Seeing the Whole

The U.S. now faces a health care challenge of such consequence that it reaches well beyond the physical and mental well-being of the nation. The cost of care now endangers the economic well-being of the next generation and beyond. While the proposed health care reform has advanced a significant development, it has not been able to identify politically viable recommendations that could shake the health care institutions at their very foundation and leave the nation with a remade arrangement for providing for its well-being.

This situation is all the more galling because of the resources that have come to be imbedded in the nation’s academic health centers. A distinctive American invention, these aggregations of schools of dentistry, medicine, nursing, pharmacy and other allied health professions are linked with teaching clinics and hospitals. As a community they advance our knowledge, train the next generation of students, and provide highly specialized and primary care. Nowhere in the world is there better specialty clinical training, more advanced bio-medical research or greater reason to hope for life saving miracles.

But this great aggregation of wisdom and resources also masks a great tragedy. For all of its capacity to focus a highly specialized lens deeper and deeper into disease and disability, it has almost lost the ability to look up from reductionistic inquiry to see how the health of an individual and a community are knit together. The systems we have built all have an internal logic which makes perfect sense -- in the system. But from the outside this strange logic seems more curious than anything proffered by the Mad Hatter.

A few examples.

A couple of years ago I was party to a discussion involving the chiefs of service of a major teaching hospital and trauma center. The purpose of our meeting was to review a proposal to add xeno-transplantation services for the use of pig livers in blunt trauma cases when human donors were not available. The essential argument was this: now that such a procedure was technically possible, this Level One trauma center must build to incorporate such capacity or it would be a sitting duck for the next plaintiff’s attorney who would ask the simple question, “Did you know that this was the state-of-the-art in care, Doctor?” I have come to think of this dynamic as the “tyranny of the standard of care.” If someone can build it you better be offering it to the patients. To build out the service in question was going to cost millions of dollars for new professionals, equipment, reconstruction and all related costs. It could and would become a model, not only providing a new type of clinical care, for which much research still needed to be completed, but also establishing the need to train new professionals to staff other centers in other teaching hospitals. Financially, this expensive service would be covered by the state and federal governments. The group was well on its way to approving the investment when I reminded them of a recent study that highlighted the problem: a significant portion of their census every day was admitted from and discharged to the street, and yet while in-patients, they could receive a service beyond anything that could be imagined.

More simply I recall a conversation with two colleagues a few years ago, one an accomplished bio-medical researcher, clinician and educator, the other a scholar of health policy at the macro level. The first had just received notice of continued funding for his laboratory to study the mechanisms by which the cocaine addiction of a mother was passed to her unborn child. He was excited about the scientific inquiry that could establish the details of the process. My other colleague listened and shared the moment’s celebration, but concluded with the most disarming of all questions, “John, isn’t it enough to know that it is not good.”

Finally I still have a twinge when I recall the great challenge and the offer of many millions of dollars from two major private foundations which were presented to me and a small group of colleagues. The foundations wanted the two great world-class academic health centers that reside in the Bay Area to “take responsibility for the health of the children of Northern California.” Not provide their care, mind you, but be responsible for improving their well-being. We begged off, pointing out that the research design would be so much more elegant if we could just redefine Northern California as San Mateo County. We never saw them again and I have never been more ashamed of a failure. Because the simple truth is they were asking us to do what only we can do.

There are those who will see these three little stories as anti-intellectual vignettes of a Luddite variety. Please don’t. See them not as an indictment but a calling to some other, perhaps higher, purposes. Those of us in the world of academic health are needed in the service of our nation. Not to correct on the margins; that is the work of the politicians we so easily dismiss. Rather, we have to find some corner of our enterprise where we might shake what we do to the foundations, looking for what is possible to meet what ails us all.

To do this work we will need a population lens as revealing as the microscope was a hundred years ago when it first revealed unimagined organisms. The new lens will need to be focused with the help of the patients, customers, clients, and the public we serve, otherwise we will blink and turn our powerful vision inward again. We need to work together across the disciplines and the professions with an uncharacteristic abandon that takes us out of ourselves. But mainly we need leadership with a vision that creates and sustains the possibilities of a new world with new answers and new solutions. There can be no real health care reform without such a change.

We can all begin today.