.
Those are some of the things I remember. It was a good four years. I can recall as a freshman, going home each night and as soon as dinner was over setting up at the dining room table and having my books spread out all over the place and studying, usually at least five or six hours, and going to bed very, very tired. It was hard work, but I think I wouldn’t change it – it was all worth it.
Anything else that you want to add?
I don’t think there’s anything.
Thank you very much.
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