Medicine in the 21st Century, Part I

THE OPEN MIND
Host: Richard D. Heffner
Guest: Gerard Burrow, M.D.
Title: “Medicine in the 21st Century”
VTR: 3/15/93

I’m Richard Heffner, your host on THE OPEN MIND. I have been for many years now. And all during them my wife has insisted that anyone could tell which of the stages of life I’m at, what crisis I’m experiencing at the moment by simply taking careful note of who my OPEN MIND guests are, what they do…what we discuss.

And surely she’s right on target today. For here I am, pushing my biblical allotment of time, worrying about my health, and my health care: how good it will be in the crunch, and how I’ll pay for it. And so my guest today is one of that handful of men and women whose work places them so squarely smack in the middle of perhaps the single most controversial and attention-getting area in American life: the practice and teaching of medicine…with all of its difficult questions about the delivery of the right amounts of health care, in the right places, at the right times, to the right numbers of Americans, namely: all of us.

Gerard Burrow is the new Dean of Yale’s School of Medicine, is described as a talented Administrator and fund-raiser, an internationally respected medical researcher and a compassionate physician.

Dean Burrow wants Yale to stand in the front lines of this nation’s debate over health care reform. He says that “The health care system [in America] is in chaos. To be spending more money than anyone else in the world, and yet to have 35 million people with no health insurance and half the children in inner cities not getting immunizations…it’s just wrong”.

And Dean Burrow also says that “what has made medicine in this country great is its entrepreneurial spirit, and we don’t want to kill that”. But he notes that “we’re getting close to anarchy. We have to replace what we have now with something”.

Now I would guess that Dean Burrow won’t tell us today precisely what that “something” will be. But he has already taken on the burden of describing what medicine in the 21st century will be or should be…and I would start there today.

Thank you for joining me today, Dean Burrow. And I, I hope you don’t mind that I go directly to the notion you have expressed that if you had to make a statement of what health care should be, you’d use a quote of several thousand years ago, “No more shall be heard the sound of weeping and the cry of distress. No more shall there be an infant that lives but a few days, or an old man that does not fill out his days”. And I wonder whether looking to the next century that you don’t think that that ambitious look to the future is perhaps what gets us in trouble.

Burrow: Well, I’m not sure, Dick. I, I think the whole question of infants and paranatal mortality is an important one. If one looks at, at the increase in longevity that we’ve had that increase has really been what we’ve been able to do in having babies become born and live towards older age. We don’t do it as well in the United States as many other countries do. And there’s absolutely no reason why we can’t do that. The other part of it may be where we get into trouble. Because I think you have to distinguish between living out one’s days, and trying to live beyond one’s days. And I think that one of the problems that we’ve gotten to in the United States at the present time, has been a desire for immortality. Rather than having somebody live well until the body wears out, that we attempt to push this beyond that period of time. I think that’s been one of the difficult areas.

Heffner: I know that I’ve been spending my time recently, well, really preoccupied with a Living Will so that I could provide that you doctors won’t make it impossible for me to live my quota and then no more. Why is it that you, we have taught doctors not to let people go?

Burrow: I think that one of the problems is that doctors have regarded death as a disease, as, as a pathological process. And therefore if you can cure or prevent that pathological process, death should not occur. I think that we partially have to re-orient ourselves and to teach that it is part of a natural process. That the body probably has a finite warranty and at the end of that it, it goes. And what our job is, is to prevent it from having the warranty lapse before its time.

Heffner: What about that warranty? How long would you say it is?

Burrow: Well, there are arguments over that, but it’s probably somewhere around 85 years. After that, that the body simply has very little reserve and begins to wear out. Now there are more people living to 100 now, but that’s partially because we’re bringing more babies along, bringing more people into the age group around 85 and so that they’ll fall out on both sides of that number.

Heffner: Yeah, but wait a minute…I’m puzzled. If more and more people are living beyond 85, how do we account for that and why shouldn’t we insist that the warranty be pushed…not to six months or a year, but to 90 or 100?

Burrow: Well, I mean I think that this is, is the, the argument. One is that if you have an apple tree, and measure how those apples fall off the tree, the, the greatest number of them will fall off in some middle range, and then some apples will fall off much earlier, and other apples will fall off much later. If you bring a larger number of people to this age, it’s going to be just like the apple trees. Some will die earlier, some will die later. There is an argument among scientists as to whether, in fact, that the life span is being extended. I think that the majority of scientists now believe that that’s not true. But there is other evidence, and I think that that’s not clear.

Heffner: And your own position?

Burrow: I believe we wear out. And so that I see a role, the role of the physician, is like the Energizer Rabbit, it is to keep the rabbit going as long as possible, and then have the battery wear down immediately. I think our role is to prevent illness from causing that to occur at an earlier date.

Heffner: It’s fascinating; you say that many physicians think of death as illness, as a disease. How does that come to be when you in the medical schools are teaching our doctors what to believe?

Burrow: Well, I…that’s a very good question. Partially it’s a disease because when people finally do wear out, they wear out with a disease process. That is that they die because their heart gives out, or they die because their lungs give out, or in, in the younger period they may have an infection. Now, if you have an infection that one can cure that. If you have heart disease it may be possible to prevent this to a certain degree. However, the fact is that as people age that their reserve capacity to deal with these diseases decreases. And if we take this into another sphere of athletics, and you look at the best times for the Boston Marathon, that they slowly decrease from about the age of 30 to the age of 80, so that no matter how good you are, and though training can make you run faster at 80 than I could run at 20, nevertheless it increases. That reserve, the ability to deal with shocks to your system, decreases with age. And it’s also true that it, it’s very low in early infancy. So that both ends of the spectrum is that an illness or something simply pushes you, you over the edge, and you don’t have the capacity to come back.

Heffner: Now a student at Yale Medical School, will he graduate, be graduated from the school having more of the philosophy intact that you have expressed then in another school? Is it a matter of where you go?

Burrow: Well, obviously as the Dean of the school, I’d very much like to say so. I think that young people and young students and young physicians get caught up with the idea of a battle. I mean one wages a crusade against cancer, or the war on heart disease. I think it gets harder to teach that there is really a finite life span. I think one becomes very involved in the technology and that’s also…I think one of the weaknesses in the Untied States is that we really have fallen in love with that technology, which can be very helpful.

Heffner: Are you suggesting that in other countries there is not that love affair with technology?

Burrow: Yes, I think so. I think that…

Heffner: On the part of the medical profession?

Burrow: To a degree. Now that may be that the resources are such that the technology isn’t available and thus people learn to do without it. In that it, it’s been said that if we’re going to control costs, that one simply has to limit the capacity of the system. And in Canada where I spent 12 years that that there aren’t as much technology and things available as there are in the United States. That has disadvantages, but it also has advantages.

Heffner: What are the disadvantages?

Burrow: Well, I think the disadvantages are that one can’t get treatment as fast as one would like it. I would have to say in the 12 years that I’ve been in Canada that I never saw anybody that needed medical care that didn’t get it when they needed it.

Heffner: But isn’t that the crucial point?

Burrow: Yes.

Heffner: I mean theoretically one can say it’s not available, that treatment is not available at the snap of a finger, if it is available here so…but then you go on to say in your years of experience in Canada you knew of no one, I gather, who suffered because of that.

Burrow: That’s correct.

Heffner: Then where are we with this technology here?

Burrow: Well, I think that there’s a feeling that the people in the United States are impatient. I mean if a diagnosis is made and we decide that you need coronary surgery, that you want that coronary surgery done within the next several days. In Canada you may not get it for a month, or perhaps two months if it’s not urgent. People don’t like to have a diagnosis made and then to wait for a prolonged period of time. And I…except we pay for that, and that’s part of the chaos that we’re in at the present time.

Heffner: Do you thin that our present concern wit financing the medical care system will lead us back from this position?

Burrow: Yes. I, I think that one of the things that clearly is going to happen is that we’re going to control costs. And you cannot control costs without limiting capacity.

Heffner: Yes, but now you, you talk about Canada, and I gather you’re talking about European countries, too.

Burrow: Yes.

Heffner: Okay. Given our culture, given our approach to things, do you think it’s possible that we will make that much sense, that good sense, or are you saying we’re going to be forced to it willy-nilly?

Burrow: Well, I think we’re going to have to be forced to it. I mean we talk about how much of the gross national product is going into medical care. I don’t think there’s anything wrong with money going into medical care as part of the gross national product, if people are happy with what they get for it. The problems that we’re getting into is you mentioned is that there are millions of Americans without health insurance. We have half the children in inner cities who have not had sufficient immunizations. So that thought we have a system where we’re spending a great deal of money. People are not happy with the system.

Heffner: You think we’re going to have to make those choices? No, strike that, I really didn’t mean that…I meant do you believe that we cannot, that we do not have the national resources to take care of the people who are now uninsured, take care of our children.

Burrow: I believe that we have the resources to do that. I believe that within the 13% of the gross domestic product that we have that we can take care of our children, and give access to the people that need medical care.

Heffner: And live on the cusp of the medical technological revolution?

Burrow: But probably no…and, and, and live on the cusp of, of the, the revolution, but we are probably not going to have that revolution everywhere and as rapidly as we want it. There is going to have to be a re-distribution of the resources.

Heffner: Geographic distribution?

Burrow: Oh, yes. I think both geographic distribution and what we have now is one segment of the population getting too little care, and probably another segment of the population getting too much care.

Heffner: Define the latter, please.

Burrow: Well that gets hard to know exactly what it is. But if you look, there are tremendous differences across the country in terms of medical care. For example, a study that was done by Dr. Weinberg that was published in the New England Journal showed that an individual in Boston is twice as likely to be hospitalized as one in New Haven, Connecticut, two cities that both have medical schools and are really not so different. So that there are, are community ideas that occur in terms of who goes into the hospital and who doesn’t go into the hospital.

Heffner: Now, that puzzles me…if you had said “Boston” and then taken a city in the Midwest, or in the Southwest, I might have understood. I would ask you to explain it. How do you account for that…?

Burrow: I’m not sure anybody really does know…is that when they looked at this, that the serious diseases…heart attacks, pneumonia, ulcer…the hospitalization rate was the same in both cities.

Heffner: Where does it begin to differ?

Burrow: And it’s things as…low back pain, or, or some of the areas where it’s not clear whether one should be hospitalized or not, they seem to be being hospitalized more frequently in Boston. Now what, what makes that happen, I don’t think anybody really understands. One of the things that certainly does is the capacity of the system to allow it to occur.

Heffner: As opposed to what? You see, I, I…I come from a generation that says there can be too little, but there really can’t be…ever be too much in the area of health care.

Burrow: Well, as opposed to…I mean an example is…let me take another one where it’s clearer. There are clearly communities where if you have angina pectoris…the heart pain, that you have an operation for it. In other communities, that same individual would not have that coronary artery by-pass. And it gets to almost be that your friends say, “Gee, I had the by-pass and I feel much better”, and so you have it, too. I think one of the problems is that we physicians don’t have very clear cut rules…I mean it’s a, it’s a hazy area as to when we should have this, and when, when we treat it medically.

Heffner: You know there’s, there’s a moment of silence because I’m so puzzled by that. I wasn’t brought up to believe that doctors are gods…not quite, but one assumes that the science of medicine, as opposed to then notion of medicine as the art of medicine, would preclude that. Now, let me ask…what do you and your fellow deans in the medical school profession…how are you dealing with that?

Burrow: Well, go back to that first question…I think that we most have said that medicine is an art based on science. And, and the issue that we’re talking about is…sits somewhere in this interface between art and science. And I think that one of the things that everybody realizes is that we’re going to have to have better outcome data. I mean we’re going to have to understand that when we do a procedure…the coronary artery by-pass…that, that in this particular circumstance it’s effective and in other circumstances it’s not effective.

Heffner: But the circumstances, by gosh and by golly, can’t be geographic.

Burrow: No, they’re not. But that isn’t…the operation…but the issue is the rules are not clear at the present time. So that in, in a particular community there gets to be a feeling that this is, is a good operation.

Heffner: Yes, but aren’t you in the cat-bird seat? Aren’t you and the other medical school deans, the people who ultimately decide, make the basic decisions because you’re teaching generations of people who become physicians, what the facts of the matter are?

Burrow: Well, I’d like to think that I were in the cat-bird seat, but I…the, the issues get into clinical care. Now, now we can teach broad strokes…I mean that it is important to have outcomes…that you need to have clear data before you make the decision. And, and these things are being taught in the medical schools. But let me give you an example…that there is an operation done for a narrowing of the, the carotid artery in the neck…called an arthrectomy…this was a very common operation…study was done in Canada which showed that this was perhaps not as effective as it should have been, and the number of operations decreased. A further study was done, and in fact showed that it was very effective, but you had to limit this to particular areas. And this is the kind of information that we need to have in order to be able to teach the students. So that what we do teach our students is to think critically, to approach the problem, to attempt to get the best data for it. And what we really need to get is a lot more data and a lot more data across the country.

Heffner: Of course, I’m…I’m going to ask you and I hope you will agree to sit still for a second program after this, and we’ll get to many of these things. But I, I’m tempted right now to ask you about whether that information isn’t part of that informational load that you have at other times and other places said makes it almost impossible for these young people in medical school to survive intact and come out to be the kinds of physicians you want them to be.

Burrow: Yes. Well, I mean…I…there is no question that one of the major issues that’s confronting medical students today is that there’s simply too much to learn. There…small pox in, I think, one of the truly great advances of this century was abolished ten years ago. We still teach the students about small pox. Ten years ago no one was taught about AIDS. Now we’ve talked about having a miniature course about AIDS. For some reason in medicine we never take anything off the bottom and simply add information on top. And so that one of the problems physicians…medical students and physicians have is sifting through all this information to find the piece that applies to their patient. But the other part of it is that I think that the information is not available. It’s very difficult to run long studies with large numbers of individuals that have a lot of different parts to it, and come up with very clear algorithms as to what should be done. I mean people are different and so that each person is, is different and that brings the art in towards the science.

Heffner: Are you choosing artists, then, in your admissions process?

Burrow: Well, we like to choose a combination of both. I mean it, it’s…one needs the science that, that science is there and there’s an awful lot of science to be known. But the patient is a human being and as such requires the artist to deal with him.

Heffner: Is there any indication, and I know this is a…this is a difficult question to deal with…but is there any indication that there is an incompatibility between the personal capacity to be the, the concerned physician, concerned about this patient and that patient, and the person who becomes so knowledgeable that he has…he or she has mastered all of that new information and the old information?

Burrow: I absolutely do not believe that. I, I think that one hears this issue when we have medical students that we, we keep just looking for grades and that, that these individuals have no humanity, or lack the humanity that’s so important. I mean the implication is that you can’t be bright and humane at the same time. And I think that the data would show, in fact, that those individuals that are the brightest are often the most humane. It, it’s, it’s attempting to meld this together, and we try very hard to do that. And I think our students do care.

Heffner: If you, if you were to use it as…to base that upon brightness, I, I would understand what you’ve just said much, much better…but if you leave out the notion of brightness…I’m sure that every student at Yale Medical School is extremely bright. The competition is so great. But when you go beyond brightness and come to the other qualities…the ones that lead you to differentiate, or lead others to differentiate between medicine as a science and medicine as an art… not everyone has that sense of artistry about them. And I, I come back again whether the capacity to absorb all that information, and you’re concerned about the need to…

Burrow: Yes…yes…

Heffner: …all that information…Isn’t going to identify itself in one group of people more than in another group of people, both groups making for people you want in your medical school.

Burrow: Well, there, there certainly are individuals who are much more comfortable dealing with numbers than they are with people. And that those individuals maybe attracted to science, they may be attracted to being accountants. I mean, you know, there, there are studies that people who don’t like to interact with people are attracted to areas like libraries, where they can work with books rather than people. No, I think it’s important and we try very hard to pick individuals who, who are attracted to people as well as to science. I don’t believe the two are mutually incompatible. I mean if you have to read molecular biology, you probably can’t read the lesser words of Goethe. But it, but it doesn’t mean that you’re any less humane.

Heffner: Of course, many people I know who…in my age bracket…who wanted to become physicians for the humanity of it, even all those years ago, 40, 45, 50 years ago, knew that they couldn’t do the science of it. Were they wrong?

Burrow: I think there’s a certain amount of science that you have to do. I mean, and one has to balance somebody and, and we’re looking for individuals who have the capacity to do the science and the capacity for humanity, if I can use that in the broadest sense.

Heffner: But more and more science as time goes on.

Burrow: But that doesn’t mean less and less humanity.

Heffner: (Laughter)

Burrow: I mean it isn’t an either/or proposition.

Heffner: Alright, if you will, stay where you are, and we’ll do another program right after this…

Burrow: Alright.

Heffner: …because obviously there’s a lot more to talk about.

Burrow: I don’t think we’ve solved it yet. Thank you.

Heffner: Dean Burrow, thank you so much…

Burrow: Thanks very much.

Heffner: …for joining me today on THE OPEN MIND. And thanks, too, to you in the audience. I hope you’ll join us again next time. And if you care to share your thoughts about our program today, please write to THE OPEN MIND, P.O. Box 7977, FDR Station, New York, NY 10150. For transcripts send $2.00 in check or money order. Meanwhile, as another old friend used to say, “Good night and good luck”.

Continuing production of this series has generously been made possible by grants from: The Rosalind P. Walter Foundation; The M. Weiner Foundation of New Jersey; The Edythe and Dean Dowling Foundation; The Thomas and Theresa Mullarkey Foundation; The New York Times Company Foundation; and, from the corporate community, Mutual of America.