Posted by: drwbortz | June 28, 2011

Healing American Health Care, Flexner II: Body Shop or Classroom?

100 years ago the fledgling American Medical Association (AMA) and the Carnegie Foundation joined in an effort to redress the wretched state of medicine in America. Its scientific value was meager, but more important was medicine’s status as an enterprise, of charlatans and hucksters. The AMA and Carnegie sought out Abraham Flexner, a young Johns Hopkins graduate educator to lead the examination.

The resulting Flexner Report is widely regarded as the single most important document in the history of current medicine. Its scathing content targeted practice, training and process. 91 of the diploma mills were driven out of existence. A new model based on the Johns Hopkins example was made the prototype.

A century after this reformulation an immense gain in medical science is in hand. Yet the medical profession again receives failing grades. It is bankrupting, unfair, dangerous, corrupt, inefficient, inconsistent and irrelevant. It confounds our leaders.  It suffers from total body pain.  Another Flexner type effort is called for.

Thomas Kuhn, the historian from the University of Chicago  observed in his book “The Structure of Scientific Revolutions”  that in order to abet a true revolution two prerequisites must obtain. First, there must be a general agreement among the aggrieved parties that a change is demanded. Appeasement is futile. Second, there must be a replacement paradigm available of sufficient dimension and power to replace the failing model.

For the colonists of 1776 a revolution was mandated. Representatives from Massachusetts, Virginia, Pennsylvania, New York and the other nine colonies together signed a parchment declaring independence, a ringing statement of consensus. Nine years later, again in Philadelphia, a similar group produced the replacement paradigm in the Constitution, endowing democracy instead of monarchy. America was born.

For medicine, despite much unrest, these two requirements have lain fallow. But now there is a growing agreement that revolution is required. Doctors, patients, labor, industry, Democrats, Republicans, the meek, and the mighty are a chorus of distress.  On a recent Stanford visit Peter Orzag said that in order for America to get on with the rest of its business it must have a major resolution of the health-care mess. The first revolutionary requirement is fulfilled.

But even more importantly, for the first time in history, there is now a sturdy replacement paradigm.  This replacement is health, instead of the ruling mantra of disease. Now we know with precision the determinants of health. Until now, health has been a bland platitude. Albert St. Gyorgy commented that health to people is as water is to a fish, a presumption.

Now we know with precise metrics the determinants of health, just as we know the much more extensively studied determinants of disease.

The exposition of health is immensely empowering. It is empowering exactly because it validates the supremacy of prevention over repair as medicine’s modus operandi. Heart disease, diabetes, cancer, frailty, and AIDS are rarely curable, but are securely preventable by the replacement paradigm of health. And they are vastly cheaper, fairer, and more relevant. Kuhn’s required replacement paradigm becomes “Health instead of disease, prevention instead of repair. I call the new model “Next Medicine.”

The scene is set to fulfill medicine’s transformation, Flexner and Kuhn revisited. Medicine’s mission is the assurance of the human potential. Its current tools of surgery, technology and pharmacy make little dent on the overwhelming confrontations of diabesity (fat children) and aging. Its technology and pharmacology are irrelevant to our society’s needs.  Current medicine fails its mission. It is a square peg for a round hole.

The Centers for Disease Contol (CDC) conjures that ours is the first generation in the history of our republic when the children will live less long than the parents.

Fully 60% of our annual medical expense of over $2.7 trillion is attributable to behaviors that are perverted, and are preventable. Nurture not Nature is the answer. Health illiteracy is our biggest problem. It cannot be addressed by the current model of repair which is now in place, because it pays.  Capitalism is not the problem, but its product is illness instead of wellness. The fee for service model embraces sickness.

Perverse incentives now prevail. We must promote health instead of disease.  We must embrace prevention instead of repair. Health must pay.

Medicine’s primary job harks back to the mission of Asclepius and Hygeia: health. “Doctor” comes from docere, to teach. Learn it. Teach it. Live it. Save trillions.

Medicine needs a new Flexner Report that would recommend classrooms instead of what are now body-repair shops.




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