Dr. Joseph Stubbs, 79M, chose to be a physician like his father, Wytch, 66M. The latter made house calls and could focus more exclusively on patient care, while his son has had to spend much more time dealing with issues of accounting and business management.

After completing medical school at Emory in 1966 and postgraduate training at Georgia Baptist Hospital, Wytch Stubbs hung out his shingle as a solo practitioner in DeKalb County. His practice grew by word of mouth, and he developed strong relationships with patients, basing medical decisions on what he thought was right. His practice was so successful that he was invited to become medical director of DeKalb Medical Center in 1988.

"It was such a pleasure to be in practice," Dr. Stubbs says. "You didn't have to be business-minded. I didn't even know what I made. A person in the front office handled that. Instead, I focused on learning and doing what I could for patients." Joseph Stubbs followed in his father's footsteps, earning a medical degree at Emory in 1979. But the younger Dr. Stubbs's practice hardly resembles that of his father.

Joe Stubbs is one of 27 doctors in a group practice extending from Albany to Tifton and Fitzgerald. While he still makes his own decisions about patient management, like most physicians today, he finds his judgment questioned more and more often.

"The things my dad taught me are still what's important in medicine: concentrating on helping people feel better rather than on the technological and pharmaceutical marvels as ends in themselves," says Dr. Stubbs. "The demands of patient care today are more complex now," he adds, "because we have to demonstrate value." The younger Dr. Stubbs spends considerable time on the business side of medicine, trying to grasp actuarial terms, cost-accrual accounting, and management issues.

The experiences of the Stubbses are not isolated examples of how medical practices have changed in the past 30 years. They represent typical patterns of a profession in flux.

Many physicians of the older generation declare the "golden age" of medicine to be over. Doctors now in training are entering the field with a new set of expectations. Perhaps the group hardest hit are physicians in mid-career, who chose the profession to be autonomous decision makers who could help people, but instead are finding their decisions and salaries curbed by outside market forces. "It is a challenging and frustrating time to be in medicine," says Dr. Wytch Stubbs. "The system is so chaotic and painful now for both patients and physicians, it will have to be replaced."

When President Lyndon Johnson proposed the creation of Medicare and Medicaid in 1965, the AMA opposed it, according to Dr. Rogers, because the plan was thought too expensive. "However, the President sold Congress on the idea," Dr. Rogers says. "And you know what happened. Costs began to rise."

In the late 1970s, "the AMA raised the flag about costs of medical care, but not much notice was taken," Dr. Rogers says. In 1973, Congress passed a law allowing the creation of HMOs as a cost-control measure. While managed care took the West Coast by storm, it came to the Southeast only relatively recently. "In the past ten years, it has marched right into Georgia," says Dr. Rogers.

The struggle physicians have with capitated care, says Dr. Rogers, is to be patient advocates in a system that encourages doctors to do less to save money. "You have to be vigilant, to watch yourself, to make sure you are doing enough," he says.

Overseeing capitated care plans requires a great deal of administrative time, with many physicians hiring extra workers just to handle these duties. Office expenses now cost physicians on average more than 60% of their gross earnings, with doctors joining together in groups to share these costs. "Doctors can't afford solo practice anymore," Dr. Rogers says. After fighting cancer and then shattering an elbow, Dr. Rogers has retired from private practice, although he continues to be active in the AMA to help physicians during this transitional time. He works with the AMA's Institute of Ethics, which deals with the ethical issues that capitation brings to the delivery of patient care. As a board member of the Medical Association of Georgia, he applies his 50 years of experience in medicine to statewide challenges as well.

"One thing is for sure," says Dr. Rogers. "With medical care now taking up 14% of the gross national product--some $1 trillion--we're going to have to do something or it's going to eat us alive. If we don't, we'll have no roads, no police, no services because we're paying for health care."

House calls today have gone the way of the solo practitioner. But they used to be an expected part of a physician's practice. In LaGrange, internist William Fackler, 44M, received $5 for each house call he made in 1950. His annual salary for the years after World War II averaged $3,300.

Dr. Fackler joined the Clark-Holder Clinic in LaGrange in the late 1940s as the sixth man in a group. "Ours was a typical format for practice in towns of this size," he says. "Our specialists treated sore throats and delivered babies. Because we all took turns on night call, everyone--pulmonologists, nephrologists, and cardiologists, not just internists--had to have experience in general medicine."

By the time he retired two years ago, Dr. Fackler had seen the clinic staff grow to 47 physicians, offering services in most specialties. After only three days of retirement, however, he was back in practice three days a week. Dr. Fackler also stays busy one day a week serving as preceptor to second-year medical students at Crawford Long Hospital.

Dr. Fackler's grandson, Keith Fackler, is now chief resident in internal medicine at Emory Hospital. "When I think about Keith, I think it's good he didn't get exposed to medicine in the good old days," says Dr. Fackler.

In four years of medical school and another three of residency training, Keith has seen dramatic change. "During my intern year, more than half my class was pursuing specialty training," he says. "By contrast, huge numbers are going into primary care now."

During his internship, Keith married Sondralyn McCard, then in her third year of medical school at Emory and today in her second year of a psychiatry residency. She too comes from a medical family. Her father, Ray McCard, 54Ox, 56C, has practiced psychiatry in Macon for more than 30 years. Both she and her husband considered careers other than medicine, and while neither regrets the decision to pursue medicine, they admit their expectations have changed.

"People are still finding good jobs with groups or on a faculty," says Dr. Sondralyn Fackler. "But there's much more uncertainty."

In looking to the future, both Facklers want to retain the ability to practice medicine the way they choose and be able to control patient care decisions.

They probably won't work as many weekends as their father and grandfather. (Recruiters now emphasize quality-of-life issues when trying to attract physicians to groups.) However, they won't be guaranteed the freedom enjoyed by the older generation either.

"Physicians are losing their autonomy," says Dr. Ray McCard. "Medicine was a cottage industry, where each of us was doing our own thing. I see it now as undergoing its own industrial revolution, based on assembly-line, bottom-line forces."

Not only the future careers but also the training of the younger doctors in this family differ remarkably from that of their grandfather and father. They have had more to learn in the same amount of time, and the cost of their education has skyrocketed compared with that of the earlier generations.

"Patients are confused about what procedures their insurance will pay for. They are unsure whether they have to call their primary doctor or not. They wonder, Am I doing what my insurance wants? To some extent," she says, "they are denied access to care that they could have had before managed care. For example, to see a dermatologist, they often have to be referred by another doctor. I don't see how the extra step saves money."

The biggest problem Dr. Meadors sees in the managed care approach to health care is the failure to address the issue of this country's uninsured. "This is one area where we have failed miserably as a society," she says.

Another frustration, she finds, is the increasing necessity of making ethical decisions based on economics. "Doctors in general are empathetic people. If a technology is available that we think will help a patient, we want to use it." But such decisions have to be based at least partly on cost. "Placing value on an individual life is hard," she says. "How do we decide a 40-year-old is more valuable than an 80-year-old, that we should spend more resources on a young adult than on a newborn? These are societal issues, not just issues for the medical community."

Dr. Joe Stubbs also expresses frustration at medical decision-making made increasingly complex by issues of technology and cost: "Now that technology has grown so much, we can no longer manage patients the old way. We need to draw on many different people with different skills to be able to consolidate all of the information now available."

The economics of managed care are also changing the basic nature of doctor-patient relationships. For example, Dr. Meadors' father, the late Dr. Garland Herndon, former head of the Woodruff Health Sciences Center, had a lifelong relationship with many of his patients (one of whom included Robert W. Woodruff). "Then, patients came to you because they wanted you in particular," Dr. Meadors says. "Now, they change physicians often because of economics."

"There is fear among doctors about whether their practice will be stable," adds Dr. Meadors. "Many can't predict what their income will be."

There also is growing distrust between physicians and hospitals, whose relationship used to be characterized as symbiotic, says Dr. Wytch Stubbs. "As hospitals have played an increasingly pivotal role in getting managed care contracts, physicians have become paranoid that hospitals eventually will make decisions that will hurt doctors as a group."

For 56 years, Dr. Denmark volunteered every Thursday at the Central Presbyterian Clinic in downtown Atlanta. On other days, she saw patients in the office in her Virginia-Highlands home, then later in a home office further out of the city near Sandy Springs. Twelve years ago, she moved to her current location in Alpharetta, where she now practices in a 150-year-old farmhouse on the property.

Dr. Denmark is unusual in that she never relied on her medical practice to support herself. "Mr. Denmark made the living," she says. She also never let her practice interfere with her family, arranging patients' schedules around feeding and nap times of her infant daughter.

Dr. Meadors, too, has shaped her career to accommodate raising children. "In the past, when women physicians started a family, they often stopped working," she says. "Now women want to continue to practice while they raise children."

Dr. Meadors switched specialities, from internal to emergency medicine, to allow more flexibility. She started an emergency medicine practice at Piedmont with two close women friends from medical school. Now the group is made up of 12 doctors, including nine women, who schedule their shifts around family and personal commitments.

Her and her colleagues' shift from internal medicine to emergency medicine serves as a gauge of the changes in medicine, Dr. Meadors says. The proportion of women in medical school classes is another gauge. When she entered medical school, she was one of only ten women out of a class of 110. Now, women make up half of those seeking medical degrees.

"The basic rewards of being a physician still exist," says Dr. Wytch Stubbs.

Although some physicians might advise their children differently, Dr. Joe Stubbs says he'd be delighted if any of his three daughters chose medicine.

Drs. William Fackler and Ray McCard feel the same way. "The public will always appreciate an honest, well-trained, and trustworthy doctor," says Dr. Fackler. When his daughter told him she had chosen to be a doctor rather than a diplomat, Dr. McCard replied, "I can't imagine doing anything else."

Dr. Meadors believes that "there is still a wonderful joy in medicine. Other than the ministry, it is the only profession where you can help someone every day. And you get paid to do it. Because of the immediacy of the problems we see in the emergency room, we can make a life-and-death difference to patients."

"Being a doctor is the greatest way in the world to earn a living," says Dr. Rogers. "Doctors are now headed into a different system of delivery of care, but they will still be doing good for people."

Dr. Denmark, who has been doctoring almost all her life, says simply, "Anything you want to do is play. Anything you don't want to do is work. I've never worked a day in my life."