University of Miami Miller School of Medicine
A VISION OF HEALTH CARE THROUGH THE LOOKING GLASS
"The time has come," the Walrus said,
Most of you recognize the title of this talk. I would like to take us for a view through the Looking Glass of Health by addressing a series of issues from the past to the present with a view of the future. This is no string of pearls although I hope at least that you will see the string. I tried to reach out to many constituencies in preparing this talk. As a result I know I have violated one of the primary rules for a lecturer, that is the rule of KISS (Keep It Simple Stupid). This is not a simple talk. It will cover a wide range of topics and like Lewis Carroll's work, some of it may seem nonsensical but I hope that in the end, have value.
In the aftermath of 9-11, we have new challenges and responsibilities, but the old ones still demand our attention if we are to leave this world a better place than we found it.
As Santana has pointed out, those who do not study history are condemned to repeat it. With this in mind, let me describe just a few trends that are shaping medicine and healthcare today. These issues, which have emerged over the past few decades, are shaping not only medicine but society itself.
And finally, last but not least in this abbreviated list, we have
We are thanatophobic, i.e. fearful of death, but the desire for longevity is qualified by quality of life issues including independence, freedom from pain, maintenance of cognitive ability, and so on. Medicine has evolved to fill this social need. Through the millennia, we have made considerable progress, but with each success there have been failures, and the contrast between advances in the art and science of medicine and the failure of medicine as a system of universal caring has become more and more vexing.
Medicine has evolved from what I believe are 3 basic traditions: the organ focused, the humoral and the spiritual. These still exist. Early Homo sapiens learned to get splinters out of fingers, treat spear wounds from unfriendly strangers, amputate and cauterize, deliver babies by caesarean and about anatomy and blood circulation. The organ tradition has evolved to contemporary surgical disciplines, with specialties ranging from brain to ano-rectal surgery, and parts in between.
Increasing knowledge and stewardship of specific body parts has lead to specialties, sub-specialties and sub sub-specialties. At our Bascom Palmer, one of the world's premiere eye facilities, we are specialized as to front, middle and back of the eye, not yet left and right eye however. We now have miracles of transplantation and vascular microsurgery. As a society we appreciate the work of organists and reward them handsomely, or at least more handsomely than we do other medical disciplines, which leads me to the humorists.
Humoralists - that is, on the Greek island of Kos, you can still visit the ancient Temple of Aesculapius and its fountain of life in the hills. Patients came to the plains below, were examined by the priest-healers, waited for days or weeks and were eventually selected to ascend to the Temple and drink of the fountain to be cured. Of course, by then, the survival curve was pretty good anyway. Meanwhile, Hippocrates sat near the coast under his plane tree and taught about the 4 humors: (sanguine, melancholic, choleric and phlegm), produced by glands which needed to be balanced for good health. Later on we worried about the miasmas from the swamps and lowlands, which could carry fever, and about nutritional deficiencies.
From balancing humors to understanding and balancing body chemistry, physiology and pharmacology, humoral practitioners evolved to various branches of internal medicine, including those in small packages now called pediatrics, old humors as in geriatrics, or with particular humoral in-balances e.g. diabetes. Now when humorists act like organists, their relative economic value skyrockets. A GI specialist earns several times more per minute by passing a tube through either end of the alimentary canal than he/she would by helping a patient with diet, stress or lifestyle or in prescribing appropriate medications. The same with cardiologists, pulmonologists, etc. Putting it differently, payors, those who pay for care, seem to value technical procedures above what is termed cognitive medicine - the thoughtful evaluation of the patient's condition and needed treatment.
Health has always had a moral aspect to it. Poor health is seen by many as the result of a curse, the evil eye or a punishment for the sins committed by an individual, according to some biblical themes, going back up to 4 generations. Ill health, particularly some diseases, carried with them particular stigma for a time. Syphilis, tuberculosis, cancer and AIDS are among these. In some cultures twins are a sign of evil, and in some societies today we see the widespread use of fetal imaging and abortion lest the family be burdened by a girl. Indeed, in some countries women commit suicide because of failure to deliver a male to the family, despite the fact that it is the sperm which actually determines sex at fertilization.
Clearly, beliefs play a powerful role in medicine and not just in other cultures. All I have to do is mention stem cell research to alert you to that interplay. Mary Tyler Moore, speaking for the childhood Diabetes Foundation, praised President Bush following his August 9th statement on limited stem cell studies, because his decision affecting basic bio-medical research was based "on deeply held religious beliefs".
Aaron Antonofsky, the famous medical sociologist, has pointed out in his book on Stress Health and Disease that to reduce stress, humans need to reduce ambiguity in their lives and find an explanation, be it scientific, technologic, political or divine. It is no surprise therefore, that early physicians were priests and that the care of the sick is a virtuous precept in most religions. This is a background for the spiritual branch of medicine.
In the Egypt of the Pharaohs, trepanation, that is, the opening of the skull to let the evil spirits out, was a valued practice. Internalized evil spirits were seen as the principal cause for abnormal behavior. When morbid sadness occurred, perhaps it was an excess of black bile, i.e. melancholy, the humoral basis for depression. The bad blood needed to be let out, but bleeding and leeches didn't help depression, nor virtually any other medical condition, so we worked hard to find ways to get the devil out of the body. We "Beat the Hell" out of mentally ill patients or dipped them into wells to "Scare the Hell" out of them.
We kept them away from the general public in basements, closets, jails or asylums. Indeed one such asylum, St. Mary of Bethlehem in London, was so well known that its name was abbreviated to the single English word Bedlam. We chained patients and charged money for public visits to the "Looney Bin". Only when it was discovered that the bizarre behavior of general paresis was the tertiary stage of an infection, syphilis, did we focus our attention on the brain as opposed to the soul of the psychiatric patient. Now spiritual medicine, with a base in neurosciences, has evolved to psychiatry and neurology and the treatment of disorders of brain, mind and behavior. Behavioral, social and biologic sciences have led to improved diagnosis and treatment, including medications, as well as psychological therapies, which have considerable clinical effectiveness.
Still, the stigmatization of the psychiatric patient persists and the use of jails or the street, rather than hospitals, to care for such people is a widespread policy, today in Florida, as in many other states. Care for mentally and emotionally impaired patients remains discriminated against widely. And perhaps this has been a significant barrier to bringing psychiatric principles to other aspects of healthcare.
It is noteworthy that science and technology are trying to do what thoughtful minds for centuries have been advocating, namely, creating bridges between the chasms that have separated those organ, humoral and spiritual approaches. Yet a fourth area of medicine has emerged, largely in our time. Biomedical advances have resulted in a focus on technology, initially as an adjunct and increasingly as a branch of medicine in its own right. From x-ray and EKG support, we now have technologic advances that can give us a functional image of virtually any part of the body and enable surgery without a scalpel. We can identify lesions in brain activity which are not even visible under a microscope. The Hollywood movie, which shrunk a spaceship so that it could be injected into the bloodstream of a VIP for the purpose of treating a brain lesion, may be remote in reality, but miniaturization has already reached the point where a unit the size of a capsule can be swallowed to visualize, ultimately, the entire gastrointestinal system.
We are indeed technophilic, i.e. we love technology, and the wondrous new technology has pushed us to buy costly equipment for every hospital and some physicians' offices as well. This inevitably leads to a major issue: the cost of healthcare and healthcare as a business.
Health, which includes medicine, is a major economic facet of our society. When health care costs became 10% of the GNP, business leaders became alarmed. More dollars were reported as going into the cost of an auto worker's health care than was spent in paying for the cost of steel in the average car (according to Califano, former secretary of HEW/Detroit auto industry).
Medicine remained focused on medicine, that is the diagnosis and care of individual patients. But, as health costs rose, business felt that its ability to compete in the emerging global economy was being compromised and employee costs needed to be constrained. Governments, federal and state alike, facing deficits recognized that Medicare and Medicaid were A) even more successful for people than its supporters predicted, and B) even more costly than its enemies warned. In addition to the costs we have mentioned, there is the cost of raising capital, the cost of compliance with regulatory agencies, the expanding need for indigent care, as well as the costs of recovering costs from potentially thousands of different payors added to the economic burden.
Let me take us on a side trip for a moment. Over the past few decades, the information revolution has allowed for the development of the virtual corporation. As an example, take a corporation with headquarters in New York, London or Paris. It is well known, perhaps as a maker of clothing. Now outside designers are contracted to do designs, someone else is hired to do the pattern, a piecework firm in Asia or Mexico is contracted to cut and sew the garments and add the company label, a shipping company is contracted to move the merchandise, a sales group sells on commission and arranges for delivery by sending information to a systems manager who organizes production and delivery to minimize warehousing and drop ship to customers as needed. But the company itself no longer actually manufactures anything - it has become a virtual manufacturer, which orchestrates the production and has its label put on a garment by a factory which next month might be producing something for a competitor. The company, of course, is interested in the lowest costs, as is the consumer, with the corporate motive the quintessential business ethic, i.e., to make a profit - the more the better.
Today's health care is being increasingly run by virtual corporations. They contract with the payors, entities which pay for employee health benefits. Then they contract with providers, including doctors and hospitals. The threat of moving the patients contracted to them, to other providers, is a strong economic engine to drive down costs. These management companies organize to deliver care at a price and to generate a profit. Even not for profit corporations need to earn enough to exceed costs.
A decade ago, at a Phi Beta Kappa lecture at our Coral Gables campus, I proposed that medicine was undergoing a version of the industrial revolution. We were evolving from a cottage industry to an assembly line approach toward medical care. Please be clear that assembly lines are not bad - most of what we wear, what we drive, how we communicate is the product of mass production, and we could not afford it otherwise, but there are negatives. Does one size fit all? In autos, perhaps - Henry Ford was claimed to have said you can buy a Model T in any color provided it was black. Some clothes have one size (teens all seem to wear xxx large). I suspect we would all like to buy "bespoke clothes" i.e. tailor made individual garments, but these come at prices most of us can't afford.
Who now decides on how an individual's health care will be formulated and delivered? In the past, physicians with agreement by the patient - the famous doctor/patient relationship. Tests were done and specialists called in, as recommended. With the patient's approval and pocketbook, the workup, tests, treatment, etc was tailor made for each patient, but with insurance companies or governments paying the bill. Over time, for the reasons I've suggested, payors objected to this approach and condemned it as giving everyone a Cadillac when they only need a Ford or a Honda. Who now decides what is the best care? Well, it's the golden rule … he who has the gold, rules.
Once money became the focus, it was inevitable that things would change, and with so much money in health care there was money to be made. The new health entrepreneur recognized the value of an organization to deliver care, at a reduced and fixed cost, to employers. For business, the prospect of contracting to save money is appealing if it reduces expenses, increases the profit line or protects against losses. Quality of healthcare is hard to define and measure and soon became subservient to money.
In balance, it must be noted that under fee-for-service healthcare there is no incentive for the provider to prevent illness - visits were from patients already sick and needing treatment and that's what the fee was about.
Given our traditions, we physicians remained concerned principally with the organs, humors, spirits and technology associated with individual care - not the population, nor the cost. Under an HMO strategy, we move away from the individual and serve the group. The payment is not made for taking care of a sick person, it's a monthly payment to a physician or group which keeps people healthy and hopefully avoids a referral to a costly specialist. In the early version of such plans, the primary care physician suffered an economic disincentive for making a referral. Under pressure this has changed somewhat, but the concept of managed care -- a system to organize care by managing it, to save money, using the HMO model -- has become widespread. A variety of other restrictions were applied in managed care initially, ranging from ½ day hospital stays for child birth to restricted or no access to the physician of ones choice, or a controlled medication plan, or pre-approval for certain tests. These organizations have the legal right not to renew a physician's contract, if he or she criticized the plan or alerted patients to treatments not covered or used specialists too much, or whatever. They were gone. Managed care meant and means just that, someone manages the physician in the provision of care to the patient.
Just as the steam engine powered the industrial revolution and we moved from a landed aristocracy to an aristocracy of entrepreneurs, clinicians lost control of patient care to the care manager - or the management company, many of which now control the care of millions of people. Changes have been made under public pressures and lawsuits. Political action arose over ½ day hospitalization for birthing and lawsuits over denial of treatments. Now there are over 1000 pieces of suggested regulations proposed in various state legislatures to address managed care abuses, and a patients Bill of Rights is in political play.
Of major concern however is the nature of the law which shields the managed care companies from being sued. While physicians remain vulnerable to malpractice for withholding care (albeit expensive), the company responsible for rejecting the claim is protected by its contractual relationship, and suing them is difficult.
What has this to do with my earlier comments on organic, humoral, and spiritual medicine? A considerable amount. Organic medicine is the most technology driven, but traditionally the best accepted. Procedures are easy to count. We have after all a limited number of organs. How many times can we take out an appendix or a prostate or gall bladder or bypass an artery. Sometimes of course the answer is more than once, but it is not open ended and the procedures themselves are defined. Accountants hate open ended expenses. So if the surgery is deemed to be needed, the price can be negotiated for the doctor and the hospital, often as a flat fee to include a defined follow up.
Humoral medicine is more complicated, but many diseases are curable and limited in duration, and, in the case of growing chronic illnesses, some companies use nurse consultants or primary care M.D.'s with specialist backup to manage the care. Technology, if it's pre-approved, is usually a no-brainer, though debates emerge. For example, how often is a mammogram or a colonoscopy indicated?
Our third area of medicine comes in for special attention by managed care primarily because of its lack of attention. Last year the Surgeon General of the United States reported: "Few families in the United States are untouched by mental illness". By conservative estimate, more than 1 in 5 Americans (21%) suffers from some form of mental illness.
The Surgeon General's best estimate of diagnosable mental illness involves 44 million people, with 19% of all Americans having mental illness alone, another 3% with a dual diagnosis and 6% with addictive disorders. So we have about 30% of the United States population with mental or addictive disorders, almost 1 in 3, and that number does not include stress or intensified pain or widespread anxiety or fear such as that occurring after September 11th. About 5.4% of all adults have a serious mental illness known to interfere with crucial aspects of their lives like work or parenting, and for half of these (2.6%) their illness is severe and persistent.
For children, about 21% have an emotional problem and about 10.3% have a serious disruptive disorder. That means that in Miami Dade and Broward, in a classroom of 30 children, 3 have a serious disruptive disorders, while 1 out of 5 kids overall have a serious emotional problem.
The spin off of mental illness can be enormous. In a study we are now conducting, an average of more than 1 child per month has been killed in Florida by an emotionally disturbed parent over the last 4 ½ years. The mentally ill die earlier, for a variety of medical reasons, as well as personal and institutional neglect and a very high suicide rate for these people who are in terrible emotional pain.
For those of us over 55, I forgot to mention that these data did not include 2 other factors. One is Alzheimer's disease, which is overall a 4% problem over age 65,but growing with the aging of the population, roughly doubling with every five years of life past 65. And the most frequent problem, depression with its associated suicide. Depression in late life is poorly recognized because it seems marked by physical illness, pain, loss of loved ones and isolation. Suffice it to say about 17%-21% of all older persons living in the community experience depression. Suicide among white males is over 6 times more prevalent beyond age 65, and homicide/suicide, while still relatively infrequent, is a growing phenomenon among couples in Southern Florida, more than doubling over the past 7 years.
Why have I emphasized these mental health data? After all, heart disease and cancer are principal causes of death. But then again, it should be noted with pride that in Dade County, a host of private fund raising groups help support cancer research and treatment, with foundations helping diabetes and Parkinson. But mental illness, which affects a third of all Americans and is identified by the WHO as the 2nd most serious medical problem in the world, receives virtually no private support, is in crisis, and that crisis, which existed before, is deepening. Some more mental health data, since I believe strongly that as we have often seen in the past, the current care of mental illness is a precursor of things to come to other branches of medicine, particularly in the vanguard of caring - what is often called Hi Touch as opposed to Hi Tech. I mean simply the quality of patient caring in medicine.
In a recent report, only 5% of depressed men who had seen a PCP in the month before killing themselves had been adequately diagnosed and treated. In South Florida, a study of over 40 older men, randomly selected from those who suicided, all had seen a physician within 60 days, and only one, about 3%, had been appropriately treated. About 1/3 received treatment which was clearly not appropriate. Estimates, based upon 100's of thousands of medical patient encounters, are that less than a fourth of moderately to severely depressed patients are appropriately diagnosed and treated.
Don't blame the doctors alone. We believe what patients tell us. In focused groups in Palm Beach County a few years ago, groups of older men and women felt that depression was the consequence of doing something wrong and that people were deservedly guilty and should just deal with it. Older persons are unlikely to seek mental health care because they and their family feel stigmatized to see a psychiatrist. "I'm not crazy" is a familiar refrain in my office. Yet we know that while as in all illness, psychological and social factors play a critical interactive role, every major mental illness is rooted in the brain.
Returning to the business of healing, failure to evaluate and treat depression increases the cost of all medical care way up. Depressed patients treated in surgery get more unnecessary operations and more days in the hospital. In medicine they get more prescriptions, complain of more pain and disability, make more visits to their doctor, log more hospital days, take more over-the-counter medication and drink more. Alcohol and substance abuse is missed a majority of times among medical and surgical patients. We don't report it to our physicians even if it becomes a major life problem, and no one asks.
Startling are recent data from the U.S. Department of Veteran Affairs. In a multi-year study of the effect of placing a mental health team into a medical or surgical setting in 15 VA hospitals across the country, including our own Miami VA, all patients not identified as having mental health problems received a mental health evaluation and then treatment as needed. The result was fewer hospital days and procedures for an average savings of over $1200 per patient. For those veterans initially diagnosed with circulatory problems, the savings of adding psychiatric care was $6000 per year. The same was found for those patients in the medical or surgical area who were found to have a diagnosis of depression or alcohol abuse. Again, savings of $6000 per year per patient. The study cost the VA about a million and a half dollars, including the cost of the research. The savings more than offset the cost. But more importantly, the health and quality of life of the patients were greatly enhanced.
Managed care companies have been dealing with mental health in a special way. Mental and so called behavioral care are eschewed. From 8 to 9% of health care dollars was spent on mental health care before managed care. These companies now spend 2-4% - that is, far less than half as much. As a senior executive of one such care company put it to me, if we invest money in prevention now it won't pay off for years, and then the people may be in a competitive plan which will profit. In most instances, managed care companies have farmed their mental health care to sub-contractors who bid competitively for this aspect of patient care in so called carve-out contracts - the cheaper the better. The carve-out companies often employ the least expensive and least trained personnel to provide the care. So much for bringing together of the mind and body.
Remember, the virtual health Corporation does not provide care, but organizes and orchestrates care. What it designs is at the cheapest price. In a bidding content for contracts from employers, cheap is better. The bottom line is, after all, the bottom line. But lest we forget, failure of quality nearly lost the auto industry in the United States. Slogans aside, whom did we turn to for quality cars or cameras, but who do we turn to now for healthcare?
I would be remiss if I didn't pay special attention to aging. After all, if medicine is helpful in preventing death the consequence is aging. We have been successful through a combination of public health improved economics - better housing, better nutrition and advances in clinical medicine. We have achieved a near miracle in doubling life expectancy at birth during the 20th century, and have showed great advances beyond age 65. As I mentioned earlier, now the fastest growing part of our population is the oldest - those over 80, 90 and proportionately, those over 100.
These three slides show the rate of increase of hip fractures and dementia. Note that while the numbers differ, the curve is the same. Eisdorfer's Rule applies - for every 5 years of life after 65, we see a doubling of medical morbidity. A 10-year increase in life expectations means a four fold increase and so on.
Clearly, a dedicated focus on positive aging, both physical and mental health, is critical. These data emphasize another critical path for our future. Caregiving, formerly focused on children, is already experiencing a major shift. During our 20's, 30's and even 40's, we raise our children (and then their children). However when we reach our 50's, 60's and 70's, the caring for our parents, in-laws and spouses emerges as a new and powerful challenge, challenges that are more psychologically and often physically demanding than child rearing. A host of data on caregiver health and mental health supports my position. Caregivers are caught in a horrible catch 22. Our current nursing homes are often seen as terrible places, and we make promises not to "send" our parents "away" to a LTC facility. Yet caring at home can be brutal. We care out of love, equity (after all look what mom did for me), ethics and so on, but the toll is great. Our newest research on caregivers of Alzheimer's patients found that in Miami a clinical depression was found in approximately 60% of all wives and daughters, 33% of husbands and 28% of sons. We know that depression is a risk factor for a variety of diseases, including cardiovascular and infectious conditions, and takes a toll on health - if the caregivers goes, so does the older patient.
In the New York Times, Tuesday Aug. 21, 2001, an article on D-7 called "Face off on the value of direct to consumer pharmaceutical", one practicing endocrinologist favored the advertisement of prescription drugs to the public, because "when they come into my office they are ready to start talking about the latest diabetes pill as treatment". He goes on to say in the 1980s, the average endocrinologist was seeing 18 patients a day - now 25-30 or more. He describes a colleague who states "just keep the meat moving," and states it's too easy to feel like we are becoming part of some kind of assembly line, with reimbursement down and less and less time with patients. The 2nd advantage to the drug advertisement was that the HMO client or customer becomes aware of beneficial drugs which may be denied by the HMO. One HMO told doctors that if they wanted to prescribe medicines "off formulary," that is to say drugs the plan would not cover, that the cost of the off formulary medicines would be deducted from the doctor's paycheck. Remember that phrase "just keep the meat moving". Is anyone here unaware of the major social changes consequent to the industrial revolution and the shift from craftsmen to assembly line workers who were challenged to move things along so as not to slow up the line?
This eventuated in unionism of course. "No, not the doctors" you say - well yes - doctors who feel a loss of control, slighted economically, unable to perform at the best of their ability, etc. etc. etc. Even the AMA no longer objects to collective bargaining for better deals with medical management groups - provided we don't strike. The inevitable consequence of union activity is to equalize management power by the concerted effort not to provide that management with the source of productivity, i.e. the work. In English, this means strikes.
As we approach the end of this excursion, I'd like to cite H.L. Menkin who wrote that for every complicated problem there is a simple solution.... and that solution is invariably wrong. Medicine has a long tradition, which often makes clinical practice look like a series of unrelated approaches to the body - what the famous developmental psychologist Piaget described in young children as parallel play, that is, we work near each other but each on his or her own thing. Medicine is now labeled as too costly, with more aged, more illness, more effective but expensive technology and medication, more educated people, more management and a profit incentive, just to name a few. Many of those who pay for care perceive the costs to be unaffordable, or at least undesirable, and cost has eclipsed quality as a critical factor. Those pressures are continuing as in yet more people, increasing aging of the old, increasing technology, an informed public with increasing expectation of success and law suits, some fair, others not.
An entrepreneurial class using the strategy of the virtual corporation has undertaken to manage care to reduce costs, at a profit, organizing care to move us from a cottage industry (doctor/patient relationship) to an assembly line approach for greater efficiency, but not without considerable impact on those who actually deliver the care. With so much money and so many people and the basic values involved, we have politicized health care. The cottage industry to assembly line movement is controlled by a managerial class supported by information technology, thus driving a more impersonal approach, and a few companies will control healthcare management nationwide. Consumers, who have become more aware and more demanding of better quality of care, turn to non-medical holistic care and spend billions of dollars at natural food counters and with non-medical practitioners.
Where do we seem to be going? As in Henry Ford's day, health workers will organize, many already are, many more are likely to, most particularly physicians. They will organize for their patients in an attempt to reclaim a more controlling voice in health care and/or for more income, particularly young M.D.'s emerging from medical schools with debts well into the six figures. We are clearly in a process of major change. Governments are and will be forced to deal with health issues, and we are likely to see cycles of regulation and deregulation with corporate lobbying, professionals lobbying and citizen groups lobbying. Our reluctance to federalize health care will lead us to a "balkanized" state approach, and I believe a national approach with a quality assuring agency like the FAA. As in some countries abroad, we will see waves of private not for profit groups, some spawned by a coalition of unions as in Israel, some by the business sector, others by emerging health and social organizations, much like the Consumer Utility Board of Oregon franchised by the state to represent the consumer in energy de-regulation - Davids in the camp of Goliath.
Lobbying groups, like the American Heart Association, Cancer Society, and AARP, have a demonstrated track record in pressuring the government. Will these and other groups emerge to influence federal and state governments to regulate health care? Of course. This is already the case, and I think that this is as inevitable as that others will pressure the same legislators for their point of view. For the wealthy there will be some re-privatization of care, including subsidization of physician groups for preferred status - like paying to use an airlines VIP lounge in an airport. One thing seems clear - the critical element in the health of the future is the public. Ultimately, the political and economic power lies in the hands of a concerned articulate and active electorate which will determine where we go. If we want more technology, there will be companies anxious to develop that technology, for a price. If we want the seriously mentally ill on the streets or back in contemporary snake pits, now called jails and prisons, there they go. If we want a 5 month wait in our JMH psychiatry outpatient clinic, we will have it and we do. Just as we will postpone elective surgery for months, as in England, or hold back the use of newer more effective and more expensive drugs, rather than better regulate drug costs to ensure a fair return at competitive prices as in other countries.
Can we save money? Of course. At an Institute of Medicine meeting a few years ago, at which child advocates were complaining about the cost of Medicare, I made a tongue in cheek modest proposal, loosely patterned after Jonathan Swift. Since average life expectancy of 65 years old is about 15 years, then we ought to give Medicare coverage for older Americans for only 15 years. If you choose to outlive the average - you're on your own.
And more, we can save money on medical education by not training doctors, nurses, Ph.D.'s and technicians. After all, if cost is the only factor, then the best cost-cutting approach is not to provide care and to let patients die.
But there are alternatives. A few minutes ago - probably seems like a few hours ago by now, I described my law of the doubling of medical problems with every 5 years of life past 65. This is a problem, but it is a problem with an opportunity. When I show the hip fracture slide to our medical students, we have a discussion of underlying conditions acting as risk factors - osteoporosis, the thinning of the bones, is a biggie here. Are we helpless as bones lose calcium and get more brittle with age? Categorically no. Early detection, a concern with estrogen, calcium and exercise can significantly postpone the problem. For depression, early detection and psychological or combined psychological and pharmacological intervention makes a difference. Mood stabilizers like lithium act to prevent manic depressive episodes. Like anti-hypertensive and cholesterol lowering medication, exercise and stress mediation prevent vascular diseases, such as strokes and heart attacks. And for quality of life issues Rogain, Celebrex and Viagara, though Viagara has been shown to have a serious side effect - it seems to cause headaches among wives.
Are we seeing a new model through our looking glass? Not just doctor/patient, but a doctor/partner relationship. People participating in their own care to maintain health and prevent physical and mental decline. Everything is in the process of change - while the history remains, the future is "in play." That is what this talk is really all about.
In some ways I've saved the best for last. What about research? A bitter sweet story. In the last analysis, basic and clinical research are the most cost effective approaches to improving the quality and quantity of life. By an understanding of basic cell biology, by releasing the secrets of the molecule and the human genomic, we will change the face of medicine and disease. Cell biology and genetic research will change the treatment of diseases across the range of human medicine. Neuroscience has replaced mythology in psychiatry, and we are on the threshold of a totally new era in understanding how we can protect against neurodegeneration, understand the revolutionary concept of neuronal regeneration in the brain and the potential of such agents as neural growth factor and stem cells for diseases such as Alzheimer's, Parkinson disease and even schizophrenia.
But will we be able to develop and use the technologies that emerge, or will we have spectacular medicine for the very few in a society that warehouses the aged, depreciates the mentally ill and limits care only to those who have the power to access it? Mental health is not only a model in its own right, but a paradigm for all branches of medicine.
The aged, our largest consumers of health care. Are we approaching a model of the future that Kurt Vonnegut described for this millennium, when older persons are obligated to enter a suicide parlor in the 7th decade of life, after a free meal at the nearby Ho Jo's, or as in the movie Soylant Green in which older persons are reprocessed for essential protein in an over populated planet? ... or...
Can we reinvent ourselves by mandating life long learning so as not to become functionally illiterate in this computer age? Should we resurrect a proposal for an older American corps, OAK, in which we are all drafted at age 65 or 70 to spend 2 years in public service and then become eligible for a new version of the GI Bill including education, health and even mortgage benefits? Can we find new roles for the aged in a society in which change is so rapid that adults now ask junior high school students for help with their computers? Is there not a role for experience and wisdom in our society?
What has this to do with health? As I've suggested, we need to move from looking at the aged as merely consumers of denture cleaners and anti-arthritis medicines in order to lead us to a culture of better self care, nutrition, physical activity, and more concern with eliminating toxins from cigarettes to environmental pollutants. While we are at it, we need to address rolelessness and isolation in a society where older Americans want to die because they have no raison d' etre - no reason for being. They feel trapped by our current no deposit, no return mentality.
Health care is arguably a right and an investment. It also protects our ethical structure. We need a delivery system for health available to all, including the 10's of millions uninsured. We could respond with an expansion of our Health Service Corp so that all young physicians would serve, helping pay their medical school debt, gaining primary care experience and helping the maldistribution of physicians. Then should they go on to the specialty of choice, including primary care.
I've discussed in some detail the fractionalization of medicine. I believe that this fractionalization of medicine has been one of the crucial elements in the loss of control by the physicians to outside managers of care. While money is important, there is also a widespread perception by patients that physicians didn't listen and don't care, except perhaps for income and Wednesday golf. Our current focus in medicine is on getting better information in the form of evidence based practice to make us better Organists, Humanists, Spiritualists and Technologists, and we give lip service to the role of the primary care physician to integrate patient care for us. But, despite better data on the scientific aspects of medicine, I believe that we still haven't gotten it, and we haven't gotten it because we don't train ourselves to listen to our patients, and we don't provide the patient with the time or our interest in what they have to say.
Now with managed care, we indeed have real trouble finding the time, and as you heard from the interview in the New York Times, we are beginning to look to patients to tell us what to prescribe based on television and newspaper advertisement. Primary care, internal medicine and family medicine are tremendously important, but they are only a front-end device for orchestrating care. The problem is that our various specialties teach residents to become less than complete physicians. Most of our post M.D. training creates the stovepipe specialist, with little knowledge and often a disrespect of colleagues in other domains of medicine. Perhaps this is because we leave this aspect of education to tertiary care hospital and departments, which are highly focused in their training and have little interest in interdisciplinary care. Cross fertilization, when it occurs, is by having one specialist talk to another specialist about a specific problem. Internists look down at psychiatrists and don't involve them in patient care until severe behavioral and emotional problems are involved, and, as often as not, are looking to the psychiatrist to take the patient away. Surgeons look down on internists because they believe that a surgical procedure could in most cases solve the problem, and at least one senior level surgeon once indicated that he couldn't wait until they had learned how to transplant the head and that would be the end of psychiatry and neurology.
Part of the solution lies, I believe, in the reshaping of the training of residents and attending physicians. Data show that medical students are intelligent and that they come to medical school caring about others in their role as future physicians, even when that requires a good deal of personal sacrifice. We know, too, that patients respect their personal doctor and the profession, but in turn that they feel unrespected, unheard and intimidated, and far too many patients leave their physician believing that many of their questions have not been answered and their concerns not addressed. I would propose a modest solution here too - training for residents should no longer be the sole responsibility of hospitals. I would propose that hospitals and medical schools partner for residency programs, that the funding stream be split in such a way that the hospital provide for the appropriate support and benefits of the resident, while the teaching of the residents be consigned to the medical school, and that this be budgeted accordingly. This however would only be the case where the medical school would undertake to have a training program, not just designed for the specialty, but designed for helping each specialist understand their colleagues and the other areas of medicine.
Business has already recognized the detrimental affect of the stovepipe mentality. Indeed the term stovepipe comes out of the business as well as governmental sectors, where they understand that the failure to communicate and collaborate across disciplines is a significant barrier to being effective. One of the things we've learned from tragedies such as September 11th is the need for cross agency collaboration for the health of the public and internal security.
Every well trained mental health professional learns about crisis theory. This theory holds that individuals change at a gradual rate, but that at points of crisis, change is accelerated. For those who are able to effectively handle the crisis, their subsequent lives are changed for the better. They are emotionally stronger, they are able to better deal with subsequent challenges and live a richer and fuller life. Alternatively, for those who ignore a crisis by denial or an inability to address the stressful situation .... a head in the sand approach … the situation seems better for the moment, but all of the data indicate that over the longer period the ripple effect of the denied crisis manifests itself in a variety of ways physiologic, emotional and behavioral, and that the subsequent adaptation of the individuals who did not handle this critical period successfully took a downhill course. While it is always difficult to extrapolate from an individual to a society or a culture, I think that this rule probably does apply. We have enough information now on disasters to know that the crisis theory I described, developed over fifty years ago, has considerable application, not just to individuals, but to groups of individuals and perhaps even societies.
One of the challenges that has emerged, as the technology and science of medicine have improved, is the relationship between what some have called high tech and high touch. Clearly, at this point, we are so enamored of the technology and the science that we tend to ignore the human being. The quartet of individuals, each of whom sings a different tune, ignores the listener, in this case the patient, with the result that patients come away feeling uncared for, despite the fact that we as professionals think we have done a great job. High tech requires a knowledge of technology and its clinical utilization in some detail. High touch requires an equally important understanding of the situation and feelings of the patient, and that is where the lack of integration and management of medicine and the crisis of caring have occurred. Mastering high tech requires a lot of time and study. Mastering patient care requires at least a similar investment of time and a sensitivity to others.
Change is difficult for everyone. Medicine, with its primary rule of do no harm, is particularly immunized against change. It is no discredit to remind ourselves of the earlier attitudes to washing and sterilizing one's hands before you go from the anatomy lab to deliver babies. It is no discredit to remind ourselves that the wearing of rubber gloves by a surgeon at Johns Hopkins was met with disdain and hostility toward those who advocated it. It took centuries for bleeding and leeches to slip from their primary role in the practice of medicine, even though we probably cost George Washington his life as a result of this practice rather than whatever disease he had at the time. "Beating the hell" out of patients lasted centuries before we understood the importance of change. Yet, there is good news.
With a scientific attitude, medicine has become more open to new information and new ideas, a wholly different view of the body, emerging from the basic biology of human genomics and perhaps the data from the physiologic impact of stress and caring. I am intrigued and pleased by the sudden increase in the relationship between clinicians and basic scientists and between neuroscience and behavioral specialists. As we focus our training on evidence-based practice, we must constantly remind ourselves of the people whom we serve. This crisis in caregiving is not a short-term event. It is an attitude on the part of those who are empowered toward those who have less power. Physicians who have been patients are different physicians because they understand what it means to be on the receiving end of care. Perhaps in our medical school admissions committee, we ought to give bonus points for anyone who has logged over two or three weeks as a hospital patient. When I taught in Architecture at the University of California Berkeley, I had all of my students spend a weekend in the Langley Porter Neuropsychiatric Hospital. To a person, they came out differently. Not only did they learn about what it means to be in an institution so far as design characteristics are concerned, but they learned the humanity of the patients and began to think of institutional planning in human terms, rather than merely to win an award for architecture aesthetics. These of course are people who were also trained to meet a bottom line.
By the end of his monologue, the walrus had lost his entire audience. In his case, they were oysters and he had consumed them. I can only hope that at this point I have not left you consumed with terminal boredom. Ultimately our future health is our choice. Let us pray for the wisdom, strength and motivation to truly care for one another because only then will we care for ourselves.
Carl Eisdorfer, PhD, MD, Chairman,
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