As the world turns: the consequences for health
Bernard Shapiro
Clin Invest Med 1997;20(6):414-8.
Dr. Shapiro is Principal and Vice-Chancellor of McGill University, Montreal, Que.
This article was presented as the 1996 John Neilson Lecture.
Reprint requests to: Dr. Stuart M. MacLeod, St. Joseph's Hospital, 50 Charlton Ave. E, Hamilton ON L8N 4A6
Contents
Introduction
As the principal and vice-chancellor of a university that is not only -- at least relatively speaking -- research-intensive but also has within it a faculty of medicine, a school of nursing, a school of occupational and physical therapy, a faculty of dentistry, and a centre for medicine, ethics and law, together accounting for a generous -- some would say too generous -- share of both our operating and research budgets as well as our waking time, I have more than a passing interest in your deliberations.
I share this interest with my colleagues, the other CEOs of universities with faculties of medicine. We also seem to share a kind of approach, which involves avoidance behaviour with respect to these faculties. On the one hand, their importance to both us and the wider society is clear. On the other hand, the complexities of these relations with the public, with the practising profession, politicians, a range of government agencies, ministries and sources of funding, hospitals and clinics, and patients, are daunting, not inviting. This is to say nothing of the conflicts of interest that abound and the sometimes deliberate obfuscation which you all practise from time to time just to make sure that, although in the university, you are not exactly of it. Given all of this ambiguity, I simply could not resist the invitation into the lion's den. After all, when I was the academic vice-president at the University of Western Ontario, it took me 2 entire years to get to the bottom of what the "real" (as opposed to the apparent) admissions policy of that particular faculty was. When David Levine, then of Hôpital Notre-Dame of Montreal, called, I accepted with alacrity.
[ Top of document ]
As the world turns
The world is, of course, turning. Indeed, our cultural, political and economic environment is shifting at such a breathtaking pace that it is difficult, even for the most acute observers, to bring things into some kind of useful focus. How, then, can one consider carefully the consequences for the "health biz"; in this case, the aspect of it that relates to universities and teaching hospitals?
Before this morning, you listened to Diane Francis, who, I assume, addressed the issue from the perspective of an actively intelligent citizen journalist. You also heard from Richard Cruess, who addressed questions as seen from inside the profession. I will attempt to find a kind of middle ground -- clearly from outside the health care profession, but just as clearly inside the academic milieu in which each of you is so active.
Universities exist to serve the society that supports them, but in what way and with what type of educational and scholarly commitment? Surely, the answer to these questions depends in large part on society's aspirations and on the challenges that it faces. It is difficult, however, to know which of the many developing and sometimes conflicting motives that we see about us will become the dominating themes in the coming decades. New challenges to the human condition are arising -- the challenges of demography, new forms of community, the environment, technology, political and cultural fragmentation -- if not disintegration -- and the challenges to the role of rationality in helping us achieve a better understanding of the human experience. These will all have an impact on the role and meaning of universities and of the health science centres within them. It is not a question of whether our enterprise -- your enterprise -- will change, but a question of how, when, by whom and at what price.
Change is not, of course, new to our experience. As both the university and the health care sectors have grown in the past half century, not only did the internal ideals and civic functions of both evolve, but the links between them and society became more varied and complex, and the influence of the state became much more marked as it responded to its increasing investments and the growing public importance of academe and health care, whether in substance or simply as social mobility ladders for their young acolytes. Indeed, it has been the capacity of our universities and health care professions to re-imagine and re-invent themselves that has enabled both to persist for so long.
The only question now is whether we can, together and now, change quickly enough to remain central to the society we are a part of. It is critical to bear in mind that faculties of medicine, their curricula, their scholarly and other programs are all designed, or should all be designed, to serve some civic purpose. Teaching and research are a public trust. It is the civic purpose served by our faculties and schools of medicine that provides the foundation for their social legitimacy. Neither faculties of medicine nor physicians nor hospital staff nor health researchers can be defended by way of preserving a portfolio of previous academic or socioeconomic privileges, nor can we preserve the right of teachers, scholars and students to special entitlements not enjoyed by other citizens. The interesting freedoms and privileges enjoyed, appropriately in my view, by many professionals in health science centres enable these professionals to meet their social responsibilities more effectively. Thus, I as a university administrator and you as health care researchers, physicians or health care administrators will be inevitably drawn into the public debates about the relation of our programs and commitments to the changing needs of society. We cannot and should not avoid such discussions. In particular, we cannot afford to view such a dialogue as undermining us or our traditions. Rather, it is only through such dialogues that our most important values can be reinforced. Indeed, conferences such as this one are examples of a contribution to such a debate, assuming that we make a valiant and serious attempt to talk with individuals and with groups other than ourselves. As each of us has no doubt experienced, discussions inside a closed system can result in the exchange of a lot of hot air.
I am glad to note that there continues to be a wide variety of competing views regarding the appropriate function of our health science centres. In some circles, for example, there are those who stress the notion of a more isolated community, where the scholarly and professional agenda responds to the beat of an internal drummer. At the same time, others celebrate the fact that, within what they regard as progressive health science centres, there is a shift from a rather narrow range of scholarship, professional training and the education of a social elite to programs and clinical opportunities for a more broadly based elite to sustain the economic, professional and cultural leadership to which we aspire. In what I assume will be an endless -- and endlessly fascinating -- debate, it will rarely be useful to talk about the idea of health or the health care system or the health care industry or the health care profession. To use a US expression, it will be not so much e pluribus unum as the other way around. This will not be, and has never been, an unalloyed advantage. The "opening up" of our minds and our practices has many positive values. On the other hand, the notion of a health care profession as a community with shared values becomes increasingly strained. This is rather analogous to the strains and tensions felt in liberal democracies. In North America, for example, the electorate has become increasingly pluralistic or multicultural and the set of shared values seems to become smaller and smaller as we strive, in the face of increasing difficulties, to meet the needs and shape the benefits for an ever more heterogenous community.
Does this inevitable tension explain the current paradox facing the academic health profession: public expectations that have rarely been higher and public confidence and support that have rarely been lower? The complaints against the academic health profession during the last 5 years have included outmoded teaching models, fragmented fields of study, trivialized scholarship, disregard of patients except as either subjects of research or objects of professional practice, conflicts of interest, and falsification of experimental results, to say nothing a continuing and quite palpably unfair public stereotype of physicians as "self-indulgent, arrogant and resistant to change." The wider university community has also been accused, to quote a relative insider such as Thomas Sowell, of "proclaiming our dedication to freedom of ideas . . . while at the same turning our institutions into bastions of dogma." Does this have any resonance with your own experience -- at least on your bad days?
[ Top of document ]
The consequences for health
In the light of all of this, I cannot pretend to share with you the future to which we are all hurtling. What I can do in the next few minutes is share with you my sense of what is happening all around us and what some of the consequences might be. I must acknowledge the value that I have attached to my discussions with the dean of McGill University's faculty of medicine, Abraham Fuks. Many of the ideas that I have come to understand as my own are, in fact, ideas to which he has introduced me. In any case, the changes that are sweeping the health care systems of North American are stunning, however much each of you may have become accustomed or inured to them. What seems to me most stunning is not the onrush of new technologies or the real crisis of funding but the changing role of the centrepiece of health care, the hospital.
Our current hospital facilities offer a range of medical services, inpatient and outpatient, within the confines of the institution. This model, while providing high-quality care, is not substantially different from the historic forerunners of our modern institutions. Our modern hospitals, while they have developed the capacity for high technology with advanced care, have not changed their social organization and interaction with their communities. It has become increasingly clear that restructuring our hospital network is not a question of size or simply a matter of building new facilities or acquiring new technologies. The real challenge is for us to engage in a major revision of the role of hospitals in society and of the way they discharge their mission within the much wider rubric of health care.
Underpinning this process -- if it is to be successful -- are a series of continuities that will redefine how we all think of health care in the future.
The first conceptual shift is to think of a hospital not as the point of the restructuring process but rather as a significant component of a health care network. This network encompasses the entire spectrum of modalities of care, from primary care in the community through to very advanced care in a central intervention centre, the successor, perhaps, to our traditional hospital. This health care network will include, in addition to the academic health science centre, a consortium of institutions, including rehabilitation centres, chronic care facilities, neighbourhood clinics, group practices, etc. In this context, the "central intervention centre" -- perhaps not too felicitous a term for the redefined university hospital -- will need to assume responsibility for the continuity of care for patients as they encounter these various entities. This will include significant aspects of preventive medicine, which are currently underfunded and poorly organized. Continuity of care will be inherent in the idea that a patient is not "discharged" as such but rather "transferred" to another node in the health care network. These nodes will include home care and community clinics so that some element in the network always retains responsibility for that individual and his or her family. For this to happen, the academic health science centre would have to accept such a responsibility. We would need far more robust communications systems traveling with the individual receiving care. A transparent and efficient informatics infrastructure will, therefore, be mandatory.
The second continuity necessary to such a developing model of care is providing care from "health to illness back to health." This is complementary to the model of health care as emphasizing a range of places where care is provided. This added continuity implies a responsibility to re-introduce the patient back into society and the workplace once the condition has been adequately treated. Again, this is a social responsibility, and it will entail the public health aspects of occupational medicine and workplace health and safety as well as major commitments to rehabilitation medicine. The third construct of continuity that will reflect the redefined university health centre is one of progression through the life cycle for the individual patient and through the entire span of age for the population. The commitment of the university health care centre to the entire range of care, from pediatric to geriatric, is not simply a matter of convenience. It stems from an understanding that we cannot otherwise provide the highest quality of care for the community nor generate the critical mass of expertise that such care requires. It is only by avoiding the artificial segmentation of the population by age that we can care for the entire family -- however catholic we will have to become in our definition of the family -- as a unit of social organization and maintain a serious commitment to lifelong care. Starting within such a model, we can readily extend our framework to the community and support the public health agendas of, for example, prenatal care, nutrition, vaccination, well-baby care, school health programs and adolescent counselling on drug abuse. This implies, of course, a multidisciplinary team of health care professionals with primary care nurse practitioners and physicians as the logical focus of interface with the clientele, i.e., those seeking health.
It is important to understand, as I am sure many of you do, the academic value of this continuity from pediatric to geriatric care. Our vision is enhanced by our special commitment to the care of children and adolescents and the administrative structures to ensure that their needs are met. The rich interface between adult and pediatric care has many advantages as well. Apart from the usefulness of the family and community care models, there is the added importance of a critical mass of expertise and technology and the opportunity for tertiary care practitioners to benefit from the synergy of a shared intellectual vision, the efficiency of shared resources, and the efficacy of avoiding duplication of a highly developed set of skills.
At the centre of this network is not simply the faculty of medicine, but rather the academic vision that it represents. The university will assume -- albeit in quite different ways -- its traditional responsibilities for teaching and training future practitioners, but it will also extend its expertise to continuing professional and community education. Most important, the members of the faculty will be responsible for developing the health care and outcomes research to ensure that the methodologies applied in the tertiary care setting or in the community achieve a desired outcome and do so cost-effectively. We need to constantly develop new and better pathways to health, both preventive and therapeutic, and public practice guidelines for patients as well as for the many health care professionals charged with providing care. All of this seems painfully obvious as the model to which we should be moving even more quickly than we are. What is likely, to make this model -- or even something like it -- difficult to achieve?
There are many difficulties, the most important of which is the fabulous success of the current system, including the research enterprise, the systems of therapy (if not prevention), and the preparation of practitioners. Why might all of this achievement be a barrier to the future rather than a gateway to it? There is, of course, the inevitable psychological sense of loss that accompanies all change. Much more important, however, is the phenomenon with which we are all familiar, that in an environment of rapid change nothing fails like success. That is, the very success that we have experienced in academic health science centres and in the health care system, more generally, has predisposed those most able to move us forward into the future to be least inclined to do so. This is especially the case in terms of the particular model of the future that I have in mind. This is, after all, a model in which the priestly function of the physician needs to be much more widely shared with other members of the health care team. Indeed, the very concept of the "team" with the physician as, perhaps, primus inter pares but not the living embodiment of the "godhead" is itself a challenge to a profession in which there seems to be little appreciation for the other human resources upon which we all, in fact, depend.
To quote, in English, a committed member of the Parti Québécois in commenting on the prospect of Quebec separation, "Whether or not you're ready, it's coming -- why not prepare?" Why not, then, rethink not only the kinds of research questions that we must address and our new obligations to disseminate research results well beyond the learned and not-so-learned journals, but also our models of medical education? Why not bring to bear a much greater focus on the allied health sciences, a new understanding of the relationship between the health care professional and the patient, and a fierce determination to recapture the curriculum for the faculty at large rather than for particular individuals -- only 3 of the many changes that will be needed to prepare our students for tomorrow rather than yesterday?
This rethinking is crucial, not only because we inside the academy, medical education and research establishments are beginning to see the signs of a different but beckoning future, but also because of how the wider public sees us. We are, after all, the establishment, and we therefore share with other "establishments" the problems of a public increasingly suspicious of elites. The by-word is not "trust me" but rather "show me." As a somewhat unhappy visitor said to me recently, "You say, but we see."
In this context of disbelief and cynicism, the academic health science centres are particularly vulnerable at the very moment when they are most needed, when only the great storehouses of knowledge, experience and talent represented in these centres can rise to the difficult challenges that lie ahead.
The source of this vulnerability is what I see as a populist but preposterous public understanding of equity within a democratic society. In my jurisdiction, the idea comes under the slogan of "regional equity," which translates into a movement of very scarce health care resources away from metropolitan or academic centres to other, usually less heavily populated areas; equity demands 1 neurosurgeon in each of 6 regions rather than 6 in a single centre where the critical mass of talent could actually produce great care. The result is a kind of "dumbing down": an ideal formula for insuring that all health care is totally accessible but just not very good. If academic health care centres are to stand for anything, it must be for a standard of quality always rising even if always just beyond our reach. We therefore must take up the role not only of practising professional but also of proactive advocate for those arrangements involving a relatively steep hierarchy of health care institutions, which will allow great institutions of teaching, research and health care to emerge.
Is this a call for elitism in medical education? I certainly hope so. After all, health education and research should be seen as moral vocations, since they each have an impact not just on the mind and on the body but on our character and will. We hardly need, therefore, to apologize for high standards. We owe these standards to ourselves and to the society that supports us. Needless to add, we will continue to undermine ourselves if we are seen to raise the issue of standards, of outcome, of quality only when there is some threat to our incomes or our accustomed way of doing things.
[ Top of document ]
Some final words
The way forward will not be entirely easy. The debates that I welcome will have their down side. In the short run, they will breed increased levels of conflict and misunderstanding, further straining the capacity of our institutions to develop the sense of common commitment and community in which professional work, education and research can flourish, and creating in the wider public, on whose active support we depend, a vision of an enterprise so hopelessly mired in its own internal strife that it is incapable of and uninterested in fulfilling its civic functions. I suppose that we will just have to learn to cope and to recognize the often positive, even healing, value of conflict, stinging social criticism and the clash of competing visions. After all, the human condition places some limit on the agreements that can be reached by a group of citizens with different ideas about what is most worthy. We are therefore at one with Job in rejecting the pretence that there is peace when our lives abound and will forever abound in deep conflicts and hard choices. Helpful to me in this great enterprise, however, is a sense not only of limits but also of modesty. Let me close with a warning from poet W.H. Auden.
In this world our colossal immodesty has plundered and poisoned; it is possible you still might save us, who by now have learned this: that scientists, to be truthful must remind us to take all they say as a tall story: that abhorred in the Heavens are all self-proclaimed poets who, to wow an audience, utter some resonant lie.
