Medicine in the 21st Century, Part II

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

I’m Richard Heffner, your host on THE OPEN MIND. And my guest today joins me for our second program examining what the practice of medicine will be like in our country in the 21st century, a subject not far from the minds of most Americans, concerned as they are right now with its medical care, with their medical care, I should say, and with its cost and its competence.

Now, Dean Gerard Burrow is the new Dean of Yale Medic al School. He is a skilled practitioner, a noted medical researcher and administrator and a compassionate physician, too.

So, let me pick up with him where we left off last time. Dean Burrow there were so many things that, that we started on and, and they led to so many other fascinating things. One of the things I picked up was when you talked about the nature of medical school education, or training…

Burrow: Yes.

Heffner: …that you don’t leave anything out. You just add to the burden of the, of the students, so that small pox continues to be taught, its, its, causes and its cures, etc., when we don’t have small pox any longer. Then you said, “But there’s very little about AIDS”, something that is…

Burrow: Excuse me…that 10 years ago nobody mentioned AIDS.

Heffner: Okay.

Burrow: Now we’re, we’re really considering giving a course on AIDS, but a great deal is being taught about AIDS.

Heffner: But suppose you do teach about AIDS. I read in The Wall Street Journal just the other day something rather distressing — that you may teach AIDS, but you are not teaching your students about another major medical phenomenon, if I may call it that, in, in American life, and that is abortion. You…medical students thought Americans seem to have indicated in the polls and in their elections that they do not disapprove of abortion, that medical schools aren’t teaching doctors skills in this area. Is that true? The Wall Street Journal wrong?

Burrow: I don’t…let me just distinguish AIDS from abortion.

Heffner: Okay.

Burrow: That, that in the sense that AIDS is a disease process with a whole series of parameters. Abortion is a procedure to terminate pregnancy. In medical school I know that students attend abortions, whether they’re actually taught in medical school as opposed to a residency when abortions are done by members of the departments of obstetrics and gynecology, they are taught that during their residency training. I mean it’s a post-graduate rather than in the medical school.

Heffner: Of course in, in the Journal’s piece…was interesting, if, if accurate. “Although an Administration supportive of a woman’s right to an abortion is leading the US for the first time in two decades, medical schools have been cutting back sharply on abortion training, and medical students appear increasingly unwilling to take such courses”. Now that doesn’t conform…

Burrow: I’m really unaware of that.

Heffner: Okay.

Burrow: I mean that I know that, that the students do attend in, in…when abortions are done, I don’t know whether there is a course on it, because as I said, it is a procedure, and it’s certainly done by the post-graduate students who are, are the residents.

Heffner: What about the…what you consider to be the obligation of the physicians you train to function in both areas…the area of abortion, which is an extremely controversial area, and in the area of caring for those who are stricken with AIDS?

Burrow: It’s just a…that’s a wide spectrum. I, I think that the physician has a responsibility to his or her patient. And that if the issue of a termination of a pregnancy comes up, and that the physician has strong moral reasons why he or she is not comfortable with that, I think that they have an obligation to let the patient know and suggest that there are other physicians who, who that they can talk to. I mean I think that physicians may feel that this is something that they cannot do, or, or counsel, but I think that then they have an obligation to, to really make sure the patient does reach someone.

Heffner: Well, let me carry that a little further. Physician “A” does not have moral scruples concerning abortion, but he does have very real, very understandable concerns about what has become a very controversial issue, and in some communities has become almost a dangerous issue to pursue. What are his obligations, do you feel?

Burrow: Dangerous in terms of what’s going around within the community…

Heffner: Yes. Yes. The doctor was killed recently for being an abortionist.

Burrow: Well, then, then I think we get back into the issue which I think about AIDS, and which I’ve written about, and that is that I think that physicians have a responsibility…to care for their patients. And if those patients have an illness that puts the physician in danger, it really is one of the roles of the physician, and it’s the role of the physician that we have not had to bear. I mean for the past 20, 30 years there have been very few diseases which patients had which have put the physician at risk. AIDS is doing that now, and I think the physician has a responsibility. I mean that if, if the physician believes that it’s in the best interest of the patient to have that pregnancy terminated, I think that the physician has a responsibility to see that that patient has that procedure done.

Heffner: Do medical schools these days teach as much by way of physician responsibility as they did when you went to medical school?

Burrow: Oh, I think more now.

Heffner: Really.

Burrow: I, I really…I think the issues as we approach the 21st century, the whole area…issue of physician responsibility and ethics which has perhaps been intermingled with, with malpractice also, I mean since they…it all comes together. So that we, we probably spend a lot m ore time doing that…with…or with formal courses.

Heffner: Why then do we find so much in the press about physicians pulling back, pulling out, indeed, pulling away from their medical practice? Now this is enormously distressing.

Burrow: Yes. I, I, I…it is distressing. I’m distressed as a member of the medical profession and I’m distressed as a teacher. I was at a reunion, well will be my 35th reunion, but the last so that would have been the 30th, and, and one of my classmates who was a very good physician said he really was going to stop practicing. I mean that he’d withdrawn. It really wasn’t fear of this, it was the paperwork, the, the…what he perceived as the interference in, in his ability to practice the way that he wanted to practice. The litigation which is, is really a problem is that, that the need to have to practice a defensive brand of medicine because you’re afraid you may be sued if you, you don’t do something. It’s been really, I think disenchantment, with many of these things in medicine. I mean on the other hand, and it’s interesting…that tends to occur more in individuals who’ve been in procedural specialties, where they have not had an on-going relationship with the patient. When I talk with physicians who have carried patients for years, my…our children’s pediatrician was also my wife’s pediatrician, so that the span…two generations. I don’t think that they feel this. I think that they’ve built personal relationships with patients. I think it’s the specialists who, who see a patient and then perhaps may never see that patient again in whom the peripheral things that occur in medicine really become an impediment to practice.

Heffner: That view that you’ve just expressed, how does it express itself, or how should it express itself then in what goes on in a medical school curriculum?

Burrow: Well, there is a huge move to go back to primary care rather than the specialties. I think that there’s a strong feeling by everybody that we have become too specialty oriented. And I think that this is a compelling reason for people to go back to where they actually end up taking care of patients on an on-going basis, and develop those relationships.

Heffner: But let, let’s take that point of view, which I, I certainly understand. In the other program that we did together, you…I mentioned the fact that I had read your comments about the burdens that you place upon medical students today in medical schools, in terms of the knowledge that they are required to acquire…increasingly…it just adds up and adds up and adds up.

Burrow: Yes.

Heffner: Textbooks that added together make thousands and thousands and thousands of pages…

Burrow: I think it was a hundred pounds and 15,000 pages…

Heffner: Just impossible for someone with a limited memory, such as myself, to, to comprehend. If you attempt, in the medical schools, to devise a curriculum that puts more of an emphasis upon general practitioners, what then happens to the information or what happens to the practice of what now are the, are the specialists? Are you going to require, then, that the general practitioner learn even more of the things that the specialist now commands?

Burrow: I think that one of the reasons that there has been this switch to specialty training is exactly what you said, that it is easier to, to know a great deal that’s available about a limited area, rather then than in a broad area. I think we’re going to have to re-look at, at the whole process in terms of education. Students are learning medicine exactly the way that I learned back in the fifties. That we…with the computers that we have now, that can…have that information, I think that what we need to do is teach clinical decision making…that is how to define the problem, to provide the computer software the informatics that would allow the individual to access that information. And then we have to decide what the multiplication tables are…what, what’s the core body of knowledge that every physician has to know. We’re in the process of doing that. The, the informatics part of that is certainly possible now, but it’s in a transitional stage. I mean the information isn’t available to allow that to occur. But it is in, in the process of happening. And once that happens then you don’t have to sit there and memorize all 15,000 pages. You just have to be able to formulate your question, so you can access the data.

Heffner: But each of us who is told by our, our internist, the person who’s closest to being a general practitioner, “there is something wrong here. I want to send you to, to this person or to that person”, we obviously look for the person who is both closest to his training periods, so that he is right there on the edge of the latest information, and has had scads and scads of experience…

Burrow: Yes.

Heffner: Now what do you do?

Burrow: Well, I think one of the things that we’re going to do at Yale is, is that I don’t think we can train enough primary care physicians in order to solve the problems. It, it’s been estimated that it would take 40 years if we started training primary care physicians now to have adequate…I think we need to build a health care team. I, I think that the health care team would include, in addition to physicians, nurse-practitioners, physicians’ associates. And individuals interested in public health. I mean the problems that people are dealing with now go far beyond what we could teach in the 4 years of medical school. And there have been studies that show that the allied health personnel, and nurses, when they do the roles that they do, do them as well as the physicians. And, and there’s considerable less education involved. And so we need to look at how to put people together in order to achieve the desired effect. One of the difficulties is going to be that means that you won’t have your physician all the time who is going to know everything about you, but you’ll be dealing with, with a team, and that’s another one of the compromises I think that we’re going to have to make.

Heffner: Do you think I’m going to do that? Seriously, you use me prototypically here…

Burrow: Alright. I, I think at some point it, it becomes so expensive for you not to do that, that you would certainly consider it. And I…my guess is there will always be some people who will be able to have their physician. But I, without knowing what the future is going to hold for health care…it does look as though we’re going to go more and more into managed care and health maintenance organizations. And that if one looks at how that happens, you don’t have control over seeing our doctor when you want to see your doctor.

Heffner: But doesn’t that fly in the face of, of this sense of the physician who has, for generations, dealt with the same people, the same families?

Burrow: Well, and I think that’s one of the trade-offs, and one of the concerns. And it’s how, how one builds that sort of continuity into that kind of a system.

Heffner: How does that…how does that come face to face with the drive toward, or the concern about what has been called “holistic” medicine…doesn’t it, doesn’t it, isn’t it, isn’t there a contradiction?

Burrow: To an extent. I…it’s interesting in, in…if…that there has been concern that as we move more and more towards scientific medicine, toward sequencing the human genome that we will move away from the patient as a, as a whole, and away from holistic medicine. I think on the contrary, that they’re going to come together. I mean if, as we get into the 21st century, and we can say rather than everybody should eat less fat, that we can say that specifically that Gerry Burrow should eat less fat. We then have to use behavior modification in, in order to, to have that individual not eat what they’re doing. And that’s part of this holistic approach of, of the preventative…and I’m talking holistic in the sense of preventative medicine, which is important. I think if one has an HMO, and by an HMO I mean that we pay a certain amount and provide total health care to you, the best thing I can do is to keep you healthy and never get sick, because that, that the HMO then is able to save that money. Under the present system, that if you get sick, I get paid, so the more times you get sick, the more I get paid…I mean we’re going to reverse that, and when we reverse it, then the issues of preventative medicine become very important. They may not be done by your physician who also took care of your children or your parents.

Heffner: How does that comport with the, with the, with the felt needs of those people who have gone into medicine up to this point? Let’s say in reference to the simple matter of dollars…maybe not so simple, but there it is. How does it, how does it relate to that because my understanding is that there are numbers of my medical friends who say, “If my son were to ask me today”, or in my generation, “If my grandson were to ask me today, I’d say don’t go into medicine” because a) the point you mentioned before, the red tape, the papers that have to be filled out, and then b) the lack of control over your own practice because you became a doctor because you wanted literally to be ‘the practitioner’ and then, c) your income is limited as for a while, a golden period for doctors, it hadn’t been. What’s that going to do about…?

Burrow: Well, let…

Heffner: …the willingness of people to take on the burden you heap on them?

Burrow: Right. Right. Let me say that our youngest…Sara…is an orthopedic resident, so I have…I really can’t think of a more exciting place to be. I know of no evidence of a physician dying of malnutrition in the past 25 years. Will the salaries be as high? No. But will they be adequate? Yes. In the Canadian system there really is less paperwork for the physician than there is in the United States’ system. So that one can devise systems where you are not mired in the, in the bureaucracy of that. And the litigation can also disappear under the particular, if particular laws are passed. So I don’t think that, that the future by saying that it’s going to be necessarily more managed care, means that, that the whole system is going to collapse. I think it could be better for physicians. I think physicians end up having more freedom to treat patients under that system, because they don’t have to be concerned that they can’t do this for a patient because the patient doesn’t have enough money.

Heffner: More freedom in treating patients, but not the same patients. Is that fair?

Burrow: That’s possible, though under the Canadian system, is that you choose your own physician. I mean it, it is a, a fee for service basis, but the fees are controlled. Again, this gets to be how that they will construct the system. I mean let, let me just say that now many obstetricians practice in groups. So you have an obstetrician, but if that individual is not on call when your baby comes, that may not be the individual who, who delivers.

Heffner: You said that one of the things, of course, that will be taught increasingly in medical schools will be what it is we have come to k now and are so rapidly coming to know so much better, the nature of our gene pool.

Burrow: Yes.

Heffner: You have said here, you’ve raised the question, “Are our social institutions capable of dealing with genetic flaws?” Now, in the time we have remaining, I want to ask you, are we?

Burrow: Don’t know.

Heffner: Is it?

Burrow: I don’t know.

Heffner: What stands in the way?

Burrow: I…I…well, I mean let me sort of pose the question. So let’s say that I can now by taking a blood sample define whether you are going to develop…for better or…rheumatoid arthritis in 25 years. I am now the president of a corporation and we’re about to hire you to be on the track to be the next CEO. If, if I had that information available, and I don’t have, at the moment something to prevent rheumatoid arthritis, will I hire you do to that? I don’t know. Insurance companies work ion an actuarial basis where they limit risk.

Heffner: Yes.

Burrow: If they know that these diseases are present in an individual, will…

Heffner: Potentially.

Burrow: Potentially. I mean and, and one is probably never going to know completely, but you’ll know with a certain degree of certitude, will you take the risk? Will you ask the question? I mean now that here are insurance companies that are asking whether…for an AIDS test before they’ll insure you…I think it’s a very difficult question. It’s not a question that physicians are going to have to answer. It’s a question that society’s going to have to answer.

Heffner: What’s your, what’s your bet when you raise the question…are our social institutions capable of dealing with genetic…

Burrow: Well, I, I believe that the glass of water is half full or even overflowing, so that I, I…

Heffner: I spotted that optimism before.

Burrow: I think that we’re going to, to face that, but it’s not an easy question to answer.

Heffner: But you see, one can face it very simply, by saying, “Look, it’s perfectly logical in a free, entrepreneurial, capitalistic system. We will take a risk up to this point, not take a risk beyond that point”.

Burrow: Yes.

Heffner: Next case.

Burrow: Yes.

Heffner: That’s dealing with it.

Burrow: Yes.

Heffner: Would you consider it dealing with it adequately and well?

Burrow: I would all depend on whether I were the individual…

Heffner: Aha…

Burrow: …who had the, the potential disease, and that I had missed the cut-off line as to what was going…it, it’s…do you want to know the future? I mean, it’s a question as to the risk. It would be how it was used. But I do think it’s an issue that needs to be addressed now before the human genome comes out and that we have to then make the decision because somebody is already using hiring practice based on it.

Heffner: Dean Burrow, is it being faced now?

Burrow: I don’t think so. I mean…I, I should really retreat a little bit…I mean certainly people are discussing it. But I don’t, I’m not aware of any sort of formal program to look at this that would lead to legislation, or whatever is going to happen. People have raised the issues. There have been symposiums on it.

Heffner: What would be the medical profession’s response if one can think of such a unitary matter to the possibility of such knowledge…not, the probability of such knowledge…the certainty of such knowledge when we do not have that same degree of certitude in terms of what you’ve suggested?…The, the way in which our society will deal with that information…”Do no harm”…won’t you be doing harm to those whose testing will lead them not to achieve what they could have achieved, to be fired, not to be insured, etc.?

Burrow: Well, I guess I believe that there’s nothing innately harmful about science or technology. It, it’s the way we use that knowledge. The, the issue of being able to put atoms together into a critical mass is not inherently evil. The use to which that information is used may be inherently evil.

Heffner: You happy with that point of view? Seriously.

Burrow: Yes. Yes. Should I back away from that and become a Luddite and say, “Therefore we should not sequence the human genome because we don’t want to unleash that”? I, I don’t think that’s the solution. I think that we really, the more knowledge we have, the better we are… I think we do need to look at how we use it.

Heffner: Look what happened in the Garden of Eden. I mean one taste of the apple and here we’ve been suffering from that ever since. Seriously though, and we have a minute left…that’s all…is the medical profession, let alone society generally, is the medical profession deeply, profoundly involved in understanding what the problems are that will derive from this ultimate knowledge?

Burrow: I don’t think as deeply and as profoundly as, as we should be. And, and I think that as, as the sequencing goes on…that, that we are going to have to be. But I think it can’t be the medic al profession alone…I think, I think that this is really a societal discussion, and has to go on within universities, has to go on among the politicians as well.

Heffner: Are you in the medical schools helping will-be doctors deal with this problem?

Burrow: Yes.

Heffner: As citizens?

Burrow: Yes. I think that we, as I mentioned before, that we really have a series of courses, are spending a great deal of time attempting to deal with these issues. And I…these students are wonderful. I mean they… the doctors that are coming out are, are superb. They’ve lost none of the things that people have talked about about doctors throughout the ages. They have a very large armamentarium of technology to help them, but what needs to happen is to learn to use it wisely.

Heffner: Dean Burrow, I’m so pleased with your optimism because in the medical area I do want to be able to feel, on the basis of expert opinion, that optimism. Thank you so much for joining me on THE OPEN MIND.

Burrow: Thank you, Dick.

Heffner: 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, our guest, 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.