Medicine is changing—for better or worse?
When I was admitted to medical school, I underwent a rite of passage: I treated myself to a top-of-the-line stethoscope. It cost 79 dollars, and its tubing was a mere 12 inches long, requiring that I get up close and personal with patients. I even recall throwing my back out once leaning over during a bedside exam.
Over the years, I noticed an interesting trend: stethoscopes were getting longer. First 18, then 24-inch models came into vogue and became standard. The latest model is 27 inches long and costs over $200.
But the most deluxe version is an even pricier digital stethoscope that amplifies sound and creates a visual tracing, facilitating interpretation; it obviates the need to master the ancient art of auscultation—discerning subtle differences in heart sounds. It has the ability to perform ECGs, and an AI-enabled app interprets the results, highlighting murmurs and rhythm abnormalities. It also comes with a Bluetooth accessory, eliminating the tether of an ever-longer tube—that enables you to be as far away from the patient as you want! It does everything but file an insurance claim—but that may be next.
It’s a perfect metaphor for the depersonalization of today’s medicine.
Medical consumers are reminded of this new reality every time they visit the doctor—er, “health practitioner”; there’s scant eye contact during a hurried appointment, with most of the time devoted to your caregiver slavishly entering data on a screen, burnishing the “electronic medical record”.
Depending on the diagnosis, the EMR may prompt the practitioner: “Which statin, blood pressure medication, or anti-depressant would you like to prescribe [complete with menu options]?” Algorithms, super-charged by AI, are replacing critical problem-solving by independent-minded physicians. You don’t need to think—for every problem, there’s a template.
When I attend my med school reunions, I reunite with brilliant classmates who love being doctors. But they lament their loss of autonomy as private equity wheeler-dealers swallow up small group practices; return on investment supplants patient care as the prime goal of healthcare. Administrators proliferate, at the same time a critical doctor shortage looms. Burnout and disillusionment are prompting a wave of early retirements of veteran practitioners.
“Doctors are less likely to own their practice. We are employees working for the worst administrators imaginable.” says Vinay Prasad in his popular Substack Sensible Medicine.
Drug costs are soaring. When I started my career, drugs could set you back a mere couple hundred dollars per year. Now, when I look up the prices of exotic medications hawked in direct-to-consumer TV ads, I’m stunned; some cost hundreds of thousands of dollars for a course of therapy, albeit that their true costs are obscured by opaque insurance reimbursement schemes. Nevertheless, medical bankruptcies soar, and Medicare and Medicaid Armageddons loom.
Technology is enabling “moonshot” initiatives like Larry Ellison’s 500 billion dollar “Stargate Project” that promises to vanquish cancer by facilitating deployment of personalized medicine, tailored to each patient’s unique genetic and biopsy characteristics. Innovative immunotherapies indeed have the potential to revolutionize our treatment of cancer, but so far these biologics are extraordinarily pricey, rife with side effects, and achieve only modest survival increments, with rare definitive cures of advanced cancers.
Same thing is happening with Alzheimer’s. Big Pharma is all-in on the “Amyloid Hypothesis”, with plaque-buster drugs of limited efficacy, shouldering aside cheaper, more plausible solutions. My recent podcast episode with investigative journalist Charles Piller, author of “Doctored”, explores corruption and fraud in Alzheimer’s research.
Facebook founder’s Chan-Zuckerberg Initiative confidently proclaims:
“Is it possible to cure, prevent or manage all diseases by the end of this century? We think so. In the last 100 years, biomedical science has made tremendous strides in understanding biological systems, advancing human health, and treating disease, but much more can be achieved in the years to come.”
No doubt deployment of tech will provide advances, but . . .
Wouldn’t it be better to invest even a tiny fraction of these huge outlays to investigate root causes of these diseases and implement lifestyle programs to stem their tide?
Meanwhile, researchers found that 72% of office visits in the U.S. involved medication or drug therapy.
When in 1983 I announced to my mom—the possessor of a mordant sense of humor—that I’d graduated med school, she presented me with a button that said, “Trust me, I’m a doctor!” That gag pin always prompted us to laugh together, but the truth is, it highlights a sad fact:
“Americans’ trust in doctors, hospitals plunged during pandemic, survey suggests”:
A Mass General Hospital study found that, “Trust in US physicians and hospitals fell from 71% to 40% during the COVID-19 pandemic across sociodemographic groups”.
It’s not just the misfires of our public health establishment during COVID that created this disillusionment; it’s the culmination of a long-standing trend. According to a recent review:
“The Harris Poll shows that the share of the public expressing a great deal of confidence in ‘the people in charge of running’ medicine had already fallen from 73 percent in 1966 to 57 percent in 1973, and eventually to 34 percent in 2012.”
Even our media portrayals of doctors have changed. We went from the heroic Drs. Kildare and Ben Casey of our childhoods to the always reasonable and compassionate Dr. Marcus Welby of the 70s to the cynical 21st Century doctors of “Scrubs” and the demented Dr. House and Nurse Jackie.
Into the breech comes a new disruptive administration vowing to radically reform healthcare to “Make America Healthy Again”. I’m hopeful, but wary of the powerful forces arrayed to defend the entrenched status quo. In any event, 2025 will be an interesting year for Intelligent Medicine. I look forward to keeping you informed!