Two Doctors

Two doctors, one Republican, the other a Democrat have expounded contrasting philosophies of medicine in two published articles.  The Democrat, Dr. Ezekiel Emmanuel, one of the main architects of Obamacare, authored a widely cited article in the Atlantic titled Why I Hope to Die at 75,  “an argument that society and families—and you—will be better off if nature takes its course swiftly and promptly.”

In the other philosophical corner is Dr. Tom Coburn, former Senator from Oklahoma who testified before the Senate Subcommittee on Space, Science and Competitiveness on the necessity of clearing a path through the bureaucracy to permit 21st century medicine to flourish.

The two articles emphasize different things, neither to the mutual exclusion of the other.  “Why I Hope to Die at 75” advocates providing a kind of mass produced, good-enough medicine for all, or at least for most.  Death and decrepitude he seems to argue, will win in the end.  The proper role of medicine is to give humanity a run of carefree life before the End.

Coburns testimony, by contrast, puts more weight on innovation.  Death and decreptitude may win — for the present — but his rule is not for always.  It is medicine’s task he seems to say, to force the Grim Reaper back, step by step, as far as he will yield.

Interestingly, Emmanuel though  quite content to live only a few more years, is himself seemingly well. “Today I am, as far as my physician and I know, very healthy, with no chronic illness. I just climbed Kilimanjaro with two of my nephews.” But that does not change his self imposed deadline. “I am sure of my position. Doubtless, death is a loss. It deprives us of experiences and milestones, of time spent with our spouse and children. In short, it deprives us of all the things we value.”

But here is a simple truth that many of us seem to resist: living too long is also a loss. It renders many of us, if not disabled, then faltering and declining, a state that may not be worse than death but is nonetheless deprived. It robs us of our creativity and ability to contribute to work, society, the world. It transforms how people experience us, relate to us, and, most important, remember us. We are no longer remembered as vibrant and engaged but as feeble, ineffectual, even pathetic.

By the time I reach 75, I will have lived a complete life. I will have loved and been loved. My children will be grown and in the midst of their own rich lives. I will have seen my grandchildren born and beginning their lives. I will have pursued my life’s projects and made whatever contributions, important or not, I am going to make. And hopefully, I will not have too many mental and physical limitations. Dying at 75 will not be a tragedy. Indeed, I plan to have my memorial service before I die. And I don’t want any crying or wailing, but a warm gathering filled with fun reminiscences, stories of my awkwardness, and celebrations of a good life. After I die, my survivors can have their own memorial service if they want—that is not my business.

Coburn on the other hand, is a three time cancer survivor with an almost visceral grudge against death. Maybe this biases his point of view. “The battle is personal for me in many ways. As a physician, I see elderly patients suffering from symptoms of early dementia, and eventually Alzheimer’s, without a real treatment in sight. The burden of the disease falls not only on patients, but on their families and caregivers. Their plight is agonizing. And I can’t offer them any effective treatments.”

As a three-time cancer survivor, I’m excited by the progress we’ve made against this deadly disease, but also mindful of how much further we have to go to conquer it. Cancer remains the second leading cause of death in the U.S.; for patients diagnosed with metastatic solid tumors—of the lung, colon, pancreas, or ovaries—far better diagnostic and treatment options are desperately needed. Diagnosing these diseases late—as we do all too often today—means that we can only delay the inevitable, at great human and financial cost.

But I’m also deeply optimistic, because I’ve seen firsthand the inventiveness, dedication, and entrepreneurship of America’s leading researchers and companies. I’m watching a flood of new information emerge that is helping researchers map out cancer’s vulnerabilities at the genomic level and develop personalized treatment programs for patients tailored to their unique tumor profile. These approaches are being made possible by advanced computing platforms for rapidly sorting through this torrent of information, guiding doctors and patients to the best treatments. For instance, IBM’s Watson is analyzing millions of journal articles, patient records, and data on approved and experimental drugs to help developed personalized cancer-care regimens faster than any single physician alone could ever do. Watson and other “big data” and machine-learning approaches are literally getting smarter every day—and will, one day, expand state of the art oncology services to every cancer patient in America in their own communities, not just patients with access to leading cancer centers.

The advent of systems biology and, more recently, quantitative systems pharmacology are helping us unravel the molecular networks of complex diseases at an unprecedented pace; simulate the effects of candidate compounds in computer models; weed out drugs likely to fail; and identify those most likely to succeed, all before a single human patient is dosed. Companies are also perfecting the art of developing targeted medicines, including genetically modified T-cells, monoclonal antibodies, and new gene-editing technologies. This approach heralds a day when researchers will use molecular scalpels to target disease-causing cells and genes—and kill or replace them with healthy versions.

Is this the Golden Age of Medicine? Not yet. How long it takes us to get there rests with you. It depends on the 21st Century Cures legislation just passed by the House, on steps that you can take to improve it even further, and on decisions that Congress will make over the next few years to enhance the climate for breakthrough innovation in the United States.

Both doctors also differ in where they believe the greatest potential financial savings lie. For Emmanuel the biggest source of savings is the implementation of standardized medicine.

living as long as possible has drawbacks we often won’t admit to ourselves. I will leave aside the very real and oppressive financial and caregiving burdens that many, if not most, adults in the so-called sandwich generation are now experiencing, caught between the care of children and parents. Our living too long places real emotional weights on our progeny. …

My Osler-inspired philosophy is this: At 75 and beyond, I will need a good reason to even visit the doctor and take any medical test or treatment, no matter how routine and painless. And that good reason is not “It will prolong your life.” I will stop getting any regular preventive tests, screenings, or interventions. I will accept only palliative—not curative—treatments if I am suffering pain or other disability. …

Instead, we should look much more carefully at children’s health measures, where the U.S. lags, and shamefully: in preterm deliveries before 37 weeks (currently one in eight U.S. births), which are correlated with poor outcomes in vision, with cerebral palsy, and with various problems related to brain development; in infant mortality (the U.S. is at 6.17 infant deaths per 1,000 live births, while Japan is at 2.13 and Norway is at 2.48); and in adolescent mortality (where the U.S. has an appalling record—at the bottom among high-income countries).

For Coburn it is in new technologies which in some cases have cut a billion dollar process lasting decades to a mere $100K in a few years where the hope for saving lies.  The industrial provision of the same old, same old can bring but limited results.

If Zeke is Dr. Public Health, Coburn fills the role of Dr. Individualized Medicine, which he sees as the wave of the future. Coburn rails at the dead hand of  “1962 cutting edge medicine” and its emphasis on treatment by group statistics. The former senator from Oklahoma believes that the biggest danger to our future is an outdated attachment to old ways of thinking.

Don’t mistake my optimism for naiveté. There are real challenges we have to overcome to embrace a cures strategy for American health care. Existing electronic medical records, for instance, don’t capture much of the data we need to support rapid development of personalized medicine protocols. Many physicians still are not well-equipped to interpret results from genetic testing. While Medicare has required EMRs for reimbursement purposes, they haven’t helped streamline the physician’s workload or enhance patient care. If anything, they’ve detracted from it.

But these challenges are largely engineering problems—problems amenable to technical solutions. The basic tools enabling precision medicine are available and are widely used across the internet, as well as in numerous industries, from retail to the Department of Defense. (The Defense Advanced Research Agency is building a machine-learning engine to identify and predict all of the genes and signaling networks driving all cancers.) Several large hospital systems, such as Intermountain Healthcare, are developing sophisticated electronic-records systems and diagnostics platforms that can serve as proving grounds for rapidly scaling up new digital medicine strategies, as well as for sharing such data.

What will it take to enable a cures strategy for America? There are many good ideas in the 21st Century Cures legislation; but the biggest one is yet to be embraced. The FDA will have to pivot from being a gatekeeper to a collaborator, one that works with many stakeholders to develop evidentiary standards for enabling digital, precision medicine on a national scale. Power will have to shift from centralized bureaucrats to empowered patients and physicians. But I have no doubt that the country that brought us Google, Intel, Amazon, and Salesforce can tackle the challenge of disrupting the FDA’s nearly 50 year-old framework for advancing innovation. Regulators will resist—just as they resisted the demands of AIDS activists in the late 1980s. Yet now, as before, when successes accumulate, regulators will take credit for embracing reform.

At any given moment, the Emmanuel vs Coburn debate would be a toss-up dependent on the public preferences. Which would you prefer? Medicine distributed with a lower mean and smaller variance or with a higher mean and a wider variance? One could make a good case for either.

But over time cumulative effectiveness must favor Coburn’s approach. A higher rate of innovation, compounding over the years, will eventually produce treatment outcomes which will dominate gains from redistribution. Emmanuel calls the American medical system the “The Perfect Storm of Overutilization”. It is doubtless highly inefficient and in many cases, especially in Medicare reimbursement, immensely corrupt. But it is also responsible for most of the medical innovation in the world.

Obviously some kind of balance has to be struck.   It cannot be all redistribution, nor can it be all innovation.  But without innovation there will be nothing to redistribute.  The effect of innovation can be quite dramatic.

One of the small towns near the Dannemora State Prison made notorious by the recent jail break is Lake Saranac. It was once the tuberculosis treatment center of the United States. “Between 1873 and 1945, Saranac Lake, New York became a world-renowned center for the treatment of tuberculosis, using a treatment that involved exposing patients to as much fresh air as possible under conditions of complete bed-rest. In the process, a specific building type, the ‘Cure Cottage'”.

Philippine president Manuel Quezon, who suffered from tuberculosis died there in 1944. “Quezón suffered from tuberculosis and spent his last years in hospitals, as at a Miami Beach Army hospital in April 1944. That summer, he was at a “cure cottage” in Saranac Lake, New York, where he died on August 1, 1944.”  It was state of the art for 1943.  For those who could afford it the best bet was to go than Lake Saranac.  There were similar sanatoria in Europe, such as in Davos, the site of Thomas Mann’s novel Magic Mountain. But even the best 1943 state of the art treatment was of limited effectiveness.

Then in 1944 streptopmycin was invented, revolutionizing the treatment for tuberculosis.  By the mid 1950s the cottages were gone.

You can tour the cottages today and visit the rooms which patients had to occupy for years.  It’s now something of a museum, an artifact of outdated technology.  “At the height of need, half of all Saranac Lake residences were caring for tuberculosis patients. In the early days, this was as simple as providing meals, housekeeping, and porch space for patients. But as the treatment was studied and refined, doctors collaborated with architects to develop the elements which had proven themselves to be important to the patient’s progress. Windows were expanded and screened, railings were solidified to block the wind, and doors were widened to allow patients in all stages of mobility to go in and out of doors as needed.”

Lake Saranac was, as the tour site explains, the “model of a caring, and curing, community”. If good intentions could restore health, then no one would have failed to get better. Yet the fact remained that the cure cottages were ultimately an ineffective approach. The benefits from a single innovation did more good for tuberculosis than all the cure cottages in the world.

In a manner of speaking the philosophical difference between the two doctors reflects the debate within the larger society.  It mirrors the relative priorities between the Left and the Conservatives.  It illustrates the irony of the nomenclature.  The Left likes to think of itself as being on the side of the future.  And Conservatives often identify themselves with the preservation of traditional values.  But the relative emphasis each puts on freedom and innovation often reverses these qualifiers.  In a very real sense the Left is also the party of the past and Conservatives, because of their fondness for laxer state control, are very often the party of the future.

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