MARK SMITH, Thoughts

                                                        Thoughts / Notes on                                 

What’s Changed and What’s Stayed the Same in Health Care

in the Past 50 Years

Mark Smith    28 May 2018


The little riff that follows is about what has changed, what has stayed the same, and what has come full circle in the field of medicine and health care during the past 50 years. That seems to be a perspective that fits well with a 50th college reunion. So much has changed, but quite a lot has stayed the same.

What follows is based on interrogating my own life experience, large parts of which are probably shared by at least many of you, plus observations gleaned from 30 years of direct personal experience as a practicing emergency physician in Washington, DC, plus what I have learned in the last seven years while serving as the chief innovation officer of a large healthcare system (the irony and the oddity, by the way, of a 30,000-employee not-for-profit healthcare system having a 71 year old as its chief innovation officer is not lost on me).

It’s an interesting perspective to take—this perspective of what has changed, what’s stayed the same, and what has come full circle. In point of fact, it is a special privilege to be here to take such a perspective, for which I am extremely grateful; many of our classmates never got the chance.

It is not often easy to conjure up how things used to be. Things fade fast. Memories desaturate. We live in the present, especially when it comes to things technologic, and it is easy to forget how things used to be

The default perspective through which many of us see the world most of the time is, for want of a better term, the pinhole myopia of the present. Going up in altitude and seeing the extended timeline below takes conscious effort.

So here is my cut. Yours will be different. I am sure you will add some, subtract others, and together we can create and visualize a rich river of time passing.

In fact, before you proceed, take a few minutes and jot down what is different in healthcare and medicine, discontinuously so, from the way things used to be “way back when.”

What Is Different

  1. Imaging technology (has revolutionized the diagnostic process)--   CT (computed tomography) / MR (magnetic resonance) / widespread use of ultrasound / PET scans for cancer activity.
  2. New Surgical Techniques ---    Minimally invasive surgery, laparoscopic approaches, catheter therapeutics, Radiosurgery  (Gamma Knife, Proton Beam, Cyber Knife) for neurosurgical procedures
  3. “Electronification” of the medical record --- and potential to use individual and population data predictively
  4. Consumer / Patient Empowerment  “The patient will see you now” with many more home diagnostics, and most importantly the home diagnostic of access to substantive information about health and disease
  5. New Patterns and Venues of Care ---  urgent care, ambulatory surgery centers, clinics in pharmacies; overarching theme--  hospital to outpatient to ambulatory to home
  6. Doctor as Employee of Large Organizations (sayonara solo practice)
  7. MidLevel Practitioners (Advanced Practice Clinicians)--- Nurse Practitioner Physician Assistant
  8. New Diseases--  HIV, Lyme Disease, Metabolic Syndrome, SARS,
  9. Emergency Medicine ---  rise of a new specialty, professionalization of the ER, higher quality of emergency care
  10. Cardiac Resuscitation --- Advanced Cardiac Life Support, chest compressions instead of pulling on the arms
  11. Treatment of Big Conditions --  heart attack and stroke …  acute clot as the culprit, with course-changing thrombolytic and angioplasty interventions
  12. New Drugs ---  for cancer, hypertension, depression, immune diseases, anti-retrovirals
  13. Shorter Length of Hospital Stays
  14. Medicare and Medicaid --  health insurance “for all”, government responsibility
  15. Evolution of Medicare Payment Model  --- Cost Plus to Fee for Service Diagnosis-Related-Groups to “Value-Based” Reimbursement
  16. Deinstitutionalization of Mentally Ill Patients
  17. Hospice Care & Palliative Care--- specialized care for the dying
  18. Joint Replacement Surgery --- knees and hips
  19. New Understandings of Diseases --  h pylori and peptic ulcer disease
  20. New Concepts---  microbiome, immune modulation

What Has Stayed the Same Over the Past 50 years

  1. Relational dimension of care --  “they don’t care how much you know until they know how much you care”; acts of genuine kindness
  2. Documentation of clinical encounter  --- text based (write, type, picklist)
  3. Arcane insurance rules and Incomprehensible patient bills --- inpatient versus outpatient, facility fees versus professional fees
  4. Macro Physiology and Anatomy – principles of disease process and disease manifestation are timeless

360 Degree Changes in Thinking

Sometimes we come full circle. What was right becomes wrong and then right again. There are probably many more examples of these but here are a few that I have personally experienced

  1. Dietary Advice: “Avoid starches” TO “Low Fat / High Carb Diet” TO “Low Carbs”
  2. Obesity --  “It’s hormonal” TO “It’s willpower” TO “It’s hormonal”
  3. Housecalls:  Doctor comes to patient’s house TO Patient goes to Doctor’s office  TO Housecalls
  4. Pathoanatomy of myocardial infarction: “Acute coronary thrombosis” as the inciting event  of a heart attack TO coronary artery spasm and metabolic mismatch TO acute clot on top of fissured coronary artery plaque as cause of coronary occlusion

What Is On the Horizon

  1. Genomics
  2. Digital Transformation --  application of data science to suggest direction and predict outcome
  3. Artificial Intelligence / Human Intelligence Augmented
  4. Wellness (with focus on nutrition, sleep, exercise)
  5. Power Shift to the Consumer
  6. Personal Health Record
  7. Payor/Provider Merging (Kaiser as the model)