We are at a cusp point in medical generations. The doctors of former generations lament what medicine has become. If they could start over, the surveys tell us, they wouldn’t choose the profession today. They recall a simpler past without insurance-company hassles, government regulations, malpractice litigation, not to mention nurses and doctors bearing tattoos and talking of wanting “balance” in their lives. These are not the cause of their unease, however. They are symptoms of a deeper condition—which is the reality that medicine’s complexity has exceeded our individual capabilities as doctors.
The core structure of medicine—how health care is organized and practiced—emerged in an era when doctors could hold all the key information patients needed in their heads and manage everything required themselves. One needed only an ethic of hard work, a prescription pad, a secretary, and a hospital willing to serve as one’s workshop, loaning a bed and nurses for a patient’s convalescence, maybe an operating room with a few basic tools. We were craftsmen. We could set the fracture, spin the blood, plate the cultures, administer the antiserum. The nature of the knowledge lent itself to prizing autonomy, independence, and self-sufficiency among our highest values, and to designing medicine accordingly. But you can’t hold all the information in your head any longer, and you can’t master all the skills. No one person can work up a patient’s back pain, run the immunoassay, do the physical therapy, protocol the MRI, and direct the treatment of the unexpected cancer found growing in the spine. I don’t even know what it means to “protocol” the MRI.
Before Elias Zerhouni became director of the National Institutes of Health, he was a senior hospital leader at Johns Hopkins, and he calculated how many clinical staff were involved in the care of their typical hospital patient—how many doctors, nurses, and so on. In 1970, he found, it was 2.5 full-time equivalents. By the end of the nineteen-nineties, it was more than fifteen. The number must be even larger today. Everyone has just a piece of patient care. We’re all specialists now—even primary-care doctors. A structure that prioritizes the independence of all those specialists will have enormous difficulty achieving great care.
Archive for May, 2011
The big challenge, as I see it, is how to enable academics to do interesting and relevant work on the cloud when it’s nearly impossible to build up the infrastructure in a university setting. John Wilkes made the point that that he never wanted to see another paper submission showing a 10% performance improvement in Hadoop, and he’s right — this is not the right problem for academics to be working on. Not because 10% improvement is not useful, or that Hadoop is a bad platform, but because those kinds of problems are already being solved by industry. In my opinion, the best role for academia is to open up new areas and look well beyond where industry is working. But this is often at odds with the desire for academics to work on “industry relevant” problems, as well as to get funding from industry. Too often I think academics fall into the trap of working on things that might as well be done at a company.Much of the debate at HotOS centered around the industry vs. academic divide and a fair bit of it was targeted at my previous blog posts on this topic. Timothy Roscoe argued that academia’s role was to shed light on complex problems and gain understanding, not just to engineer solutions. I agree with this. Sometimes at Google, I feel that we are in such a rush to implement that we don’t take the time to understand the problems deeply enough: build something that works and move onto the next problem. Of course, you have to move fast in industry. The pace is very different than academia, where a PhD student needs to spend multiple years focused on a single problem to get a dissertation written about it.
Too often I think academics fall into the trap of working on things that might as well be done at a company.
Sometimes, there could even be some pressure from the industry itself to solve their problems at the University, though Matt does not talk about that scenario.
Remarkably, however, Kerala in the recent past has shown a slightly higher growth rate than the Indian economy as a whole, and only a slightly lower growth rate than Gujarat with which it is always compared unfavourably as a destination for private capital. The gross domestic product at factor cost in constant (2004-5) prices in 2009-10 was 25 per cent higher than in 2006-07 for the country as a whole; for Kerala the gross state domestic product was 28 per cent higher and for Gujarat 31 per cent higher. Growth rate, though much advertised these days by Central government spokesmen, is an utterly inadequate index for judging economic progress. Even by this criterion, however, Kerala, despite not joining the rat race for attracting capital, has performed quite creditably.
Some may argue that Kerala would have done even better if it had also exerted itself to be hospitable to private capital; but that is erroneous. A state cannot both expand welfare expenditure significantly and be generous in providing inducements to private capital. State government resources being limited, a strategy of providing inducements to private capital takes up so much of these resources that little is left for increasing welfare expenditures noticeably. According to a report in The Hindu, for instance, the Gujarat government promised to give out Rs 31,000 crore, no doubt spread over several years, to induce the Tatas to shift their Nano plant to that state. With such largesse, clearly the scope for increasing welfare expenditure gets severely constricted.
Putting it differently, we have here two alternative development strategies, which cannot really be combined. One uses the public exchequer to induce capitalists to invest in the state in the belief that this investment will generate growth. The other uses the exchequer to increase government expenditure on a variety of schemes, in particular welfare schemes, in the belief that this will not only directly benefit the people, but also, as a consequence, enlarge the domestic market, to cater to which there will be an automatic increase in investment, not necessarily of big capitalists but of a range of small entrepreneurs.
I do not have to tell you which one of the strategies is better!