Gatsby believed in the green light, the orgastic future that year by year recedes before us. It eluded us then, but that’s no matter—tomorrow we will run faster, stretch out our arms farther. . . . And then one fine morning – –
So we beat on, boats against the current, borne back ceaselessly into the past.
– F. Scott Fitzgerald, “The Great Gatsby”
Roy Smythe–(Forbes)–Healthcare is frequently described as an “art and craft,” while simultaneously as a technical and scientific endeavor, and providers of care have been comfortable with this paradox up to now. F. Scott Fitzgerald suggested, after all, that “the test of a first-rate intelligence is the ability to hold two opposed ideas in mind at the same time and still retain the ability to function.”
However, as the first crop of the digital revolution’s technologic fruits are just now beginning to ripen, and taking on increasing importance in medicine, fewer may be comfortable with the dichotomy. Entrepreneurs steeped in the promise of technology to “disrupt” at times scoff at the description of healthcare as art and craft, while others vigorously defend this orientation as the essence of the doctor-patient relationship.
Regardless the debate, the provider of the future will in some cases become more a guide than an intervener, as technology becomes more powerful and more capable of supplanting the need of expert human input. However, the likelihood of technology completely supplanting the need for human empathy and understanding is remote.
In this light, those that draw and interpret the maps of medicine in the future will remain important to us, even if they do not accompany us hand-in-hand as we travel on every journey. They will help us to understand which paths we should walk, remind us of the dangers and pleasures along the way, encourage us to imagine the trek’s destination, and perhaps assure us of its completion.
Before the industrial revolution all goods were indeed “crafted” — fashioned one at a time by hand. And up to the present medicine has been practiced in a similar manner. However, despite the fact that there will be an ongoing need for art and craft in healthcare, the imperative to better manage the health of populations suggests that more effective “mass production” processes must be applied.
Here I would reframe the concept of population health management — not as depersonalization of care for individual patients as some exhort, but as the next logical step in the evolution of public health.
Now that we are not routinely dying from cholera, why not tackle en masse cardiovascular disease, obesity and inactivity as well as predisposition to future preventable diseases?
Few would suggest that clean air and water be provided only on an individual and case-by-case basis. Most would also hesitate to submit that we should not mass immunize for certain infectious diseases (yes — contested by some, but not worthy of discussion), or that we not monitor and report on the distribution of epidemics in populations. Another way to think about it is that we are just trying to move up on a healthcare “Maslow’s hierarchy”. We have made great progress (not everywhere, admittedly) in meeting basic physiologic needs and safety concerns, but we have a great distance to go for self-actualization as it relates to health.
If we are to comfortably take on a mass production mentality for health, we need to have a manufacturing schema designed to produce the product we desire. Other industries understand succinctly the products they seek to produce, and the schema that is necessary to create them. In healthcare we should be seeking to manufacture health, and therefore the comparable schema we employ should be designed to do so.
Unfortunately, it isn’t.
The automotive industry manufacturing schema is easy to understand, and goes something like this:
Raw Materials (Steel) + Tools (Robots, Welders, Painters) + Labor (People) = Car
Taking the same approach, what is the health care manufacturing schema – one that we might use to mass-produce the next level of public health?
We might be inclined to believe that it is this:
Raw Materials (people) + Tools (diagnosis, treatment, prevention and management technologies) + Labor (people) = Health
However, it is really structured something much more like this:
Raw Materials (sick people) + Tools (diagnosis and treatment technologies) + Labor (people) = revenue, market share, and recovery from acute illness
Much as past public health efforts required that we lay clay, steel and plastic conduits to remove waste from our dwellings, we are now laying digital conduits that could have similar powerful impact. However, how can we expect to mass-produce health, when our manufacturing schema isn’t structured to do so?
One of the problems we face is the use of “tools” themselves. In addition to diagnosis and treatment tools, we need to implement myriad technologies that are becoming available that may predict some illnesses prior to development, manage those already present more effectively before they require intense intervention, or prevent them altogether.
I recently asked Dr. Robert Wah, the president of the American Medical Association, about the use of these new tools by physicians: “How will you work to help physicians accept the new tools and processes that are becoming available in health care — understanding that there can be a great deal of resistance to change?”
He hastily replied, “I have to disagree – physicians have always been very accepting of change, and have adopted many new technologies.”
What he suggests is correct, but only within the existing manufacturing schema.
Over the past century, physicians have readily adopted new diagnosis and treatment technologies. However, these types of tools do not necessarily change the overarching model of health care delivery – one that has brought us as far as it likely can.
Most know F. Scott Fitzgerald, quoted earlier, as the author of The Great Gatsby. He captured, as New York Times characterized in his obituary, “the skill of a reporter and the ability of an artist,” the post WWI culture of Western society.
Fitzgerald was born in St. Paul, Minnesota in 1896 — around the time that modern public health efforts were ramping up significantly across most parts of the United States. Minnesota initiated mandatory smallpox vaccination in 1883 for school-aged children, and Fitzgerald and other children born in the Twin Cities during this period were spared the risk of contracting this deadly disease as a result.
However, no matter his fame and accomplishment later in life, a combination of depression, heavy smoking and alcoholism led to Fitzgerald’s untimely death at age 44 by heart attack on December 21, 1940.
Despite the adoption and use of marvelous diagnostic and treatment capabilities since Fitzgerald’s death, and the many public health successes allowing most of us to at least have the opportunity to live into adult life, we continue to be “borne ceaselessly into the past.” Men and women are still dying comparably untimely deaths more than a half-century later.
Dr. Roy Smythe is a Forbes contributor and the Chief Medical Officer for Valence Health, a Chicago-based health care consulting, services and operating company that seeks to facilitate the ability of providers of care to manage medical and financial risk.
