Monday, December 05, 2011

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.



Anonymous said...

Speaking of Change, Check out whats going into effect Jan 1, 2012

The Center for Medicare and Medicaid Services will require pre-payment audits on hospital stays for cardiac care, joint replacements and spinal fusion procedures, according to the American College of Cardiology in a letter to members. Shares in both industries fell with Tenet Healthcare Corp., the Dallas- based hospital operator, plunging 11 percent to $4.18, the most among Standard & Poor's 500 stocks. Medtronic Inc., the largest U.S. maker of heart devices, dropped 6 percent to $34.61

Pluripotent said...

I wouldn't worry too much about this. The good people involved with the PPACA teaming up with other existing bureaucracies such as the FDA to tackle this problem. They are going to make sure that nothing changes much for many, many decades to come.

Tim Hulsey, MD said...

Wes said, "Because the only thing unchanging in medicine right now is change itself."
Unbeknownst to me as I grew up, that's the way the world is. There is no getting to a comfortable spot and relaxing. How disappointing! But that was true for all of history. Human adaptability is the key to the success of the species. That adaptability works best in an evolutionary process. Forcing it artificially causes problems.
I have long since quit promoting medicine as a profession to young people. It is outrageously expensive, takes a long time, and for the little we are appreciated afterward, perhaps not worth it. Oh, I do think being able to take the human body apart and put it back together again is an ultimate skill. Though, I would probably get more appreciation If I was a welder and built bridges. Motorists would be thankful everyday for the convenience. Skilled tradesmen are in demand, make good money, and have less personal liability. Then, again, maybe I'm just a skilled tradesmen of another kind. BUT I'm also a patient advocate. If we all become employed, we'll lose that role to the patient's detriment. Hospitals don't take an oath. What do we do when what the employer wants is antithetical to that oath? When the oath is meaningless, our profession becomes a skilled trade. The welder has no call to be the drivers advocate.
Lest anyone be confused, there has been a concerted progressive effort to remove our role as the patient's advocate. The strength of the doctor patient relationship has been eroded so that cost efficiency can be the driving force of medical care. Actually that's incorrect! Care has been removed. I should say "medical treatment." Actually, to Obama, it's not even treatment– it's medical "coverage!" The public will be pissed when they find out medical providers are just part of the Water, Sewer, Sanitation, and Health Department, and about as easy to deal with as those folks!