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San Francisco, CA, November 10, 2002 - Ralph Snyderman, M.D., chair of the Association of American Medical Colleges (AAMC), chancellor for health affairs at Duke University, and president/chief executive officer of Duke University Health System, issued the following statement today at the AAMC's 113th Annual Meeting: "Medicine has been identified as a profession since earliest recorded history, yet the impact of science on the practice did not begin in earnest until the early part of the 20th century. At that time, the emerging sciences of anatomy, chemistry, germ theory, and physics created greater understanding of human biology and the pathogenesis of disease. For the first time, the scientific approach started defining mechanisms of health and disease in human beings, and the potential applications to medicine were profound! However, medical practice at that time was virtually untouched by the emerging knowledge that was creating opportunities for the rational practice of medicine. Medicine in the early 1900s was still largely anecdotal, unscientific, and very much unregulated. In addition to a small number of scientifically-based medical schools, there were hundreds of "store front" schools that would grant medical licenses with virtually no scientific training. Fortunately, in the early part of the 20th century, the Carnegie Foundation commissioned a study on medical education. The findings of this study, termed the "Flexner Report," noted that medical practice was not being sufficiently impacted by science. It concluded that medical education should be structured so physicians would be well grounded in science and in understanding the pathophysiology of disease. This conclusion had a profound effect on medical education and helped define the structure of the contemporary academic medical center - that is, a medical faculty involved in research and affiliated with a teaching hospital in which the practice of medicine is learned by medical students and residents in training. An example of this is the "Johns Hopkins model," an outstanding school of medicine, with medical faculty involved in research and practicing in a teaching hospital. This structure facilitated the emergence of specialized medicine as more and more was learned through advances in understanding disease and how to treat it. Duke is steeped in the philosophy of the Flexner Report. In 1924, James B. Duke, one of the great philanthropists of the last century, developed the Duke Indenture and funded the development of Duke University's Medical School and Teaching Hospital. The language in the Indenture was greatly influenced by the Flexner report: "The advance of science and the science of medicine growing out of bacteriology, chemistry, physics, X-Rays, make hospitals essential for obtaining the best results in medical and surgery." It is not an accident that virtually all of the initial faculty of the Duke Medical School came from the faculty of Johns Hopkins Medical School. Since World War II, there has been a national investment of well over a trillion dollars for biomedical research and development. This has fueled a momentum in medical advances that resemble the leading edge of a great tsunami. Emerging fields of genomics, proteomics, and metabolomics will allow us to understand disease better and facilitate early diagnosis and effective treatment. The impact of genomics, with the recent sequencing of the human genome, will give us new therapeutic proteins, disease targets for small molecules, and pharmacogenetics to define populations in which drugs work, do not work, or cause side effects. Gene therapy will soon provide benefits as well. Most importantly, however, will be the greatly enhanced ability to predetermine an individual's risk for disease. Risk assessment provides a new way to think about the practice of medicine - prospectively. The ability to assess risk, to identify the probability of disease occurring before it does, and to do something about it is an emerging competency. Within the next ten years, we will likely have the ability to determine risks for any common disease. This will allow the practice of "genomic medicine" so that at birth, we will assess an individual's susceptibility to diseases, such as diabetes, coronary artery disease, breast cancer, prostate cancer, colon cancer, Alzheimer's, and many other diseases. Think of the power this will give us to predict and prevent disease. When I was an intern, which is not totally prehistoric, we had as a visiting professor one of the leaders in cardiovascular disease. He told us that the way to recognize individuals susceptible for a heart attack was by the thickness of their wrists, how much hair they had on their arms, and their body type. That was "state of the art" risk assessment in the late 1960s. Look at where we are now in our ability to determine risk and to prevent or treat cardiovascular disease. Even without the input of genomics, we have the capability to determine a person's risk for certain diseases. Using heart disease as an example, we approximate risk based on family history, lipids, stress tests, ultrasound, imaging, and angiography. These can predict coronary artery disease before a heart attack occurs. We also have means of preventing this if a person is willing to watch his/her diet, exercise, take aspirin and depending on the individual, statins or other forms of therapy. What this will lead to is the practice of medicine that is proactive, predictive, and customized for the individual. To practice this way, we will need to integrate our delivery systems to provide continuity of care and to have patients thoroughly involved in their own health. Much of what people need to do to improve their health will be based on what they are willing to do, i.e. diet, exercise, risk reduction, etc. We already have many tools to practice this new form of medicine. However, our health care delivery system is not organized or structured to take advantage of these powerful new capabilities. The current practice of medicine is largely reactive rather than proactive. People go to their doctor when they are sick. As physicians, our natural reaction is to identify the defect, whether it's molecular or structural, and fix it. Interventions are sporadic and are heavily directed by physicians alone rather than in partnership with the patient. We have a fractionated delivery system, the relationships amongst the parts are not synergistic. Costs are expensive and inefficiently deployed. What we need to do is to practice prospective health care. We need to be able to detect an individual's risk for developing disease, detect the earliest onset of disease, and prevent or intervene early enough to maximally benefit the individual. We can already do much of this, but we are lacking effective delivery systems as well as effective reimbursement mechanisms. In fact, current reimbursement systems actually punish the development of prospective health care. We must also look at things from the patients' perspective. Patients are now subjected to a dizzying array of health care possibilities but are confused by the options available: primary care physician, specialist, complimentary and alternative therapies, on-line information, and nutritional and/or herbal products. For those in need of immediate care, there are also choices to be made: urgent care centers or emergency rooms where little, if any, attention is paid to continuity of care, let alone health care planning. The current medical record is a strong indication of how we physicians are trained to think. The first thing we do is to ask the patient about their "chief complaint." Even the phrase is prejudicial. From the chief complaint, we move on to take a history of the present illness and then on to a differential diagnosis and plan of treatment. This is a very good way to develop a "root cause analysis" of disease, but it does not force us to think about planning for the future. In addition to seeing patients when they have an illness, we need to develop a health profile, assess current health status, and then do a risk analysis based on genetic, environmental, and lifestyle considerations. We then need to assess the best pathways for them to minimize the likelihood of developing a disease or deal with it at a very early stage. In short, we need to begin developing individualized health care plans and health systems to facilitate their implementation. How can we start implementing prospective health care? We can start
with chronic diseases, which account for the majority of health
care expenditures. One hundred and twenty-five million Americans
have one or more chronic conditions, and we have an aging population
that will increase this amount. Chronic diseases already account
for roughly one trillion dollars worth of health care expenditures.
Chronic disease develops over time. For example, diabetics must
worry about the development of blindness, renal failure, or peripheral
vascular disease. However, these complications to not appear until
years after onset of diabetes, which provides a window of opportunity
to delay or prevent these complications. Unfortunately, our health
care We have the capability now for early intervention for most chronic diseases, and we know that with many diseases-coronary artery disease and adult onset diabetes for example-that we can prevent complications if effective intervention occurs early. However, our current health care system is not designed for this. We need to shift our focus from acute care to prospective health care. We need to develop individual health plans that include a risk assessment for the development of chronic diseases. We need standards of care programs for identified risks for both chronic and acute diseases. We need a provider team to facilitate the care of people, particularly those with chronic diseases. For individuals with congestive heart failure or diabetes, it is doubtful that a single provider could handle all of the patient's needs. Instead, these patients need access to a team of health care providers, including a care coordinator. We need to focus on patient education and motivation, because we are trying to prevent problems that have not yet occurred. This will require a commitment by the patient to modify his/her lifestyle. Interactions between patient and care system need to be ongoing. There needs to be a collaborative and ongoing relationship between the provider, the patient, and an integrated delivery system so that everybody gets what they need when they need it. There have been documented reports showing that managing care really does work for patients with congestive heart failure, diabetes, and asthma. At Duke, we have been preparing our institution to start dealing with prospective health care and have initiated pilot programs. We still have a long way to go. Reimbursement systems do not allow prospective programs to occur on a grand scale as they do not fund preventative care, and they reward expensive interventions. Hopefully, rational reimbursement can be negotiated amongst providers and payers, but it is likely that political forces in support of such approaches will be needed. Ultimately, universal health coverage will be needed to support the development of individualized health plans for all as well as access to the appropriate level of care on a continuing basis. This concept of managing care is not new, but managed care didn't it work. Why? When managed care was introduced some 30 years ago, the capabilities for predicting risk and deploying effective interventions were just emerging. Managed care was driven almost entirely by economics and was not focused on improving the quality of health. It dealt with populations, not individuals. Appropriate delivery systems to integrate and manage care were not generally available. Additionally, it had virtually no buy in from physicians! I would argue that one of the main failures of managed care was it never had the buy in and support of the medical profession and academic medicine. Physicians were not trained to understand its rationale and benefits, and practice models weren't developed to allow it to work. If done right, the development of a health care system that focuses on prospective health care will be every bit as transformational as the coupling of science to medicine was in the 20th century. How is this to be accomplished? Academic medicine, insurers, and payers (both public and private) will need to work together to develop delivery models. We need to adapt medical education to address all the forces that are going to be transforming health care at the time when our students are practicing as physicians need to be part of the solution and not part of the problem. We need research on how prospective care can best work. We need to develop funded pilot practice projects, so that we do not go broke trying to determine what works and what does not. Then we will have to develop models for effective delivery systems. I do not believe that we will need fully-owned integrated delivery systems, but I believe we will need to integrate operationally to provide a continuum of care. One of the most necessary aspects will be the development of appropriate reimbursement mechanisms. We need to have the Center for Medicare and Medicaid Services, insurers, and, indeed, all payers support this objective and to fund it appropriately. The outcome will be a far more health-oriented and cost-effective system. As a next step, I support the creation of an AAMC Institute on Prospective Care. We in academic medicine can lead the transformation of American health care in the 21st century as our predecessors did in the 20th century. # # # # # # The Association of American Medical Colleges is a not-for-profit association representing all 129 accredited U.S. and 17 accredited Canadian medical schools; nearly 400 major teaching hospitals and health systems, including 68 Department of Veterans Affairs medical centers; and 94 academic and scientific societies. Through these institutions and organizations, the AAMC represents 109,000 faculty members, 67,000 medical students, and 104,000 resident physicians. Additional information about the AAMC and U.S. medical schools and teaching hospitals is available at www.aamc.org/newsroom. |
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