life/death.  we removed the mechanical respirator from an older woman because her family requested it be done.  over the next few minutes her skin gradually changed from pink to pale as the remaining oxygen in her blood was consumed by her tissues.  her heart slowed and then it stopped.  it was a moving scene.

Quoted from my brother’s college textbook, Financial Accounting, which I borrowed and have been perusing. Chapter One = balance sheets. This is the same brother that gave me a photocopied set of every annual letter Warren Buffet has ever written to his shareholders for Christmas two years ago. Thanks Dave.

“A characteristic common to all recognized professions—such as medicine, law and accounting—is the need for individual practitioners to resolve many problems with their own professional judgement. The problems encountered in the practice of a profession are often complex, and the specific circumstances unique. Consequently, no written set of rules exists to provide answers in every situation.”

In medicine this is certainly true and will always remain such—this is somewhat obvious—but what is less obvious is that this rule is becoming ever more inconsequential.  Here’s why: medical judgment has become more and more standardized over the last several generations at a rate that does not have historical precedent.  Over the last two decades, especially, very smart physicians have stratified risk factors mathematically, calculated numbers needed to treat (NNT’s) for nearly every medical and surgical intervention, defined ranges of normal and abnormal for all conditions, and forumulated practice standards and checklists for most every medical decision pathway.  (These practice pathways extend exactly to the very point of confounding molecular experimental conditions that leave us with drugs and interventions that are equally as likely to harm us as to help us).  These advances underpin the successes of medicine historically, of course, but of even more importance for the present state of the profession they represent  potentially huge implications for society and industry that have yet to be put forth.  For when such repeating patterns and systems are given to the lay population in a conceptually simple fashion, which is no doubt technologically feasible in our time for many circumstances, the economy of medicine will shift.  

Physicians, when contrasted to the other professionals mentioned—lawyers, accountants, musicians, etc.—have a very unique profession due to the fact that they spend years being taught to perceive the subtleties of the human biologic mechanism as opposed to systems based in man made conceptual convention.  This distinction is important to realize when ordering a system of medical understanding.

Medical knowledge at its root is composed of a set of physical phenomenon that have always existed and have been discovered, rather than created. Our domain is not a rule produced by the collective human mind as is, say, “constitutional law” or “corporate income tax” but rather simply the compendium of biologic causes and effects which have always existed and only subsequently—in the recent historical timeframe of the last 150 years—been observed, recorded and taught.  Once they are learned they tend to remain constant and very seldom change.  Other professions such as law and accounting, in contrast, are rooted fundamentally in fabrications of the human mind and are by their very definition subject to changing tides of politics, era and philosophy, as are art, music, fashion, etc.  Legislation and popular vote can change tax law but it will never change the classic symptoms of appendicitis, cholecystitis, or meningitis.  Thus non-medical professional applications root themselves in a combination of human social history and community, while medicine remains focused on the individual who is in practical, biological terms unchanging.

We doctors have historically attempted to hone in on a finite target from a position of curiosity and previously unknown variable.  In contrast those practices founded in human conception move in the opposite direction—their funds of knowledge have sprung from the elemental nature of humanity to create complex and artful systems of conception, language and order which did not previously exist.  The system of medicine is regressive, in a sense, as it looks into the past and towards the miniscule, while the others are forward moving, taking the fundamentals without questioning their cause and creating new orders and laws from it.  While neither system better or worse for such characteristics, this distinction is important and carries significant practical implication for the medical profession philosophically at this unique point in history where our introspection into the body is yielding less and less practical information per unit of time invested in it. 

A lawyer must by definition understand the legal system of a specific state within the context of a relative community, historical precedent, era, etc.  As a fundamental corollary such a professional could never hope to practice in a foreign land for these very same reasons.  Medical doctors, by contrast, are free to skillfully apply their knowledge on any human body and in any counry regardless of where a person resides relative to a map.  This unique characteristic of the medical profession will be, I believe, when realized fully, associated with vast implications for investors, governments and society because when data is married to technology allowing parts of the traditional domain of the doctor to be rendered clearly to lay persons independently, judgements medical doctors were once paid to make will become less needed.  And once this is reached it may not change.  Bad for doctors, perhaps, but good for society.

This realization, then, taken inseparably from a hypothesis that medical breakthrough is reaching the point of practical diminishing return, would be a logical jumping-off point for the profession to purposefully rethink it’s role in modern society and prompt transition from discovery of new information to more efficient representation of well-tried data in realms of education and care delivery.  The teaching of conceptual professions requires mastery of a constantly shifting field of reference specific to time and place, which will always be a relative education.  Medicine, however, requires only thorough exposure to the set of constants that are relatively unchanging.  It is true, of course, that medical constants only begin to become apparent over time periods and physical scales that are both vastly smaller (molecules) and larger (decades) than the human is trained to perceive with his five senses, and that traditionally this has required years of study and experience in a hospital and with cadavers and microscope, however, it does not mean that such hurdles can’t be overcome by the power of data collection and modern media capability. Medical logic, because of its ever-decreasing amount of subjective debate on a practical level, is distinct in that it possesses the possibility of being taught similarly to to how a language or an alphabet is learned. 

Any language will seem complex to a novice, especially at first, and of course not everyone will understand and speak languages with the same fluency… but not every lay person needs to be stuck in the contemporary pattern of simple lay medical grammar and limited by webMD access. Exposure to the language, like exposure to anything consistently observable and reproducible, can shift an individual’s ability to use it and interpret it.  Technology can now make the subtle sets of data more evident visualy, reproducible and available to the basic logicigal bases we reason by.  This may be the key to a new system that could create a solution to our modern medical problem at the root.

The health breakthroughs available to our five senses—experiments and treatments that are repeatable under controlled circumstances without causing more harm than good, undertaken in a clinically applicable timeframe—may be nearing exhaustion.  We may have reached the point of diminishing returns from a perspective of cost/benefit.  And while it is obviously imprudent to argue that professional judgment would ever become irrelevant to the field of medicine it is not illogical to suppose that its domain could be decreased by a defined set of rules given to the population in understandable terms, thereby moving the task of medical decision making from doctor to patient, along with a significant portion of the 17% of GDP which is currently spent on American healthcare.  Properly conveyed knowledge of constants could shift economic expenditure away from medicine and towards more beneficial contemporary social causes. 

Such a transition would alter the profession and society in a significant way and perhaps be reason to rationally shift a large portion of our societal spending from discovery of ever-less applicable medical minutia to fundamental education of the population with the wealth of knowledge we already possess. It will likely be that the modern physicians whose names will be memorialized in textbooks for the next generation of students will be those individuals who can collect and visualize data patterns spanning the scales from molecules to centuries and communicate these clearly, rationally and visually. Gone are the days of palpating a gallbladder and assigning your name to the painful grimace a jaundiced patient reflexively makes.  We’re due to move on as a profession.  The low hanging clinical fruit has been picked and catalogued and much of the remaining knowledge may forever remain outside of the realm of rational understanding due to matters of scale and exponential variability.  This is a big idea… if it is true.    

It needs to be more affordable.

It’s a right not a privilege.

It should be free.

Who pays for it?

Insurance companies meddle with it up.

Market choice fragmentation increases the cost of administering it.

Canada has it.  France has it.

The government controls it.

Electronics record it.

The internet will revolutionize it.

So what exactly is healthcare?  This is the interesting fundamental question and this is where the potential for massive marketing confusion and political smoke and mirrors lay.   The fundamentals of healthcare hardly ever get talked about on the evening news and, indeed, it seems “the dream of reason did not take power into account,” as Paul Starr stated beautifully with the first sentence of his very good book on healthcare.  Regardless, the basic fixes are not that political or sexy in terms of marketing.  They are just a set of relatively simple rules based on collective observation.