Looking back and gazing forward

At the 1955 American Medical Association convention in Atlantic City, New Jersey, AMA chairman Dr. Lowry McDaniel presented his predictions for the end of the 20th century: Synthetic food, he said, would bring an end to famine. The average human lifespan would reach 150. Infectious diseases would be wiped out. Cancer would be treated with a viral vaccine or radioactive compounds.

Side effects of menopause would be easily and safely treated with hormones.

And degenerative diseases of the body would be wiped out.

McDaniel’s score was zero, as – 13 years after the beginning of the millennium – none of these prognostications has come true.

Thus Hebrew University Medical Faculty dean Prof. Eran Leitersdorf was quite brave to predict the future of medicine when he co-chaired convention marking the 60th anniversary of the first graduating class of the HU-Hadassah Medical Student graduates. Held 11 days ago at the Jerusalem International Convention Center, it was attended by nearly 1,000 physicians from around the country and the world, including over 100 current medical students in the faculty. In addition to being a social reunion to compare personal and professional details, the conference was aimed at looking at medicine over the coming four decades – until the medical school marks its centennial. Of the medical faculty’s 5,000 graduates, about 3,000 are still alive.

Prof. Leitersdorf, an internal medicine specialist and expert on lipid metabolism, graduated from the medical school in 1975. His conference cochairman was Prof. Benjamin Drenger – a senior anesthesiologist at Hadassah University Medical Center and chairman of the Israel Association of Anesthesiology – who chairs the medical school’s alumni group and is keen on having them becoming more involved in special projects.

“There have been many failed technology predictions,” Leitersdorf told participants. “Even Albert Einstein said in 1932 that there will never be nuclear energy.” There were 40,000 medical applications for smartphones right now, said the dean, “But it’s hard to predict if there will be millions to choose from in 40 years. I also don’t know how important biotechnology, nanotechnology and regenerative medicine will be in medical care or [how to predict] the occurrence of major disasters like a falling asteroid that would affect [global] health.

“But I can predict that the world’s and Israel’s population will continue to grow. [I] can predict that the burden of noncommunicable diseases will change in relation to environmental changes and regulatory interventions, especially cigarette smoking, the food industry and road traffic control; these diseases will cause the deaths of 87 percent of all Israelis.”

Leitersdorf also suggested that Russia and Japan will soon have a negative birth rate, while there will be large population increases in the Middle East and less growth in the Americas. Chronic disease will cost governments and the public around the world $47 trillion dollars in 2030, and – judging from the current trend – pharmaceutical companies will be less and less willing to invest in new drugs because of the high cost of research and development.

As a result, said the medical school dean, the emphasis will be on prevention of disease – such as government regulations to bring smoking down to the absolute minimum. Less than 10% of the population will smoke in 2050, he predicted. The consumption of alcohol and unhealthy dietary components will be discouraged through regulation as well. Barring a cure, dementia will increase many times in 2050, while the prevalence of heart disease will continue to decline. “There will be no choice but to stop road accidents by using driverless cars” run by robotic systems, he continued.

Crowded countries will mean more infectious diseases, especially because there will be many more people living together in cities and air traffic promotes the spread of disease. Jets will even fly differently – in formation – so they don’t crash into each other in crowded skies. Global warming will lead to pandemics, said Leitersdorf. A recent US congressional report predicted that in 2045, government spending for healthcare and Social Security will “consume all tax revenues.”

Although health promotion and disease promotion activities constitute only 1% of health expenditures in the US and 2% of Israel’s today, “prevention will be the name of the game, as well as strict regulation and improved education about health. And doctors will face unprecedented ethical issues, because adequate care will not be affordable for everyone, so painful choices will have to be made.”

“THERE ARE some things you can predict based on current trends, but some things are unpredictable,” noted Prof. Rivka Carmi, president of Ben-Gurion of the Negev in Beersheba and a well-known pediatrician and geneticist. Carmi worried about the 25% dropout rate of physicians today. “Some leave right after completing their studies. Research by working doctors is also declining.

Bench-to-bedside research that is used for the benefit of patients is also disappearing. Some claim it’s a luxury,” she said.

But Prof. Ran Tur-Kaspa, dean of the new Medical School of the Galilee in Safed and a leading expert on liver diseases at the Rabin Medical Center, said he wasn’t worried about those who opt out of doctoring. “A physician has to be involved in society and finance, not just in their patients. These subject must interest us today. If graduates go to work for pharmaceutical companies, they cannot be called dropouts, as it is still medicine. If they move to hi-tech companies, they can still be involved in medical issues. Even becoming Knesset members – as a number of physicians have – is OK, because they can fight for medicine. Doctoring is a versatile profession. People change and develop, so changing professions is not necessarily bad.”

The teaching of medicine has also changed significantly, said Tur-Kaspa. “We have to teach students how to learn, not to insist on endless memorization.” But the Safed dean, who also graduated in Jerusalem, said that the role of physician/researcher remains very important.

They must have time for research as part of their job and special funds that don’t compete with those who have PhDs but are not physicians, he went on.

Prof. Amitai Ziv, deputy director-general of Sheba Medical Center at Tel Hashomer, spoke about the use of medical simulation for teaching MDs. Ziv, who a former Israel Defense Forces pilot, became so enamored with simulation in the air force that he established and continues to head Messer, the national center for medical simulation. This center helps select suitable candidates for medical school by using actors to play the role of patients; helps give medical students new skills and teaches medical students and residents new techniques.

In 1910, numerous US medical schools that operated at a low level without standards were closed down.

There are much higher standards today, certainly in Israel, said Ziv. But too much of study is still tests on information, not of abilities as a doctor. “Do our medical schools produce the best doctors? Things have to be added, including advanced training and other things. Medicine is not just the heroic saving of life, but also talking to patients at the end of life, safety and avoiding errors. Medical students must have skills in data mining, identification of abuse cases and have the skill to write down information that the doctor who works after you can understand.”

Fast solutions must be found for major problems such as the lack of public money and the growth of individuals’ copayments for medications and medical services, said Prof. Arnon Afek, head of the Health Ministry’s medical administration in charge of supervising hospital services. “This trend began when the government eliminated the employers’ tax and parallel tax to contributing to the coverage of workers’ medical expenditures,” said Afek. “So there is less public funding and more private financing, and now we are seeing the fruits – strikes and sanctions. Private medicine could be allowed to develop – but only if it is alongside a financially healthy public system. There must be fair competition with supervision and regulation of private institutions. If not, it will develop badly. Private funding of medical care has gone too far. The public system must be strengthened.”

Prof. Yehoshua Shemer, a former ministry director-general and now chairman of Assuta Medical Centers, said he cares enough as much about public medicine as anyone, even though he heads a powerful and profit-making private system that performs 100,000 operations a year. “Private medical services can be supplied with public funding,” he said, hinting as supplementary health insurance policies of the four public health funds. “There must be as much equality as possible. I [don’t] deny that our health system is outstanding.

We have very good doctors, and it is thanks to them. But the public system has many failures. More money has to be invested in the public system, but you also need a private system because it is more efficient and is competition for the other.”

One physician who went on to become an MK – gynecologist Dr. Rachel Adatto – said that healthcare isn’t on the national priority list. “It was hardly mentioned in the Trajtenberg Report [on promoting social justice.] The Finance Ministry is much too powerful in the field; it tells the Health Ministry what to do and sets priorities. A young economics graduate who is the Treasury liaison for health services arrives and makes major decisions. There is a huge dichotomy between a health system praised by the OECD and the situation patients find in hospital corridors,” Adatto declared. “Many people in the periphery of the country can’t take advantage of their supplementary health insurance because there aren’t enough top medical specialists there to consult. I am in favor of SHARAP [private medical services] in all the public hospitals if there is strict legislation and supervision.”

Dr. Bishara Bisharat, director-general of the Scottish Hospital in Nazareth, said the National Health Insurance Law that went into effect in 1995 greatly benefited the Arab Israeli population. “A quarter of them didn’t have health insurance before that [because the health funds didn’t accept them or the individual could not afford it]. We thought the law would narrow the gaps; Arabs have two years’ shorter life expectancy compared to Jews.” Bisharat called for the introduction of a differential basket of health services for the Arab sector so it could catch up more with the Jewish sector. Arab women, he said, are more likely to die of breast cancer than Jewish women. And Jews are much less likely to get cardiac rehabilitation after a heart attack than Arabs.”

But Bisharat later conceded that more health education must be conducted by and for his community and that mortality rates are higher because almost half of Arab men smoke, and tobacco is a major killer.

Drenger concluded that Israeli physicians are not used to the custom in the US and elsewhere of contributing to their alma maters so the institution they graduated from can flourish and disadvantaged students can benefit. He is trying to introduce this into his alumni group. “I would like to start a simulation center – not one that competes with Messer but one that offers unique teaching services – in Jerusalem. I would be very happy for alumni to sponsor scholarships for needy students and to have all types of private donors, not only graduates but also companies if they meet our standards.”

This would certainly be a worthy venture long before Jerusalem’s medical school marks its 100th anniversary.