A Little Medical Crystal Ball

I heard this over the weekend:

"The students of today are training for a field that doesn't currently exist."

Seems hard to believe, right?

And yet, when I started medical school, there were no iPhones. In fact, there weren't even cell phones. My first cellphone was acquired while I was in fellowship training and came with a shoulder bag to hold the battery pack. (Man, was I cool to have one!) When I started as an intern, if I wanted to see a patient's chest x-ray I headed down to the file room to check out the patient's xray folder containing all of the films performed on the patient at that hospital and physically removed the particular film of interest from the folder and placed on a lightbox to review. Gosh, we even still had had and used manual blood pressure cuffs.

Things sure have changed. The pace of innovation in medicine has been staggering. Who would have thought you'd need to have typing proficiency to become a doctor? Electrophysiologists, once the boring antiarrhythmic testers of ischemic ventricular tachycardia, don't just test arrhtyhmias, but now routinely ablate them permanently. Stents, unheard of just 20 years ago, are now commonplace. And percutaneous aortic valve replacements and mitral valve repairs? You've got to be kidding me! Congestive heart failure too, once a pre-morbid condition, is now become chronic disease Public Enemy #1 (never mind the dirty truth that it's the innovative drugs and devices that keep people alive and have cost our health care system so dearly). As a result, "readmissions" for heart failure, the inevitable end run of all heart disease, have become a cardinal sin for hospitals thanks to our new health care reform law, punishable by non-payment.

Think practice patterns will change and senior "rehab centers" will benefit as a result? (Does a bear poop in the woods?)

Which leads me to contemplate where things will end up ten or twenty years from now under continued governmental belt-tightening. Will our medical students be better served to learn more medicine, or will should they be shifting their focus to business in an effort to forward themselves? Who will doctors find themselves serving more, their patients or their employers? Will the greatest challenge in health care be promoting life or will it be to promote a death with dignity and without expensive end-of-life care? How will doctors be paid: by salary? By specialty? Or maybe by an obscure, non-transparent concocted "work unit" that an outside hospital consultant group creates?

Even the the grand plan of hospitals called "build it and they will come" is crumbling. Like independent doctors' offices, many smaller hospitals, previously flush with cash and good credit lines, are suddenly finding it harder to stay afloat independently thanks to cuts to Medicare payments. Consolidation continues in health care where only the strongest richest and most politically-connected will survive. Young doctors need to understand these things, lest they work in an environment that might not have their best patient-care interests at heart and their workplace is sold to other larger hospital group intent on cost-saving and 'efficiencies.'

Like it or not, the medical world is rapidly morphing into a business-oriented world. Everything will have a cost and a benefit. It's the "to whom" that will be where doctors' influence will come in: the financial benefit to a hospital system will not always be in the patient's best personal interest. Strattling this divide will be doctors' greatest challenge for all doctors going forward.

But new medical students should not lament: there will still be tons of opportunities for them. Rather, they should accept that right now, this minute, they can have no idea where their current priorities and technical, clinical, and social skills will take them. But they should know this: they'll really need to stay flexible.

Because the only thing unchanging in medicine right now is change itself.

-Wes