Medicine and Health Care

Medicine

Two of the great civilizing gifts bequeathed by the Middle Ages, medicine and the university, no longer reflect their original ideals. Much time and change have gone by; civilizations adopt and adapt. The monumental effects of the Industrial Revolution now are far surpassed by the development of digital computing, its myriad applications, and the Information Revolution. The advances in technology, and the ease and rapidity of information transfer have brought sweeping changes inour society. Advancement is possible without losing sight of the history and ideals of an institution, but it is not easy. The institutions of medicine and the university are caught up in change. The first of these, unfortunately, failed in the transition, and the second is in danger of following the same course (1).

 Medicine, originally the application of art and science for the benefit of the patient, and a visible manifestation of the beginnings of a social conscience, now measures. throughput of patients per unit time. The physician, as we have known that person through history, no longer exists. Technology and business models govern medical care.

 Patients are much better served because of the technological revolution, and will be far better served in the future. Medical information is available immediately, permitting standardization and improvement of care. Diagnostics are rapidly becoming portable, cheaper, faster, and personal. It soon will not be necessary for a physician to interpret data - electrocardiograph machines have been doing that for more than 40 years. Better diagnostic medicine is now available to a larger audience. The result is the devolution of medicine into an efficient service industry that provides health care at an acceptable level for everyone, and includes a larger potential patient population than ever before. Most patients would agree that this is an improvement. However, the unanticipated result has been that the intensity of the physician-patient interaction, one of the closest of human bonds, has largely disappeared.

Physicians who have watched the decline of the stature of a profession that aspired to high ideals would most likely agree with patients on the improvements, but with the reservation that the intangible cost was quite high (1). The consequences of the application of technology to medicine have been beneficial and will become more so. However, the consequences of the application of for-profit business models to health care have been disastrous in this country. If the university, part of the bedrock of Western Civilization, does not benefit from the lessons made eminently clear by medicine, and follows the same path, it would be catastrophic.

Medicine and the University

Historically, the university, like medicine, enabled an intellectual and social upper class, and laid the knowledge foundation for the advancement of society. Its faculties were granted social status, and the university was set apart from the town to recognize its importance and allow it to focus on the pursuit and promulgation of knowledge. It had a goal to understand the universe in theological and philosophical contexts, and, as the Middle Ages and the Enlightenment progressed, in the context of the natural sciences. The university never was a service provider in the sense that medicine was, but it now appears to be on its way.

 Higher education is at risk of losing its historic aspirations and diminishing the value of an intellectual life. It appears to be confounding information transfer with education. Technology makes this easy, and provides appealing ways of presenting information, all of which is good. What could be lost is the contact with the scholar who provides context and perspective.

 University years are a time when one learns to think and evaluate. It is an intangible—like the influence of the physician in medicine—but an even more important intangible since education is the milieu that teaches students how to remain intellectually aware for a lifetime. If the ideals of the university are lost, or significantly diminished, along with them will go concepts of abstract truth; ethics; norms of human behavior; the importance of history; the scientific method; and the teaching of things that address the mind and spirit (2,3,4).

 There is evidence that this is occurring, yet little outcry within the academy except in those institutions that have taken formal stands against this decline—primarily private, smaller, liberal arts institutions. This may presage a two-tiered system maintained by those who can afford it: higher education in the original sense of the term with prolonged faculty-student interaction versus information transfer without the perspective needed to truly assimilate it.

 This is conceptually not dissimilar from concierge medicine with its close physician-patient interaction for those willing to pay for it versus corporate health care for the larger audience. Both make use of relevant technology but the former uses it as an adjunct to medicine while the latter simply uses it. In both instances a woman with hypertension would receive medication. But only in the physician-patient interaction would a careful inquiry discern that the real cause of her high blood pressure is her child who has a serious disease. The appropriate management of the mother’s hypertension would be directed to managing her response to the child’s illness. One method of treatment is qualitatively much better even though both receive the same medication, just as students receive the same degrees.

 One of the conditions that helped to bring down the classical edifice of medicine was hubris within the medical profession (1). As a group, little attention was paid to the effects of cost increases, and the fact that many people could not afford therapy was ignored. Physicians practiced their art with little attention to the gathering storm of public indignation. A similar situation exists today: the indifference of university faculty and administration to the cost of education; retreat into the tenure system when professors are called to account for their behavior; indifference to the poor results of their teaching; some class offerings that are trivial at best; the development of second careers as outside consultants while secure in salaried and tenured positions within the university; the curtailment of free inquiry and discussion by unruly student groups; and acquiescence by pliant  administrators and pandering faculty (5).

 The appearance of for-profit universities; increasing use of community colleges; the equating of a college education to job training with cost/benefit comparisons; demands to eliminate tenure; an awareness that higher costs have not bought a better education; and the denigration of the teaching profession is the response by the community. Is this not a replay of the ruin of medicine?

In Part II we shall examine the university system more directly.