July 24, 2022

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Re-Imagining Medicine

Reprinted from EconLib

Twice per year a group of medical students and I put on a “Mini Medical School” for high school students in our city’s public school system. About 50 students, nearly all from disadvantaged backgrounds, gather for a day at our medical school, attending a special class and learning a variety of medical skills in our simulation center. One year, one of the volunteer medical students putting on the program told the story of his own improbable path into medicine. A former kindergarten-through-12th-grade student in the same public school system, he shared how during his younger years, every time he told his teachers that he wanted to become a doctor, they would counsel him that he was being unrealistic, that his prospects for finding a path into medicine were vanishingly small, and that he should choose some more feasible educational path, such as learning a trade. He and his story captivated the high schoolers. What most impressed them was less what he said than his presence—there he stood, a fourth-year medical student who looked like them, but in a white coat, with a stethoscope draped around his neck, just one month from receiving his medical degree. Nothing could have more fired the students’ imagination about what was possible for them. In him and his story the students could see their own reflections. By the end, it felt as though every student in that room had grown two inches taller.

Adam Smith recognizes that when we talk about the moral imagination, we often do so in connection with the sympathy we feel for the suffering of others. Yet Smith also recognizes that sympathy can act far beyond the bounds of misfortune. Just as we can imagine the pain or sorrow a person must be enduring as a result of an injury or illness, we can also imagine how it would feel to be told that something you happen to want very much is impossible for you. These high school students—many of whom came from single-parent families—qualified for free school lunches, and had no family members or neighbors who worked in health care, emerged from their encounter with their public-school predecessor suspecting, and in some cases convinced, that more might be possible for them than they had been led to believe, feeling more determined than ever to pursue it. Many of them, too, had been told by teachers or family members that, because of where they were coming from, such destinations in life were impossible for them to reach. Yet now, for the first time, they could see themselves as participants in the same larger story as the medical student, and their sense of the range of possibilities before them was both expanded and transformed. The key was less to give them more information than to nourish their imaginations, enabling them to see themselves in a role they had not considered realistic.

Unfortunately, the stunting of imagination in medicine is not restricted to disadvantaged youth who never before dreamed of careers as physicians. It continues long after high school into college education and beyond into medical school and even the practice of medicine itself. Many physicians experience it throughout their careers. The fundamental problem is this—conformity. From their first days in school, most physicians are taught not to make mistakes. Consider the ubiquity of multiple-choice testing. When they take examinations, their mission is to select the “one best response” from a predetermined set of answer choices. Every question on every test has one right response, in comparison to which each of the other options is incorrect. The correct response has been designated by the teacher or the psychometrician who designed the question. Examinees are not asked to argue the relative merits of different available responses or to consider alternative conditions under which other options might be preferable, but simply to choose from a, b, c, d, or e. From the earliest years of schooling, this contributes to the presumption that what needs to be known is already known, and that to perform well, students simply need to commit it to memory. The central task of the student is to memorize, imitate, and above all, conform to expectations.

The reasons that medical education relies so heavily on multiple-choice testing are not difficult to fathom. To begin with, it is both efficient and inexpensive. It might take hours for a faculty member or evaluator to assess a learner’s oral or essay responses, but multiple-choice responses can be graded almost instantaneously and in large numbers by a computer. Moreover, compared to oral and essay-based forms of evaluation, in which the judgment of an evaluator plays a prominent role, multiple-choice testing appears to be both fair and objective. Every student takes exactly the same examination, and every examination is graded exactly the same way, creating the impression of a subjectivity—and hence bias-free form of evaluation. Finally, the examination can be administered in more or less exactly the same way at many different geographic sites and times without adding substantially to costs. Of course, there are corresponding downsides, including the fact that evaluation is not tailored to the distinctive interests and abilities of each learner, capacities such as curiosity, creativity, and resilience go unassessed—any human element of assessment is lost—and learners often feel they are being treated as numbers rather than people. The lack of dialogue between learner and evaluator means that conformity rules, as all possibility of dialogue is completely forsaken.

Another sign of medicine’s culture of conformity can be found in the contemporary state of medical records. Several decades ago, before such records were computerized, physicians wrote “notes” on their patients. Whether an inpatient or outpatient, every patient had a chart, and physicians would make notes following each patient encounter, capturing such elements as past medical history, the story of the present illness, the findings of physical examination and laboratory testing, and plans for further diagnostic evaluation and care. This approach required the physician to think everything through and formulate a coherent plan. In a sense, every physician was a storyteller, and one of the signs of excellence was the ability to formulate a succinct but comprehensive and coherent account of the patient’s care. Today, by contrast, a great deal of the medical record is composed by selecting items from lists of available choices and drop-down menus. Medical students and physicians are not asked to formulate an account but to populate a template. And in most cases, the lists of options are constructed as much or more for coding and billing purposes—making sure the practice or hospital complies with regulations and gets paid—as they are to foster good patient care. Many patients can relate to the feeling that their physician is more focused on satisfying the requirements of the medical record system than listening to their story.

Still another indicator of the ascendancy of compliance culture is medicine’s growing reliance on policies and procedures. Fewer and fewer physicians are engaged in solo and small-group practice, and more and more are going to work for large single- and multiple-specialty groups, hospitals, and health systems, not as independent professionals with an ownership interest in their practices but as employees. As a result, medicine is becoming increasingly bureaucratized. In a small group, everyone can know everyone else, and operations can be based to a large degree on personal acquaintance, respect, and trust. But as more and more physicians work in organizations with hundreds, thousands, and tens of thousands of employees, it becomes impossible to base practice on personal relationships, and, to an increasing extent, organizations rely on generic policies and procedures. As greater emphasis is placed on compliance, the distinctive excellences of each physician tend to be devalued. What matters most is not whether care was customized to the needs of each individual patient but whether the physician followed protocols meant to apply to all patients. As a result, the practice of medicine tends to undergo depersonalization, and physicians come to resemble functionaries in a production process, what some have called “assembly-line medicine.”

The problem, of course, is that creating an imperative to conform to expectations prioritizes convention, the avoidance of deviation from standards, the earning of credentials, and the control of thought processes over innovation, risk taking, the pursuit of new knowledge, asking previously unformulated questions, and discovery. Physicians are molded into the kind of people who know what they are taught to know and do what they are taught to do and who fear making mistakes—deviating from standards and expectations—more than almost anything. In this model of premedical and medical education, the best students are not the ones who ask the best questions but the ones whose responses most often conform to the answer key. They know the textbooks of today forward and backwards, but they have become less and less well-equipped to write the textbooks of tomorrow.

For a variety of reasons, this is a problem. For one thing, the riddle of human health and disease has not yet been solved, and we humans are still subject to a barrage of diseases for which cures are quite a long way off—among them cancers of various types, heart disease, and dementia. If we keep answering the same questions in the same way, these scourges will continue unabated. It is quite possible that in many cases, we have not been posing the right questions. Patients afflicted with these and many other diseases need physicians who can ask good questions, not just to arrive at a correct diagnosis and prescribe appropriate therapy, but also to understand the roots of disease in the lives of patients and to help patients coping with their conditions lead the best lives of which they are capable. To perform well as physicians, it is not enough to know the disease. It is necessary to know the patient, and to recall that we are not just treating diseases but also first and foremost caring for patients with diseases. The stunting of skepticism, creativity, and risk taking takes a toll on physicians, by preventing them from developing fully as professionals and persons. In the words of John Stuart Mill, “A state that dwarfs its people, even for beneficial purposes, will soon find that with small people no really great thing can be accomplished.” The medical profession needs to stop dwarfing its members.

Consider an even richer story. Charlie Dotter and Bill Cook helped to usher in a revolution in medicine. Dotter was an academic physician in Oregon, now often referred to as the “father of interventional medicine.” Cook was an entrepreneur who built the world’s largest privately held medical device manufacturer out of a two-bedroom apartment in Bloomington, Indiana. Dotter and Cook first met one another at a medical trade show in Chicago in 1963. It soon became clear that Dotter was a rare physician, someone who loved to innovate and take risks. A radiologist, he was once asked to inject dye into the main artery of an elderly diabetic patient’s leg, to see whether the surgeon would need to amputate below or above the knee. She had developed infected foot ulcers that were not healing, and taking her leg seemed the only way to preserve her life. When Dotter saw the artery, however, he discovered a very short narrowing that he thought he could open up by passing progressively larger catheters through it. When he did so, circulation to the foot was restored, and over time, her ulcers healed. She ended up living an additional two years, eventually succumbing to pneumonia, but she died with two feet and all ten of her toes. Dotter was not conforming to standards. He was exploding them, opening up a radically new mode of therapy for narrowings and blockages throughout the body.

Most of the culture of medical education could be likened to a spelling bee. In such a setting, the student who wins is the one who can spell words correctly. Dotter, by contrast, was inventing new words. He was not reciting from the textbooks of the past but helping to write the textbooks of the future. By all accounts, Dotter’s imagination was not dwarfed but developed to gigantic proportions. He was constantly coming up with new ideas. For one reason or another, many of these ideas were bad. Some offered too few benefits or carried too high a risk, and others simply would not work. But Dotter kept imagining and trying out, and from his fertile imagination sprang many ideas that have become standards in contemporary medicine. He did not allow his fear of making a mistake to prevent him from conjuring up and trying out something new. Instead, he imagined boldly and followed his ideas. In this respect, he represented a stark contrast to the habits inculcated by contemporary medical education, which tends to make avoiding mistakes the highest priority and implicitly encourages learners to attempt very little beyond memorizing what they are told. From Dotter’s point of view, perhaps the greatest sin against medicine is not to make a mistake but to fail to attempt something that matters.

Bill Cook was a nearly perfect complement to Dotter. He, too, had once attended medical school, but after a few days of classes, he realized that he had placed himself on a kind of assembly line. For years to come, he and his classmates would enroll in the same classes, sit through the same lectures, and take the same tests. Concerned that such an environment would be stifling for him, he spoke to the dean, asking how long he could continue to test the waters before it would be impossible for another student on the waiting list to take his place. The dean told him he had a week. At the end of that week, Cook returned and resigned his place in medical school. He did not want to be injected into the same mold as every other student. He wanted to play a role in refashioning the mold. So he started his own company, making his products in the second bedroom of his family’s small apartment. His company made the guidewires, catheters, and other devices that Dotter and physicians like him needed to create a new medical field of image-guided diagnosis and therapy. He and Dotter would make prototypes out of guitar strings, automobile speedometer cables, and vinyl insulation stripped from telecommunication cables. One of Cook’s first employees recalled that he loved to try out something new, and he was “willing to risk everything if he believed in what you were doing.”

It did not take long for Dotter and Cook’s innovations to attract attention. A 1964 magazine article features photos of Dotter performing what was then one of the world’s first angioplasties, opening up an artery in a patient’s leg. Again, one of Cook’s first employees reports what it was like to see products they had made by hand in Cook’s two-bedroom apartment. “Holy cow,” he said, “we are really making a difference here.” Dotter’s thirst for innovation was so fierce that in some cases he made his colleagues uncomfortable. One time he was presenting at grand rounds at his hospital, talking about the advances in medicine that might be possible if a catheter could be placed in the heart and measurements taken of the pressure in different chambers. To the surprise and horror of his audience, Dotter then rolled up his sleeve and revealed that he had placed such a catheter in his own heart, which he then hooked up to a device and used to display his own pressures. Many feared that Dotter would drop dead on the spot, but he did not, and such pressure measurements have since become routine in the care of seriously ill patients. Cook was known for telling his employees to try something. Even if it didn’t work, it would get them involved in the problem, formulating, testing out, and refining their own ideas.

Cook did not care about the educational pedigree or academic honors of his employees. For example, one of the most successful presidents of the company started out as a secretary, answering the phone, greeting people who came in the front door, and handling Cook’s correspondence. She did not have advanced academic credentials such as an MD or PhD, an MBA, or even a college degree. In fact, she had never attended college. But she was an eager learner, paid close attention to how the company operated, and understood most of the employees of the company, partly because she shared their background. Another Cook president had been a high school music teacher and band director, but Cook admired the way he dealt with people. What mattered most to Cook was not a transcript or a resume but whether a prospective employee was the kind of person who latched on to a job, took responsibility for making sure it was done right, and truly cared about the quality of work they did. As one early employee said, he did not look over people’s shoulders, because he knew they were the kind of people who cared about improving the quality of the work for its own sake. And Cook cared about his employees. He was often seen walking around the production floor, talking with people, and he and the company’s other leaders made it a point to have only one dining room, ensuring that everyone ate lunch together.

Cook’s leaders operated not by sitting in a board room and formulating strategic plans or generating policies and procedures to which everyone must conform. Instead, they spent most of their time out in the field, meeting and talking with physicians. The goal of Cook’s field representatives was not to sell products—in fact, they were not allowed to take orders. Their goal was to listen to physicians, find out what problems they faced and how Cook might collaborate with them to design and produce solutions, and to make sure that their ideas for improving patient care had a chance to see the light of day. Cook was a company built not from the board room or the C-suite but from the front lines, the company’s relationships with physicians such as Dotter. This approach turned out to be highly conducive to innovation. Of course, many ideas did not pan out, but others did, and this helped to usher in a new era of image-guided, minimally invasive medical diagnosis and therapy. The goal was not to follow convention, avoid making mistakes, ensure that everyone held the appropriate credentials, control every word and action of every employee, or to confine people to a set of policies and procedures, but to foster creativity, collaboration, and risk taking that could enhance the care of patients.

Such a culture is sorely needed in medicine today, when despite advances in knowledge and the expenditure of ever-greater amounts of money, the pace of biomedical innovation has slowed considerably since the period of 1950 to the 1980s. Numerous factors are responsible, but one of the most important is the growing culture of compliance that dominates the careers of physicians beginning during the earliest years of formal education and continuing right through to their final days of practice. We are not selecting for, nurturing, or rewarding imagination in medicine to the degree we should, and patients, physicians, and our society are paying the price for it. To reverse this trend, we need to recognize and explore more deeply both the costs of conformity and the rich bounty that can arise from fostering creativity. Just as disadvantaged high school students can discover new career paths in medicine, so medical students and practicing physicians can discover new pathways of innovation in medical education and practice, which will enable them to push the envelope of excellence in medicine. Physicians are bright people, and we sacrifice a great deal when we stunt the development of their imaginations. As we unfetter their creative faculty, we are likely to realize benefits not only in biomedical innovation but also in the fruits of moral imagination as manifested in relationships with patients.