Doctoring has changed dramatically in the past century and will change even more in the coming decades.
By JUDY SIEGEL-ITZKOVICHdoctor cartoon 298.88(photo credit: Norman Rockwell)
Family doctors of a century ago wouldn't recognize their profession today. Having few drugs and little medical technology to effect dramatic cures, they were nevertheless revered by most of their patients, and performed careful physical examinations. Patients even dressed up for doctor's appointments. The most common conditions in 1900 were acute infectious diseases, from which people either died quickly or recovered "miraculously." Today, many primary-care physicians hardly touch their parents, but send them off for automated lab tests and sophisticated scans. They have a whole armory of drugs and treatments for mostly chronic disorders.
Fifty years ago, hospital and health fund managers were primarily interested in getting patients well and keeping staff happy, but today the pressures of efficiency and outsourcing have intruded on this ideal.
Yet the slow changes in medical care since 1900 are nothing compared to the revolution that is predicted over the next few decades - drugs suited to individuals based on their unique genetic makeup; Internet-based diagnoses; embryonic stemcell replacement of damaged tissues and organs; non-physician practitioners taking over much of the work of family doctors; nanoscale sensors travelling inside the body to detect and even treat problems; and other trends not even imagined today.
THE BRAVE new world of health care and how to reform the existing system was the major topic at a three-day Third International Jerusalem Conference on Health Policy which earlier this month brought hundreds of doctors, economists and other professionals from 37 countries to the Jerusalem International Convention Center. Well organized by the Israel National Institute for Health Policy Research, it provided a lot of food for thought about whether the Health Ministry, Treasury, hospitals, health funds and Israel Medical Association are ready for what lies ahead.
Because health systems around the developed world are facing the same problems, the national institute - established by the 1994 National Health Insurance Law - decided to create an international advisory committee chaired by eminent expert Prof. Richard Saltman of Emory University's School of Public Health in Atlanta.
Prof. Mordechai Shani, who co-chaired the conference with Saltman, said reforming the health system has been a goal for many years, but that the process is more like trial and error, as mistakes are made and repeated. Some countries have replicated problematic health systems in other countries, while US health services are in a class by themselves, with 16% of the Gross Domestic Product spent on healthcare - twice the Israeli rate, even though 46 million Americans have no health insurance at all.
"The US 'system' is not really a system at all, but a disordered, chaotic arrangement with very low health outcomes," Shani declared. "The waste alone is enough to provide coverage for the tens of millions of uninsured." He predicted that US Medicare, for Americans over 65, will "go broke, as private business won't be able to pay for their employees and the average annual premium will be $35,000 by 2015."
SHANI, A former Health Ministry directorgeneral and currently head of the Gertner Institute for Epidemiology and Health Policy Research at Tel Hashomer, said the push for specially trained nurse practitioners to take over some doctoring tasks is aimed at saving money and giving chronically ill patients more attention. Some countries have offered patients the freedom to decide if they want a specialist nurse or a doctor, while in more rigid systems, such as the German one, patients who get skin cancer after failing to undergo regular screening have to pay part of the cost of treatment.
Saltman added that decentralization of health services has been a "strategic cornerstone in health policy since the 1960s." But the belief that decentralization is good "has started to come undone. Norway, for example, recentralized ownership of hospitals back to the national government, and Denmark is recentralizing health care funding away from regional governments. This shift, especially in Europe, is being driven by changing and more expensive medical and information technologies, growing national economic constraints and globalization."
Dr. Hans Stein, head of the European Health Policy unit of Germany's health ministry, said rapidly growing inequity between rich and poor, increased privatization and higher patient expectations are making health "a more dominant topic in political discussions everywhere, but I'm doubtful if it will improve things. Globalization will lead to greater interdependence and even convergence of different health systems... There is no scarcity of innovative ideas, and an abundance of research papers on how health systems should be reformed. The question is whether the ideas remain on paper or are implemented.
"Governments tend to be conservative; I have been in one for over 40 years, and officialdom is afraid of experiments and innovations." He advocated global health strategies and actions, new partners in industry and non-governmental organizations, new international laws and special agencies that promote disease prevention and health promotion not restricted by national boundaries."
University of Southern California-San Francisco health promotion expert Prof. Steven Schroeder tried to defend the US health system against Shani, who said Israel and other Western countries had nothing to learn about health care from the Americans.
"It is true that we don't do very well in infant mortality and life expectancy. We can do much better, but if you reach 65, you're insured for health care. Premature death results mainly from poor lifestyles, exposure to environmental dangers, genes and social factors. The level of health care you get, even if perfect, would reduce premature death by only 10 percent. But smoking prevalence in the US is at an all-time low. Deaths from car accidents are down due to seatbelts and very punitive action against drunk driving." Nevertheless, conceded Schroeder, "overweight due to inactivity, sedentary jobs, poor diet, TV watching and computer use is bad and promoting the obesity epidemic."
Why is healthcare so costly in the US?
"We have fewer doctors than most OECD countries, but a much higher percentage of specialists," explained Schroeder. "Everyone who works in healthcare makes a lot more than their counterparts in other countries. We don't have a lot of hospital beds, but once you're in one, you're more likely to go to an expensive intensive-care unit and undergo a lot of sophisticated procedures such as angioplasty, open-heart surgery and carotid artery surgery. All this drives up costs. There is no rationing of care in the elderly, and our patterns of care are adopted in other countries. We pay more for drugs - about 10% of our health budget is for pharmaceuticals - and they are more expensive.
"To reduce costs, health systems could restrict supply, but people are able to get around limits with politics and lawyers. We had a physician shortage, and then we imported them from countries that couldn't afford to lose their doctors. We pay doctors on a per-diagnosis basis. We have a gatekeeper mechanism so one can't see a specialist without permission, but this has made primary care much less popular.... America has the best of systems and the worst of systems. If you are insured, a 12-month wait for hospitalization, as in Britain, would make you a laughingstock. Americans insist on being treated immediately."
Many of today's patients know more about their disorders than their doctors, who don't have the time to update themselves on the Internet, said Prof. Martin McKee, an expert in European public health at the London School of Hygiene and Tropical Medicine. "The world is getting a lot more complicated. If you were a teacher and wanted to open a school 100 years ago, you would need only a room, tables, chairs and a blackboard. Today you need a lot more, and health care has not escaped this trend."
The rise of chronic diseases requires some self-management by patients, but "there must be negotiation with them rather than just telling them what is best. You can't transfer all responsibility to patients because it won't really save money. Just look at efforts to save money in the UK: A cheap telephone directory inquiry service and rail privatization both turned into disasters," McKee said.
PROF. NAOKI IKEGAMI of Keio University School of Medicine in Japan said he tells his medical students that if they don't like talking to old people, they had better leave school. "That will be their profession. Ageing is a big problem in my country," which has the highest life expectancy in the world. "The percentage of elderly in the population was 7% in 1970, is 20% now and will be 27% in 2020."
He described his country's system of longterm care insurance, established in 2000 to cope with the growing numbers of elderly. Those certified as being eligible in a battery of physical and mental tests, he said, are entitled to a free choice of medical providers, with copayments reaching 10% of costs up to a ceiling for low-income individuals. Monthly benefits range from $450 to $3,300 for home and community care, and in institutional care some to all "hotel" costs are covered depending in income and how fancy the amenities. But Ikegami said benefits were so generous that 16% of the elderly became eligible, even though only 12% were planned for inclusion; the government decided in April to cut back services for those who are not very disabled.
Many participants shuddered when they heard the lecture prepared by Prof. John McKinlay, a former head of the Boston University Center for Health and Advanced Policy Studies (delivered by Australian sociology Prof. Evan Willis because McKinlay suddenly contracted a respiratory infection). He predicted that family doctors will become virtually extinct in the coming decades, and that non-physician clinicians such as nurses, Internet diagnoses and hospital specialists would largely replace them. With the system driven by cost considerations, the primarycare physicians who remain, he predicted, will be "gatekeepers" who refer patients to others. The general practitioner is "already becoming marginalized," he added, and medical students realize this, with most of them wanting to be specialists. The kindly image of TV's Marcus Welby a quarter of a century ago, he said, has been replaced by the impersonal doctoring of ER.
Although numerous participants later argued that this prediction was more suited to the American health system than to that in Israel or Europe, all agreed that market forces, competition and cheaper workers would be the global trend.
Perhaps we are heading for a system ruled by computerized databanks, as suggested in the videoclip caricature presented by Maccabi Health Services director-general Prof. Yehoshua Shemer during his lecture. A man is shown ordering pizza by phone in 2010.
"Your medical records show that you have high cholesterol and high blood pressure," he is told by a synthetic voice. "You can't have pizza. And I see you live in an orange zone with a higher crime rate, so there is a higher fee for delivery. But you can afford that: You just returned from a trip to Hawaii. Still, you've gotta watch your waistline. It's 42 inches. If you order meat, you're entitled to a discount on a sickness magazine, but you must pay cash."
"It's funny, said Shemer, a former Health Ministry director-general, "but maybe it's not too far away."
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