Medicine as Metaphor

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Digested First Pages:.

Medicine as Metaphor

Why "Medicine as Metaphor?"

Hello all,

I look forward to sharing in a spirited discussion with you about six or seven key issues related to medicine.

Before we dive in, I want to cover my tail by making one thing perfectly clear (to quote a still-remembered former American president) "I accepted this assignment with unbounded enthusiasm but virtually no time to make ready for taking the helm of a six-week conference. However, because I've been living with and thinking and writing about the topic for many years, what I lack in readiness I hope to try to make up in liveliness."

In these opening notes I delineate some thoughts about the structure our discussion but I am well aware that a good exchange is likely to take on a life of its own and spin off in unexpected tangents. I will also share more information than you may want to know about me, not because I want to take advantage of a relatively captive audience, but rather to inform you about where I'm coming from in relation to what we will talk about. If during the conference I appear inclined toward overly strong assertions and positions, it's intended to stimulate vigorous debate. Truth to tell I have a fair and open mind. Why, I even been known, once or twice in my life anyway, to be persuaded to change my position about an issue. I will do my best to acknowledge and respond to each message that comes in, but I know Harlan Cleveland (from his Leadership conference) and I'm no Harlan Cleveland--" now and then, I like to get a good night's sleep.

I chose the conference title "Medicine as a Metaphor" because I have tunnel vision about Medicine and I believe that in one way or another "Medicine" encompasses virtually every issue confronting us as a people. Take your pick: economics, both applied and theoretical; equity in the treatment of individuals with respect to quality of services and access to them, finances, personal respect; the erosion of caring in a society becoming immune to outrage; the ebbing of idealism and the way we care for the very young, the very old, the disenfranchised, the physically and mentally incapacitated; the spread of free market worship into realms that need to be sheltered from its intrusion because of fundamental incompatibilities between free market idolatry and the basic values of good Medicine; morality and integrity in our communal life; the need to cope with and guide fast-paced technological advances; money problems, governance problems (who runs the country for whom?); international relations (AIDS, bioterrorism, etc.); and on and on. You name it, the issue is there in the heart of today's Medicine. Thoreau saw the world in a grain of sand, I see it in Medicine. In six weeks we'll only scratch the surface (and I'm not even a dermatologist).

1:1 Leonard Laster What do I mean by "Medicine?"

For me, Medicine serves as an umbrella term to cover the services, activities, behavioral attributes brought to bear in caring for sick people and in trying to keep healthy people from becoming sick. It encompasses a variety of professions: doctors, nurses, technicians, researchers, administrators, etc. It includes a range of settings, organizational structures, financial entities, laboratory types, corporate entities, etc. in which these people do their work: offices, clinics, hospitals, government facilities, academic health centers, pharmaceutical companies, for-profit HMOs, etc.

Incidentally, by "Doctor" I mean a medical school graduate who cares for sick people, a physician. I realize there are many other doctors in the universe -" Ph.D.s, veterinarians, osteopaths, optometrists, nurses, practitioners of fine arts, etc., but allow me, please, to use "doctors" to mean doctors.

1:2 Leonard Laster Why the word "Medicine" and not the phrase "Health Care?"

Because I do not trust the label "Health Care." I regard it as a euphemism introduced as PR spin to persuade people that the main purpose for seeing doctors is to be kept well and this will solve the problem of the escalating costs of medical care. I grant you doctors ought to try their best to keep people from becoming sick or experiencing the negative consequences of aging, and to help people stay happy. I grant you, for the moment anyway, we're living longer and many of us, especially the tennis players (except the walking wounded among them), are feeling much better than temporal age would have permitted in the past. I give credit for this happy change to exercise, eliminating smoking, better eating habits, etc. But unfortunately this progress may be dissipated before too long by such factors as rampant obesity, continued substance abuse, AIDS, etc.

But even in this era of increased longevity and better health (for some segments of the population at least) the truth is most of the heavy lifting in what doctors do is trying to keep up with or get ahead of the battle against human disease by treating sick people. In my eyes, the preferable name for this work is Medicine rather than Health Care.

Digression: Between 1969 and 1972 I was a resident Democrat in the Nixon White House. The NIH Director assigned me out of my research lab (I'm an M.D., trained internist, who worked at the NIH from 1954 to 1969 exploring the biochemical basis of human disease and taking care of sick people with poorly understood diseases) to the President's Office of Science and Technology. I worked with Nixon's Science Advisor and covered biomedicine and related issues. During that time Nixon and his people (Paul O'Neil, then in the Bureau of the Budget was deeply involved in Medicine's problems) paid a surprising (to me) amount of attention to Medicine. I believe Nixon issued the first Health Message by a U.S. President. They insisted on using the term Health Care. I objected, but no one listened. I think, too, they felt it had a positive political spin to it.

1:3 Leonard Laster Where I'm Coming From

This is to give you some insight to the roots of my views and attitudes. People who value their time will skip this message.

A few years ago I wrote a book, Life After Medical School. It explored the general question of how people determine their professional by using medicine as a metaphor. I presented the stories of 32 doctors who went in and came from different directions in medicine -" family practice, physician to the homeless, CEO of Merck, Governor of Vermont, Surgeon General (if only for ten minutes -" she was bounced for talking about masturbation), etc. Only a few fell into my category -" knowing from childhood you wanted to be a doctor. At age 6 I suffered from a ruptured appendix and developed peritonitis. That was before the age of antibiotics and by all odds I should have died. The idea of doctor may have started then.

Next came books The Citadel, Microbe Hunters, Arrowsmith, etc. Then came medical school-- "delivering a baby for the first time and holding the miracle of humankind in your hands."

I trained as a real doctor but went off to the NIH intending to stay for two years. I stayed for 22 and learned the meaning of excellence. When I left Harvard my mentor told me to stay at NIH for two years and then come back. The Clinical Center of the NIH was brand new," I was in the first wave of doctors to populate," and my mentor said it would be a boondoggle full of bureaucrats. "The Congress would have been better advised to have given the money to Harvard," he said. In my time there some nine of the bureaucrats who worked there, a few down the hall from me, went on to win Nobel Prizes. I like to think it was because they were working near me but perhaps not. Those of us who were fortunate enough to share in that time look back on a genuine Golden Age, a true Camelot.

Then I was volunteered to Nixon's Science Advisor. I saw the tension between Science/ Medicine and Politics. After three years and two Science Advisors, Nixon abolished the office of Science and Technology and threw us out into the street.

Eventually I ran academic medical centers -" VP of Downstate in Brooklyn (4 yrs), President of the Oregon Health Sciences University in Portland (9 yrs) and Chancellor of UMass Medical Center in Worcester (3 yrs). I established a research center in Oregon that is now one of the leading centers for molecular neurobiology in the world. In 1991 I became Chancellor Emeritus at UMass and was appointed Distinguished University Professor of Medicine, Health Policy and Janitorial Services at UMass. I stepped out in June, 2002.

I served as a director of Tektronix and Standard Insurance in Oregon. I'm now a director of TEI Biosciences and the Photoelectron Corporation. I have consulted with pharmaceutical companies, private business people who wanted to establish a research center to jumpstart their local economy, etc.

I'm working on a second edition of the Life After book and four others books. Last May I became a working columnist for the Times—no, not The New York Times, The Cape Cod Times. My wife, a working artist, and I live in Woods Hole. As of June 15 I'm not retired but rather redirected. I take the writing seriously and I worry about what's happening to Medicine. My credo is that I envy no man his wealth, position, power or fame. I envy only those who homes are connected to the main sewer line in Woods Hole.

1:4 Leonard Laster What will we talk about? Unless our conversation takes us off in unexpected directions, here is the outline I propose to follow.

Topic 1: PREMISE: Medicine in this country has become almost entirely a for-profit, free-market enterprise. Even the so called not-for-profits (such as academic medical centers and government institutions) are now forced because of economic pressures to behave like the for-profits to survive. I have nothing against the free market (I serve on boards and I would not object to becoming wealthy, but only if I could do it by legal and moral means) but the free market does not belong in each and every facet of our societal lives. Among the sectors from which we should exclude free market principles and behavior, Medicine ranks at the top. Some of the fundamental inherent attributes of the free market are irrevocably incompatible with good medicine.

I will present my reasoning and provide examples of how insinuating the free market into medicine hurts patients. Then we can debate whether I'm nearer to right or wrong.

Topic 2: PREMISE: As with Gresham's Law about good and bad money, the free market philosophy drives out all the others. Further, once introduced into a sector, the free market does not relinquish its hold very readily. So, unless the health care sector implodes like communications, high tech, and the rest, and becomes unattractive to free market adherents, it is destined to remain a for-profit sector.

If we agree a change is needed, we could discuss approaches to modifying today's situation. Do not jump to the conclusion that I'm an advocate of a system based on nationalized medicine. In my view it has serious defects, some as worrisome as the free market approach.

So then, what should we do? If I knew the answer I'd be out pushing to solve the problem because I see us heading for a cataclysmic implosion of our Medical System. But I don't know the answer and so I spend my time writing and yakking.

Topic 3: PREMISE: The current situation is leading to bigger and bigger health care organizations, both private and public. Organizations that grow beyond a certain size lose their capacity to deal fairly and humanely with individual clients. (I have a piece called "Big Systems, Little People" to dredge up.) People are getting lost in the shuffle and too many of us will suffer from it or even die. What to do?

Topic 4: PREMISE: The free market trend has skewed the culture of medicine away from caring. Medicine was never perfect and it always had its share of rogues. But today's culture appears to have reconfigured medicine-™s underpinnings. I have a piece called "MD/MBA -" Not my Doctor" to share. It aroused a groundswell of hostility from the doctors with MBAs.

For our own good we need to restore "idealism" to various components of our society -" doctors, clergy, legislators, members of the judiciary, etc. How?

Topic 5: PREMISE: In times like these, the admirable drive to learn more about human biology and chemistry and about how we can use basic research to improve our lives, takes a back to seat to aspiring to patent one's laboratory findings and make a killing as CEO of a biotech start-up.

Have we twisted the culture of medical research to our detriment? If so, what do we do about it?

Topic 6: PREMISE: Too many unthinkable, unbelievable events have come to light in our world politics and world business -" but medicine has had its share. The doctor in England who killed many (50 or 100) of his patients, apparently for the fun of it, the doctor who left a patient during surgery to get to the bank, the pharmacist who diluted cancer medicines to up his profit and then gave some of his loot to his church, etc.

What does this tell about what we have become as a people? Are we really very different from past generations, or have we suffered a grim sea change in our communal character? Subject to change but these are for openers.

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