By
2010, Bill Haynes had spent almost four decades under attack from the
inside of his skull. He was fifty-seven years old, and he suffered from
severe migraines that felt as if a drill were working behind his eyes,
across his forehead, and down the back of his head and neck. They left
him nauseated, causing him to vomit every half hour for up to eighteen
hours. He’d spend a day and a half in bed, and then another day
stumbling through sentences. The pain would gradually subside, but often
not entirely. And after a few days a new attack would begin.
Haynes
(I’ve changed his name, at his request) had his first migraine at the
age of nineteen. It came on suddenly, while he was driving. He pulled
over, opened the door, and threw up in someone’s yard. At first, the
attacks were infrequent and lasted only a few hours. But by the time he
was thirty, married, and working in construction management in London,
where his family was from, they were coming weekly, usually on the
weekends. A few years later, he began to get the attacks at work as
well.
He saw all kinds of
doctors—primary-care physicians, neurologists, psychiatrists—who told
him what he already knew: he had chronic migraine headaches. And what
little the doctors had to offer didn’t do him much good. Headaches rank
among the most common reasons for doctor visits worldwide. A small
number are due to secondary causes, such as a brain tumor, cerebral
aneurysm, head injury, or infection. Most are tension headaches—diffuse,
muscle-related head pain with a tightening, non-pulsating quality—that
generally respond to analgesics, sleep, neck exercises, and time.
Migraines afflict about ten per cent of people with headaches, but a
much larger percentage of those who see doctors, because migraines are
difficult to control.
Migraines are
typically characterized by severe, disabling, recurrent attacks of pain
confined to one side of the head, pulsating in quality and aggravated by
routine physical activities. They can last for hours or days. Nausea
and sensitivity to light or sound are common. They can be associated
with an aura—visual distortions, sensory changes, or even speech and
language disturbances that herald the onset of head pain.
Although
the cause of migraines remains unknown, a number of treatments have
been discovered that can either reduce their occurrence or alleviate
them once they occur. Haynes tried them all. His wife also took him to a
dentist who fitted him with a mouth guard. After seeing an
advertisement, she got him an electrical device that he applied to his
face for half an hour every day. She bought him hypnotism tapes,
high-dosage vitamins, magnesium tablets, and herbal treatments. He tried
everything enthusiastically, and occasionally a remedy would help for a
brief period, but nothing made a lasting difference.
Finally,
desperate for a change, he and his wife quit their jobs, rented out
their house in London, and moved to a cottage in a rural village. The
attacks eased for a few months. A local doctor who had migraines himself
suggested that Haynes try the cocktail of medicines he used. That
helped some, but the attacks continued. Haynes seesawed between good
periods and bad. And without work he and his wife began to feel that
they were vegetating.
On a trip to
New York City, when he turned fifty, they decided they needed to make
another big change. They sold everything and bought a bed-and-breakfast
on Cape Cod. Their business thrived, but by the summer of 2010, when
Haynes was in his late fifties, the headaches were, he said, “knocking
me down like they never had before.” Doctors had told him that migraines
diminish with age, but his stubbornly refused to do so. “During one of
these attacks, I worked out that I’d spent two years in bed with a
hot-water bottle around my head, and I began thinking about how to take
my life,” he said. He had a new internist, though, and she recommended
that he go to a Boston clinic that was dedicated to the treatment of
headaches. He was willing to give it a try. But he wasn’t hopeful. How
would a doctor there do anything different from all the others he’d
seen?
That question interested me,
too. I work at the hospital where the clinic is based. The John Graham
Headache Center, as it’s called, has long had a reputation for helping
people with especially difficult cases. Founded in the nineteen-fifties,
it now delivers more than eight thousand consultations a year at
several locations across eastern Massachusetts. Two years ago, I asked
Elizabeth Loder, who’s in charge of the program, if I could join her at
the clinic to see how she and her colleagues helped people whose
problems had stumped so many others. I accompanied her for a day of
patient visits, and that was when I met Haynes, who had been her patient
for five years. I asked her whether he was the worst case she’d seen.
He wasn’t even the worst case she’d seen that week, she said. She
estimated that sixty per cent of the clinic’s patients suffer from
daily, persistent headaches, and usually have for years.
In
her examination room, with its white vinyl floor and
sanitary-paper-covered examination table against the wall, the
fluorescent overhead lights were turned off to avoid triggering
migraines. The sole illumination came from a low-wattage table lamp and a
desktop-computer screen. Sitting across from her first patient of the
day, Loder, who is fifty-eight, was attentive and unhurried, dressed in
plain black slacks and a freshly pressed white doctor’s coat, her auburn
hair tucked into a bun. She projected both professional confidence and
maternal concern. She had told me how she begins with new patients: “You
ask them to tell the story of their headache and then you stay very
quiet for a long time.”
The
patient was a reticent twenty-nine-year-old nurse who had come to see
Loder about the chronic daily headaches she’d been having since she was
twelve. Loder typed as the woman spoke, like a journalist taking notes.
She did not interrupt or comment, except to say, “Tell me more,” until
the full story emerged. The nurse said that she enjoyed only three or
four days a month without a throbbing headache. She’d tried a long list
of medications, without success. The headaches had interfered with
college, relationships, her job. She dreaded night shifts, since the
headaches that came afterward were particularly awful.
Loder
gave a sympathetic shake of her head, and that was enough to win the
woman’s confidence. The patient knew that she’d been heard by someone
who understood the seriousness of her problem—a problem invisible to the
naked eye, to blood tests, to biopsies, and to scans, and often not
even believed by co-workers, family members, or, indeed, doctors.
She
reviewed the woman’s records—all the medications she’d taken, all the
tests she’d undergone—and did a brief examination. Then we came to the
moment I’d been waiting for, the moment when I would see what made the
clinic so effective. Would Loder diagnose a condition that had never
been suspected? Would she suggest a treatment I’d never heard of? Would
she have some special microvascular procedure she could perform that
others couldn’t?
The answer was no.
This was, I later came to realize, the key fact about Loder’s
capabilities. But I didn’t see it that day, and I was never going to see
it in any single visit.
She
started, disappointingly, by lowering expectations. For some ninety-five
per cent of patients who see her, including this woman, the diagnosis
is chronic migraines. And for chronic migraines, she explained, a
complete cure was unlikely. Success meant that the headaches became less
frequent and less intense, and that the patients grew more confident in
handling them. Even that progress would take time. There is rarely a
single, immediate remedy, she said, whether it was a drug or a change in
diet or an exercise regimen. Nonetheless, she wanted her patients to
trust her. Things would take a while—months, sometimes longer.
Success
would be incremental.
She asked the
woman to keep a headache diary using a form she gave her to rate the
peak level and hours of headache each day. She explained that together
they would make small changes in treatments and review the diary every
few months. If a regimen produced a greater than fifty-per-cent
reduction in the number and severity of the headaches, they’d call that a
victory.
Haynes told me that
Loder gave him the same speech when he first saw her, in 2010, and he
decided to stick with her. He liked how methodical she was. He kept his
headache diary faithfully. They began by formulating a “rescue plan” for
managing his attacks. During an attack, he often vomited pills, so she
gave him a supply of non-narcotic rectal suppositories for fast-acting
pain relief and an injectable medicine if they didn’t work. Neither was
pleasant to take, but they helped. The peak level and duration of his
attacks diminished slightly. She then tried changing the medications he
used for prevention. When one medicine caused side effects he couldn’t
tolerate, she switched to another, but that one didn’t produce any
reduction in headaches. He saw her every three months, and they kept on
measuring and adjusting.
The most
exotic thing they tried was Botox—botulinum-toxin injections—which the
F.D.A. had approved for chronic migraines in 2010. She thought he might
benefit from injections along the muscles of his forehead. Haynes’s
insurer refused to cover the cost, however, and, at upwards of twelve
hundred dollars a vial, the treatment was beyond what he could afford.
So Loder took on the insurer, and after numerous calls and almost a year
of delays Haynes won coverage.
After
the first few rounds of injections—each treatment lasts three months
and is intended to relax but not paralyze the muscles—Haynes noticed no
dramatic change. He was on four medications for prevention, including
the Botox, and had four escalating rescue treatments that he could
resort to whenever a bad headache began to mount. Three years had
passed, and progress had been minimal, but Loder was hopeful.
“I
am actually quite optimistic about his long-term outlook for
improvement,” she wrote in her notes that spring. “I detect slow but
steady progress. In particular, the extremes of headache at the upper
end have come down nicely and vomiting is much less of a problem. That,
in my experience, is a clear sign of regression.” Haynes wasn’t so sure.
But after another year or so of adjustments he, too, began to notice a
difference. The interval between bad attacks had lengthened to a week.
Later, it stretched to a month. Then even longer.
When
I met Haynes, in 2015, he’d gone more than a year without a severe
migraine. “I haven’t had a dreadful attack since March 13, 2014,” he
said, triumphantly. It had taken four years of effort. But Loder’s
systematic incrementalism had done what nothing else had.
I
later went to visit Haynes and his wife at their lovely nine-room inn
on the Cape. He was tall and lanky, with a John Cleese mustache and the
kind of wary astonishment I imagine that men released after years in
prison have. At sixty-two, he was savoring experiences he feared he’d
never get to have in his life.
Migraines
had ruled his life for more than four decades. For the first time, he
could read a book all the way through. He could take jet flights without
fear of what the air pressure might do to his head. His wife couldn’t
say enough about the difference.
“It’s
almost a miracle,” she said. “It has been life-changing for me. It
makes me so happy that he’s not ill. I feel good about my future. We can
look forward together.”
Recently, I
checked in again, and he hadn’t had another headache. Haynes doesn’t
like to think about what would have happened if he hadn’t found the
headache clinic. He wished he’d found it decades earlier. “Dr. Loder
saved my life,” he said.
We
have a certain heroic expectation of how medicine works. Following the
Second World War, penicillin and then a raft of other antibiotics cured
the scourge of bacterial diseases that it had been thought only God
could touch. New vaccines routed polio, diphtheria, rubella, and
measles. Surgeons opened the heart, transplanted organs, and removed
once inoperable tumors. Heart attacks could be stopped; cancers could be
cured. A single generation experienced a transformation in the
treatment of human illness as no generation had before. It was like
discovering that water could put out fire. We built our health-care
system, accordingly, to deploy firefighters. Doctors became saviors.
But
the model wasn’t quite right. If an illness is a fire, many of them
require months or years to extinguish, or can be reduced only to a
low-level smolder. The treatments may have side effects and
complications that require yet more attention. Chronic illness has
become commonplace, and we have been poorly prepared to deal with it.
Much of what ails us requires a more patient kind of skill.
I
was drawn to medicine by the aura of heroism—by the chance to charge in
and solve a dangerous problem. I loved learning how to unravel
diagnostic mysteries on the general-medicine ward, and how to deliver
babies in the obstetrics unit, and how to stop heart attacks in the
cardiology unit. I worked in a DNA virus lab for a time and considered
going into infectious diseases. But it was the operating room that
really drew me in.
I remember
seeing a college student with infectious mononucleosis, caused by the
very virus I was studying in the lab—the Epstein-Barr virus. The
infection causes the spleen to enlarge, and in rare cases it grows so
big that it spontaneously ruptures, producing major internal bleeding.
This is what happened to the student. He arrived in our emergency
department in hemorrhagic shock. His pulse was rapid and thready. The
team could barely detect a blood pressure. We rushed him to the
operating room. By the time we got him on the table and under
anesthesia, he was on the verge of cardiac arrest.
The
resident opened the young man’s belly in two moves: with a knife he
made a swift, decisive slash down the middle, through the skin, from the
rib cage to below his umbilicus, then with open-jawed scissors pushed
upward through the linea alba—the tough fibrous tendon that runs between
the abdominal muscles—as if it were wrapping paper. A pool of blood
burst out of him. The resident thrust a gloved hand into the opening.
The attending surgeon stood across from him, asking, in a weirdly calm,
quiet voice, almost under his breath,
“Have you got it?”
Pause.
“Now?”
Pause.
“You have thirty more seconds.”
Suddenly,
the resident had freed the spleen and lifted it to the surface. The
organ was fleshy and heavy, like a sodden loaf of bread. A torrent of
blood poured out of a fissure on its surface. The attending surgeon put a
clamp across its tether of blood vessels. The bleeding stopped
instantly. The patient was saved.
How
can anyone not love that? I knew there was a place for prevention and
maintenance and incremental progress against difficult problems. But
this seemed like the real work of saving lives. Surgery was a definitive
intervention at a critical moment in a person’s life, with a clear,
calculable, frequently transformative outcome.
Fields
like primary-care medicine seemed, by comparison, squishy and
uncertain. How often could you really achieve victories by inveigling
patients to take their medicines when less than half really do; to lose
weight when only a small fraction can keep it off; to quit smoking; to
deal with their alcohol problem; to show up for their annual physical,
which doesn’t seem to make that much difference anyway? I wanted to know
I was doing work that would matter. I decided to go into surgery.
Not
long ago, I was talking to Asaf Bitton, a thirty-nine-year-old
internist I work with, about the contrast between his work and mine, and
I made the mistake of saying that I had more opportunities to make a
clear difference in people’s lives. He was having none of it. Primary
care, he countered, is the medical profession that has the greatest
over-all impact, including lower mortality and better health, not to
mention lower medical costs. Asaf is a recognized expert on the delivery
of primary health care around the world, and, over the next few days,
he sent me evidence for his claims.
He
showed me studies demonstrating that states with higher ratios of
primary-care physicians have lower rates of general mortality, infant
mortality, and mortality from specific conditions such as heart disease
and stroke. Other studies found that people with a primary-care
physician as their usual source of care had lower subsequent five-year
mortality rates than others, regardless of their initial health. In the
United Kingdom, where family physicians are paid to practice in deprived
areas, a ten-per-cent increase in the primary-care supply was shown to
improve people’s health so much that you could add ten years to
everyone’s life and still not match the benefit. Another study examined
health-care reforms in Spain that focussed on strengthening primary care
in various regions—by, for instance, building more clinics, extending
their hours, and paying for home visits. After ten years, mortality fell
in the areas where the reforms were made, and it fell more in those
areas which received the reforms earlier. Likewise, reforms in
California that provided all Medicaid recipients with primary-care
physicians resulted in lower hospitalization rates. By contrast, private
Medicare plans that increased co-payments for primary-care visits—and
thereby reduced such visits—saw increased hospitalization rates.
Further, the more complex a person’s medical needs are the greater the
benefit of primary care.
I finally
had to submit. Primary care, it seemed, does a lot of good for
people—maybe even more good, in the long run, than I will as a surgeon.
But I still wondered how. What, exactly, is the primary-care physician’s
skill? I visited Asaf’s clinic to see.
The
clinic is in the Boston neighborhood of Jamaica Plain, and it has three
full-time physicians, several part-timers, three physician assistants,
three social workers, a nurse, a pharmacist, and a nutritionist.
Together, they get some fourteen thousand patient visits a year in
fifteen clinic rooms, which were going pretty much non-stop on the day I
dropped by.
People came in with leg
pains, arm pains, belly pains, joint pains, head pains, or just for a
checkup. I met an eighty-eight-year-old man who had survived a cardiac
arrest in a parking lot. I talked to a physician assistant who, in the
previous few hours, had administered vaccinations, cleaned wax out of
the ears of an elderly woman with hearing trouble, adjusted the
medications of a man whose home blood-pressure readings were far too
high, and followed up on a patient with diabetes.
The
clinic had a teeming variousness. It didn’t matter if patients had
psoriasis or psychosis, the clinic had to have something useful to offer
them. At any given moment, someone there might be suturing a
laceration, lancing an abscess, aspirating a gouty joint, biopsying a
suspicious skin lesion, managing a bipolar-disorder crisis, assessing a
geriatric patient who had taken a fall, placing an intrauterine
contraceptive device, or stabilizing a patient who’d had an asthma
attack. The clinic was licensed to dispense thirty-five medicines on the
premises, including steroids and epinephrine, for an anaphylactic
allergic reaction; a shot of ceftriaxone, for newly diagnosed gonorrhea;
a dose of doxycycline, for acute Lyme disease; or a one-gram dose of
azithromycin for chlamydia, so that someone can directly observe that
the patient swallows it, reducing the danger that he or she will infect
someone else.
“We do the things
you really don’t need specialists for,” a physician assistant said. And I
saw what a formidably comprehensive range that could be.
Asaf—Israeli-born and Minnesota-raised, which means that he’s both more
talkative and happier than the average Bostonian—told me about one of
his favorite maneuvers. Three or four times a year, a patient comes in
with disabling episodes of dizziness because of a condition called
benign positional vertigo. It’s caused by loose particles of calcified
debris rattling around in the semicircular canal of the inner ear.
Sometimes patients are barely able to stand. They are nauseated. They
vomit. Just turning their head the wrong way, or rolling over in bed,
can bring on a bout of dizziness. It’s like the worst seasickness you
can imagine.
“I have just the trick,” he tells them.
First,
to be sure he has the correct diagnosis, he does the Dix-Hallpike test.
He has the patient sit on the examination table, turns his head
forty-five degrees to one side with both hands, and then quickly lays
him down flat with his head hanging off the end of the table. If Asaf’s
diagnosis is right, the patient’s eyes will shake for ten seconds or so,
like dice in a cup.
To fix the
problem, he performs what’s known as the Epley maneuver. With the
patient still lying with his head turned to one side and hanging off the
table, Asaf rotates his head rapidly the other way until his ear is
pointed toward the ceiling. He holds the patient’s head still for thirty
seconds. He then has him roll onto his side while turning his head
downward. Thirty seconds later, he lifts the patient rapidly to a
sitting position. If he’s done everything right, the calcified particles
are flung through the semicircular canal like marbles out a chute. In
most cases, the patient feels better instantly.
“They
walk out the door thinking you’re a shaman,” Asaf said, grinning.
Everyone loves to be the hero. Asaf and his colleagues can deliver
on-the-spot care for hundreds of conditions and guidance for thousands
more. They run a medical general store. But, Asaf insisted, that’s not
really how primary-care clinicians save lives. After all, for any given
situation specialists are likely to have more skill and experience, and
more apt to follow the evidence of what works. Generalists have no
advantage over specialists in any particular case.
Yet, somehow, having a
primary-care clinician as your main source of care is better for you.
Asaf
tried to explain. “It’s no one thing we do. It’s all of it,” he said. I
found this unsatisfying. I pushed everyone I met at the clinic. How
could seeing one of them for my—insert problem here—be better than going
straight to a specialist? Invariably, the clinicians would circle
around to the same conclusion.
“It’s
the relationship,” they’d say. I began to understand only after I
noticed that the doctors, the nurses, and the front-desk staff knew by
name almost every patient who came through the door. Often, they had
known the patient for years and would know him for years to come. In a
single, isolated moment of care for, say, a man who came in with
abdominal pain, Asaf looked like nothing special. But once I took in the
fact that patient and doctor really knew each other—that the man had
visited three months earlier, for back pain, and six months before that,
for a flu—I started to realize the significance of their familiarity.
For
one thing, it made the man willing to seek medical attention for
potentially serious symptoms far sooner, instead of putting it off until
it was too late. There is solid evidence behind this. Studies have
established that having a regular source of medical care, from a doctor
who knows you, has a powerful effect on your willingness to seek care
for severe symptoms. This alone appears to be a significant contributor
to lower death rates.
Observing
the care, I began to grasp how the commitment to seeing people over time
leads primary-care clinicians to take an approach to problem-solving
that is very different from that of doctors, like me, who provide mainly
episodic care. One patient was a Spanish-speaking woman,
younger-looking than her fifty-nine years, with a history of depression
and migraines. She had developed an odd set of symptoms. For more than a
month, she’d had facial swelling. Her face would puff up for a day,
then go back to normal.
Several days later, it would happen again. She
pulled up pictures on her phone to show us: her face was swollen almost
beyond recognition. There had been no pain, no itching, no rash. More
recently, however, her hands and feet had started swelling as well,
sometimes painfully. She had to stop wearing rings. Then the pain and
numbness extended up her arms and into her chest, and that was what had
prompted her to come in. She was having chest pain as she sat before us.
“It feels like a cramp,” she said. “My heart feels like it is coming
out of my mouth. . . . The whole body feels like it’s vibrating.”
Doctors
in other settings—say, an emergency room or an urgent-care clinic—would
use a “rule out” strategy, running tests to rule out possible
conditions, especially dangerous ones, as rapidly as possible. We would
focus first on the chest pain—women often have less classic symptoms of a
heart attack than men do—and order an EKG, a cardiac stress test, and
the like to detect coronary-artery disease. Once that was ruled out, we
might give her an antihistamine and watch her for a couple of hours to
see if the symptoms went away. And, when that didn’t work, we would send
her home and figure, Oh, well, it’s probably nothing.
This
was not, however, the way the woman’s primary-care physician approached
her condition. Dr. Katherine Rose was a young, freckle-faced physician
two years out of training, with a precise and methodical air. “I’m not
sure I know what’s going on,” she admitted to the woman.
The
symptoms did not fit together in an obvious way. But, rather than
proceed directly to an arsenal of tests, Rose took a different, more
cautious, more empirical approach, letting the answer emerge over time.
It wasn’t that she did no tests—she did an electrocardiogram, to make
sure the woman really wasn’t in the midst of a heart attack, and ordered
a couple of basic blood tests. But she didn’t expect that they’d show
anything meaningful. (They didn’t.) Instead, she asked the patient to
take allergy medicine and to return to see her in two weeks. She’d
monitor her over time to see how the symptoms evolved.
Rose
told me, “I think the hardest transition from residency, where we are
essentially trained in inpatient medicine, to my practice as a
primary-care physician was feeling comfortable with waiting. As an
outpatient doctor, you don’t have constant data or the security of
in-house surveillance. But most of the time people will get better on
their own, without intervention or extensive workup. And, if they don’t
get better, then usually more clues to the diagnosis will emerge, and
the steps will be clearer. For me, as a relatively new primary-care
physician, the biggest struggle is trusting that patients will call if
they are getting worse.” And they do, she said, because they know her
and they know the clinic. “Being able to tolerate the anxiety that
accompanies taking care of people who are sick but not dangerously ill
is not a skill I was expecting to need when I decided to become a
doctor, but it is one of the ones I have worked hardest to develop.”
The
woman’s symptoms disappeared after two weeks. A physician assistant
figured out why: the patient had run out of naproxen, an analgesic
medication she took for her migraine attacks, which in rare instances
can produce soft-tissue swelling, through both allergic and nonallergic
mechanisms. She would have to stay off all medications in that class. An
urgent-care team wouldn’t have figured this out. Now Rose contacted the
Graham Headache Center to help identify an alternative medication for
the woman’s migraines.
Like
the specialists at the Graham Center, the generalists at Jamaica Plain
are incrementalists. They focus on the course of a person’s health over
time—even through a life. All understanding is provisional and subject
to continual adjustment. For Rose, taking the long view meant thinking
not just about her patient’s bouts of facial swelling, or her headaches,
or her depression, but about all of it—along with her living situation,
her family history, her nutrition, her stress levels, and how they
interrelated—and what that picture meant a doctor could do to improve
her patient’s long-term health and well-being throughout her life.
Success,
therefore, is not about the episodic, momentary victories, though they
do play a role. It is about the longer view of incremental steps that
produce sustained progress. That, such clinicians argue, is what making a
difference really looks like. In fact, it is what making a difference
looks like in a range of endeavors.
On Friday, December 15, 1967, at 4:55 P.M.,
the Silver Bridge, which spanned the Ohio River, was funnelling the
usual crawl of rush-hour traffic between Gallipolis, Ohio, and Point
Pleasant, West Virginia, when a shotgun-like blast rang out. It was the
sound of a critical link in the bridge’s chain-suspension system giving
way. In less than a minute, 1,750 feet of the 2,235-foot span collapsed,
and seventy-five vehicles dropped into the river, eighty feet below.
“The bridge just keeled over, starting slowly on the Ohio side then
following like a deck of cards to the West Virginia side,” a witness
said. Forty-six people died; dozens more were injured.
The
newly established National Transportation Safety Board conducted its
first major disaster investigation and reconstructed what had happened.
Until then, state and federal government officials regarded such
catastrophes as largely random and unavoidable. They focussed on
building new bridges and highways, and employed mainly reactive
strategies for problems with older ones. The investigation determined
that corrosion of the four-decade-old bridge, combined with an obsolete
design (it was built to handle Model T traffic, not cars and trucks
several times heavier), had caused the critical fracture. Inspection
could have caught the issue. But the Silver Bridge had had just one
complete inspection since its opening, in 1928, and never with such
concerns in mind. The collapse signalled the need for a new strategy.
Although much of the United States’ highway system was still relatively
new, hundreds of bridges were more than forty years old and had been
designed, like the Silver Bridge, for Model T traffic. Our system was
entering middle age, and we didn’t have a plan for it.
The
federal government launched a standard inspection system and an
inventory of public bridges—six hundred thousand in all. Almost half
were found to be either structurally deficient or functionally obsolete,
meaning that critical structural elements were either in “poor
condition” or inadequate for current traffic loads. They were at a
heightened risk of collapse. The good news was that investments in
maintenance and improvement could extend the life of aging bridges by
decades, and for a fraction of the cost of reconstruction.
Today,
however, we still have almost a hundred and fifty thousand problem
bridges. Sixty thousand have traffic restrictions because they aren’t
safe for carrying full loads. Where have we gone wrong? The pattern is
the same everywhere: despite knowing how much cheaper preservation is,
we chronically raid funds intended for incremental maintenance and care,
and use them to pay for new construction. It’s obvious why.
Construction produces immediate and visible success; maintenance
doesn’t. Does anyone reward politicians for a bridge that doesn’t
crumble?
Even with serious traffic
restrictions, one in a thousand structurally deficient bridges collapses
each year. Four per cent of such collapses cause loss of life. Based on
the lack of public response, structural engineers have judged this to
be “in a tolerable range.”
They also
report that bridges are in better condition than many other parts of
our aging infrastructure. The tendency to avoid spending on incremental
maintenance and improvements has shortened the life span of our dams,
levees, roads, sewers, and water systems. This situation isn’t peculiar
to the United States. Governments everywhere tend to drastically
undervalue incrementalism and overvalue heroism. “Typically,
breakdowns—bridge washouts, overpass collapses, dam breaches—must occur
before politicians and voters react to need,” one global infrastructure
report observes. “Dislocation leads to rushed funding on an emergency
basis with dramatically heightened costs.”
None
of this is entirely irrational. The only visible part of investment in
incremental care is the perennial costs. There is generally little
certainty about how much spending will really be needed or how effective
it will be. Rescue work delivers much more certainty. There is a
beginning and an end to the effort. And you know what all the money and
effort is (and is not) accomplishing. We don’t like to address problems
until they are well upon us and unavoidable, and we don’t trust
solutions that promise benefits only down the road.
Incrementalists
nonetheless want us to take a longer view. They want us to believe that
they can recognize problems before they happen, and that, with steady,
iterative effort over years, they can reduce, delay, or eliminate them.
Yet incrementalists also want us to accept that they will never be able
to fully anticipate or prevent all problems. This makes for a hard sell.
The incrementalists’ contribution is more cryptic than the rescuers’,
and yet also more ambitious. They are claiming, in essence, to be able
to predict and shape the future. They want us to put our money on it.
For
a long time, this would have seemed as foolish as giving your money to a
palmist. What will happen to a bridge—or to your body—fifty years from
now? We had no more than a vague idea. But the investigation of the 1967
Silver Bridge collapse marked an advance in our ability to shift from
reacting to bridge catastrophes to anticipating and averting them.
Around
the same time, something similar was happening in medicine. Scientists
were discovering the long-term health significance of high blood
pressure, diabetes, and other conditions. We’d begun collecting the
data, developing the computational capacity to decode the patterns, and
discovering the treatments that could change them. Seemingly random
events were becoming open to prediction and alteration. Our frame of
medical consideration could widen to encompass our entire life spans.
There
is a lot about the future that remains unpredictable. Nonetheless, the
patterns are becoming more susceptible to empiricism—to a science of
surveillance, analysis, and iterative correction. The incrementalists
are overtaking the rescuers. But the transformation has itself been
incremental. So we’re only just starting to notice.
Our
ability to use information to understand and reshape the future is
accelerating in multiple ways. We have at least four kinds of
information that matter to your health and well-being over time:
information about the state of your internal systems (from your imaging
and lab-test results, your genome sequencing); the state of your living
conditions (your housing, community, economic, and environmental
circumstances); the state of the care you receive (what your
practitioners have done and how well they did it, what medications and
other treatments they have provided); and the state of your behaviors
(your patterns of sleep, exercise, stress, eating, sexual activity,
adherence to treatments). The potential of this information is so
enormous it is almost scary.
Instead
of once-a-year checkups, in which people are like bridges undergoing
annual inspection, we will increasingly be able to use smartphones and
wearables to continuously monitor our heart rhythm, breathing, sleep,
and activity, registering signs of illness as well as the effectiveness
and the side effects of treatments. Engineers have proposed bathtub
scanners that could track your internal organs for minute changes over
time. We can decode our entire genome for less than the cost of an iPad
and, increasingly, tune our care to the exact makeup we were born with.
Our
health-care system is not designed for this future—or, indeed, for this
present. We built it at a time when such capabilities were virtually
nonexistent. When illness was experienced as a random catastrophe, and
medical discoveries focussed on rescue, insurance for unanticipated,
episodic needs was what we needed. Hospitals and heroic interventions
got the large investments; incrementalists were scanted. After all, in
the nineteen-fifties and sixties, they had little to offer that made a
major difference in people’s lives. But the more capacity we develop to
monitor the body and the brain for signs of future breakdown and to
correct course along the way—to deliver “precision medicine,” as the
lingo goes—the greater the difference health care can make in people’s
lives, as well as in reducing future costs.
This
potential for incremental medicine to improve and save lives, however,
is dramatically at odds with our system’s allocation of rewards.
According to a 2016 compensation survey, the five highest-paid
specialties in American medicine are orthopedics, cardiology,
dermatology, gastroenterology, and radiology. Practitioners in these
fields have an average income of four hundred thousand dollars a year.
All are interventionists: they make most of their income on defined,
minutes- to hours-long procedures—replacing hips, excising basal-cell
carcinomas, doing endoscopies, conducting and reading MRIs—and then move
on. (One clear indicator: the starting income for cardiologists who
perform invasive procedures is twice that of cardiologists who mainly
provide preventive, longitudinal care.)
Here
are the lowest-paid specialties: pediatrics, endocrinology, family
medicine, H.I.V./infectious disease, allergy/immunology, internal
medicine, psychiatry, and rheumatology. The average income for these
practitioners is about two hundred thousand dollars a year. Almost
certainly at the bottom, too, but not evaluated in the compensation
survey: geriatricians, palliative-care physicians, and headache
specialists. All are incrementalists—they produce value by improving
people’s lives over extended periods of time, typically months to years.
This
hundred-per-cent difference in incomes actually understates the degree
to which our policies and payment systems have given short shrift to
incremental care. As an American surgeon, I have a battalion of people
and millions of dollars of equipment on hand when I arrive in my
operating room. Incrementalists are lucky if they can hire a nurse.
Already,
we can see the cost of this misalignment. As rates of smoking fall, for
instance, the biggest emerging killer is uncontrolled hypertension,
which can result in stroke, heart attack, and dementia, among other
conditions. Thirty per cent of Americans have high blood pressure.
Although most get medical attention, only half are adequately treated.
Globally, it’s even worse—a billion people have hypertension, and only
fourteen per cent receive adequate treatment. Good treatment for
hypertension is like bridge maintenance: it requires active monitoring
and incremental fixes and adjustments over time but averts costly
disasters. All the same, we routinely skimp on the follow-through. We’ll
deploy an army of experts and a mountain of resources to separate
conjoined twins—but give Asaf Bitton enough to hire a medical aide or a
computerized system to connect electronically with high-blood-pressure
patients and help them live longer? Forget about it.
Recently,
I called Bill Haynes’s internist, Dr. Mita Gupta, the one who
recognized that the John Graham Headache Center might be able help him.
She had never intended to pursue a career in primary care, she said.
She’d planned to go into gastroenterology—one of the highly paid
specialties. But, before embarking on specialty training, she took a
temporary position at a general medical clinic in order to start a
family. “What it turned into really surprised me,” she said. As she got
to know and work with people over time, she saw the depth of the impact
she could have on their lives. “Now it’s been ten years, and I see the
kids of patients of mine, I see people through crises, and I see some of
them through to the end of their lives.” Her main frustration: how
little recognized her abilities are, whether by the insurers, who expect
her to manage a patient with ten different health problems in a
fifteen-minute visit, or by hospitals, which rarely call to notify her,
let alone consult her, when a patient of hers is admitted. She could do
so much more for her patients with a bit more time and better resources
for tracking, planning, and communicating. Instead, she is constantly
playing catch-up. “I don’t know a primary-care physician who eats
lunch,” she said.
The
difference between what’s made available to me as a surgeon and what’s
made available to our internists or pediatricians or H.I.V. specialists
is not just shortsighted—it’s immoral. More than a quarter of Americans
and Europeans who die before the age of seventy-five would not have died
so soon if they’d received appropriate medical care for their
conditions, most of which were chronic. We routinely countenance
inadequate care among the most vulnerable people in our
communities—including children, the elderly, and the chronically ill.
I
see the stakes in my own family. My son, Walker, was born with a heart
condition, and in his first days rescue medicine was what he needed. A
cardiology team deployed the arsenal that saved him: the drips that kept
his circulation going, the surgery that closed the holes in his heart
and gave him a new aortic arch. But incremental medicine is what he has
needed ever since.
For twenty-one
years, he has had the same cardiologist and nurse practitioner. They saw
him through his first months, when weight gain, stimulation, and
control of his blood pressure were essential. They saw him through his
first decade, when all he turned out to need was someone to keep a
cautious eye on how his heart did as he developed and took on sports.
They saw him through his growth spurt, when the size of his aorta failed
to keep up with his height, and guided us through the difficult choices
about what operation he needed, when, and who should do it. Then they
saw him through his thankfully smooth recovery.
When
he began to struggle in middle school, a psychologist’s evaluation
identified deficits that, he warned us, meant that Walker would probably
not have the cognitive capacity for college. But the cardiologist
recognized that Walker’s difficulties fit with new data showing that
kids with his heart condition tend to have a particular pattern of
neurological deficits in processing speed and other functions which
could potentially be managed. In the ensuing years, she and his
pediatrician helped bring in experts to work with him on his learning
and coping skills, and school planning. He’s now a junior in college,
majoring in philosophy, and emerging as a writer and an artist. Rescue
saved my son’s life. But without incremental medicine he would never
have the long and full life that he could.
In
the next few months, the worry is whether Walker and others like him
will be able to have health-care coverage of any kind. His heart
condition makes him, essentially, uninsurable. Until he’s twenty-six, he
can stay on our family policy. But after that? In the work he’s done in
his field, he’s had the status of a freelancer. Without the Affordable
Care Act’s protections requiring all insurers to provide coverage to
people regardless of their health history and at the same price as
others their age, he’d be unable to find health insurance.
Republican
replacement plans threaten to weaken or drop these requirements, and
leave no meaningful solution for people like him. And data indicate that
twenty-seven per cent of adults under sixty-five are like him, with
past health conditions that make them uninsurable without the
protections.
The coming years will
present us with a far larger concern, however. In this era of advancing
information, it will become evident that, for everyone, life is a
preexisting condition waiting to happen. We will all turn out to
have—like the Silver Bridge and the growing crack in its critical steel
link—a lurking heart condition or a tumor or a depression or some rare
disease that needs to be managed. This is a problem for our health-care
system. It doesn’t put great value on care that takes time to pay off.
But this is also an opportunity. We have the chance to transform the
course of our lives.
Doing so will
mean discovering the heroism of the incremental. That means not only
continuing our work to make sure everyone has health insurance but also
accelerating efforts begun under health reform to restructure the way we
deliver and pay for health care. Much can be debated about how: there
are, for example, many ways to reward clinicians when they work together
and devise new methods for improving lives and averting costs. But the
basic decision has the stark urgency of right and wrong. We can give up
an antiquated set of priorities and shift our focus from rescue medicine
to lifelong incremental care. Or we can leave millions of people to
suffer and die from conditions that, increasingly, can be predicted and
managed. This isn’t a bloodless policy choice; it’s a medical
emergency. ♦
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