In the Nation's Interest
Health Care, Medical Science or Healing Art?
A significant element in the dispute over health-care reform seems to involve conceptions of the prospects for costs, and cost savings. Some people seem predisposed to believe that the prospects for cost saving (assuming sound, even aggressive public policy) are severely limited, while others are more optimistic. To some extent, the difference between these views may be based on different conceptions of what the practice of medicine really is, or should be.
The pessimistic view about potential cost savings seems often to be associated with the conception of medicine as a "healing art." Taking this perspective to an extreme - a caricature - solely for purposes of argument, the physician operates in a world without regularities or rules. The task of the physician is to spend time with the patient, look into his or her eyes, hear the patient's symptoms in endless detail, weigh all of the circumstances, and then intuit the proper diagnosis and treatment from a wealth of training and experience. Thus, again to caricature, the physician is an artist. No one would interrupt Beethoven in meditation over his Chorale, and no one should interrupt the physician, either.
From this perspective, the prospects for "efficiency" in health care are just about nil. The physician needs to take unrestricted amounts of time to practice his or her art, and so if productivity is measured as output per hour, it is irrelevant - at best - in medicine. The ideal is "as much as it takes," in terms of time and all other resources. Looking to cut costs in the health-care system is worse than fruitless. The only objective is to get more to cover more people, with better, more intensive care.
So again from this perspective, the vision of a brave new world of "efficient" health care - partially embodied in current integrated delivery systems - is frightening. Doctors meet with patients on time quotas. Treatments come from veritable electronic cookbooks; doctors hear symptoms, type them into computers, and treatments come out before the patient has completed his or her description. The patient is hustled on his or her way, with no advice as to long-term maintenance of health through proper diet or other life-style behavior, and the doctor is paid a bonus for "efficiency," in the name of heartless profit maximization on the part of corporate health-care systems.
Again, this has been a caricature. Here is a second, different one.
A contrary conception of current practice holds that medicine is not an art, but rather a science. This view would say that today's typical physician leaves medical school with a particular idiosyncratic approach to medicine, which is the sum and total of knowledge that he or she will have for an entire career. The physician meets with a patient, looking into the patient's eyes, asking endless questions about symptoms, while charging third-party insurance payers by the hour. The physician orders batteries of tests (from a physician-owned technical facility) that more than bracket the patient's likely ailment, schedules follow-up appointments to review the results, repeats many of the tests (at additional fees) just to be sure, and eventually finds a way to a treatment that may or may not be correct, and may or may not be undertaken before the ailment self-corrects.
From this very different perspective, the current practice of medicine trails behind the progress of medical science. An unfortunate share of the services provided by the medical profession is unnecessary or redundant, and both the selection of services and the means of their delivery are not wholly selfless. Physicians hopelessly attempt to intuit diagnoses and treatments from inadequate databases of thoroughly amortized training and selective memory of experience, while an expert system could tell them with precision in nanoseconds. This retrograde practice pattern is a major reason why care costs so much, and why so many people cannot afford insurance or even basic health care. Forces within the institutions of medicine protect the status quo and inhibit needed change.
So again from this contrary perspective, there are enormous savings to be gleaned from the improvement of the delivery of health care. Physicians could see more patients, and more quickly arrive at sound diagnoses and treatments. Excessive and redundant tests could be eliminated. The health system could cover more people with quality care at lower cost.
These are two caricatures. Neither is wholly accurate. But where are the elements of truth?
In fact, there are elements of truth in both views. But the bottom line is fortunate: There is the potential for substantial savings through greater efficiency in the delivery of high-quality health care. That is, the efficient application of medical science can deliver the healing arts to more people at lower cost.
Before noting where each caricature is right, is worth noting where each is wrong.
The healing-art vision is unrealistic in its conception of limitless one-on-one medicine. The nation cannot afford unlimited physician time with every non-physician individual. There are not enough physicians, and there never will be. If we start by entitling every insured person with unlimited resources, we by that fact condemn all others to a lack of coverage, and even growing numbers of those currently insured to a loss of coverage or inadequate care. We need to create a system that holds at least the possibility of good care for all. We must be realistic.
On the other hand, medicine clearly is not a pure science. The human body is complex beyond the limits of current knowledge and knowledge tools, and every body is different in infinite detail. The implicit expert system of scientific medicine unfortunately often is confronted with unprecedented combinations of symptoms, or symptoms that lead to multiple divergent diagnoses.
Thus, the health-care system must steer a course somewhere in reality, between these two caricatures.
The overall picture can be seen through the lens of the issue of physician time with the patient. The healing-arts vision of treatment through the laying on of the doctor's hands is not real. Nor is the caricature of medical science providing an exact computer-generated answer for every question. The logical truth is that the health system must triage incoming cases between those where the diagnosis is clear and the treatment is routine (by contemporary standards), and others where the conditions are complex and the stakes are high. Because the health-care system is human, it will be imperfect, and so there will be triage errors in both directions. However, the answer to this reality is neither to throw so much in medical resources at each routine case that many more-vulnerable people must go unserved, nor to restrict the most complex cases to mechanical diagnoses that do not fully address the problems.
The only answer to this conundrum is to leverage the physician's scarce time - with systems and teamwork, some of the key elements of scientific, efficient medicine. In truly complex cases, the physician first approached by a patient will not necessarily be the one best equipped to find the answer. The physician will need a way to reach out to others for experience and ideas to address such highly complex problems. This is not the classic one-on-one doctor-patient relationship. It is much more in the form of what scientific medicine would provide.
But what about the basically healthy patient, at the other extreme in degrees of medical complexity, who needs guidance to follow a healthy lifestyle and avoid the onset of chronic problems such as obesity? The healing-arts perspective is correct in that every person needs advice, consultation, and preventive health care. But such preventive care need not be delivered by a physician. Nurses, dieticians and physical therapists, as parts of teams led by physicians, can provide the necessary guidance - just as nurses and other medical paraprofessionals can care for those patients with common colds, rather than complex medical conditions. Physicians today rarely do their own recordkeeping and billing; there is evidence that the efficient use of support staff could extend still further. It is as if Beethoven were freed from the task of drawing his own musical staff on blank paper; he would have more time to concentrate on his art.
There are more ways to leverage physicians' time with more-scientific - some might say impersonal - organizational models. As just one example, the medical literature - clinical trials, for example - is growing so fast that a physician seeing patients probably cannot keep pace. Larger groups can afford the overhead (a pejorative term in some discussions of health care) to devote personnel to review and explain the new literature. Physicians with such support can spend more time with their patients and deliver better care.
Even those who believe in a healing-arts model of medicine probably would agree that scientific organization could allow physicians to deliver the health arts more efficiently. Given the rising cost of health care, the nation needs all the health-care efficiency it can get. If the American people are not willing to accept the same streamlining of the delivery process in health care that they have embraced in every other industry, there is no apparent way that we can extend quality care to all Americans.
Commentaries are the views of the authors and do not necessarily represent policies of the Committee for Economic Development.