I was sitting in the lobby of my hotel in Cozumel, Mexico, when I got a message from my editor asking me for a blog on the future of medicine and my personal challenges as the year draws to an end. I was about to embark on the Ironman race, and wasn’t even sure about making it to the New Year, but decided to start the blog anyway.
The first thing that comes to mind in medicine is change. I have had to modify everything I learnt in training. The way I do procedures has changed completely—for the better. Better imaging has allowed us to see and understand the body more completely. In cardiology, one of the major changes has been the ability to modify and replace parts of the heart with minimally invasive methods, so that patients can heal faster. Aortic valve replacement through an artery in the leg has now become the standard for most patients. No more open heart surgery. Patients are up and walking the same day. The mitral valve is headed that way, too, with a new clip that can reduce the leak in the valve in patients too sick or unable to have surgery. Newer stents and fancy drills have been developed to clear blockages. Stroke prevention has improved by leaps and bounds with new procedures and drugs. Stroke treatment has improved, with techniques for unblocking arteries of the brain recently approved. Electrical abnormalities of the heart can now be mapped out and ablated (zapped out with cryotherapy or radio frequency), so that people can live without lifelong medications.
The biggest change, however, has been in the way we approach heart attacks. A heart attack occurs when an artery is abruptly blocked, leading to death of the heart muscle it supplies. There has been a concept of door-to-balloon time, which is the time from when the patient with a heart attack hits the door of the emergency room, to the cardiologist getting a balloon to the blocked artery to open it. Data has shown that a time of less than 90 minutes helps improve mortality rate and saves the heart muscle. In the US, hospitals are part of a national database, with every case being tracked. Hospitals and providers get penalised if they fall outside of standard deviations.
Other areas that are tracked routinely are mortality rates, procedural complications, reasons for procedures, readmission following heart failure treatment and chances of getting an infection post procedure. You can get this data on any hospital and any doctor. Going forward, hospitals and doctors are going to have to disclose more data to the public, including cost of any given procedure.
The heart transplant scenario has seen an explosion of technology with ambulatory artificial heart machines lasting longer. Artificial hearts (also called left ventricular assist devices) have changed from being a bridge to heart transplant, to an alternative to heart transplant, what we refer to as destination therapy. Cancer treatment continues to struggle, but early diagnosis, education and intervention have started to make a dent to the curve. The change is endless and exciting.
The problem, however, is access and resources. There is only so much money in the pot. Right now, the United States spends $3.4 trillion a year on health. That is 18 per cent of the GDP. In contrast, India spends a little over 1 per cent on health. The spending of dollars right now is interesting—one quarter goes towards care of people during their last year of life. Another significant area of expense is people with one or more chronic illnesses, victims of accidents, plus victims of violent crime. This 5 per cent of the population accounts for 50 per cent of medical costs. In spite of all this expenditure, 12.2 per cent or 3.2 million of the American population remains uninsured. The cost of uncompensated care for the uninsured is $84 million.
I don’t have a solution to these problems. I am just a doctor trying my best to keep up with the ever changing insurance regulatory system, while taking care of my patients. But this data gives rise to some big ethical questions about end-of-life care, how much to spend on any given individual, and access to care. We, as a society, need to ponder these issues, because sooner or later they are going to get to breaking point.
Medicine is increasingly going towards a protocol-oriented treatment goal. Every patient with a given disease will be treated the same, with any deviation being scrutinised. This is both good and bad. The good part is that the minimum standards are met. The bad part, of course, is that we are all different. What works for Peter may not necessarily work for Paul. I worry that future generations of doctors will be so ingrained into protocol medicine that they will lose their gut instinct.
Which brings us to personal responsibility. You have been given this wonderful, unique, one-of-a-kind, complex machine that can never be replicated. How you take care of it, is your personal freedom. Sooner or later, however, you have to pay the piper, which will be expensive, painful and you will also have to deal with the likes of me for the rest of your lifetime.
On the practice front, I am fortunate to work with a bunch of exceptional doctors and human beings. We continue to be an independent practice that works closely with the hospital, but not governed by the hospital administration. We report to our patients.
On a personal front, despite the regulatory changes in medicine, I love the practice of it. I am fortunate that I have been given a set of skills that can make a difference to people. I love interacting with my patients, I love hearing their stories, their passions, their highs and lows. I, in turn, share my life with them. I get inspired by them, feed off their positivity in trying circumstances. I realise that as a doctor, even if I can’t fix a problem, I can be there for them, give them options, be there with them to the end, make a difference. In return, my day is filled with hugs and kisses.
As I get older, I am more aware of my own mortality. As an interventional cardiologist, my odds of cancer are extremely high. There has never been a group of people exposed to as much radiation as interventional cardiologists in the history of mankind. We get radiated with every procedure we do, the consequences of which will only be known decades later. We are the test subjects. I am at the peak of my career, but cardiologists are plagued with back and neck issues due to the lead they wear all day. I know that at some point, one of these issues is going to catch up with me.
I have become a lot softer, more forgiving. I take time to enjoy the practice of medicine, savour the smiles, hold hands a little longer, hug a little more. I think I have the best job on earth, and hell, I get paid, too. I have three delightful children, a loving, supporting wife, and I survived the Ironman. If I were to do it all over, I wouldn’t change a thing.
Arab is chairman, department of medicine, and director, division of cardiology, at Florida Hospital Memorial Medical Centre, United States.