PLANK JUNE 13, 2012
Last month, I had the privilege of speaking at commencement exercises for the health professional schools at Nova Southeastern University. It was a homecoming of sorts: I spent most of my childhood in South Florida, about fifteen miles from the campus. But a lot has changed. When I left in the late 1980s, the sports/concert arena where I spoke did not exist. Neither did the hockey team that plays there. As for NSU, I remember it as a small, relatively obscure school, with maybe a few thousand students overall and no significant presence in health care. Now it has nearly 30,000 students overall, making it the eighth-largest independent, non-profit university in the country, according to the website.
The real treat for me was the chance to talk about health care with people about to enter the field. The graduates were all receiving masters and/or and doctorates, in everything from pharmacy and physical therapy to medicine and dentistry. I got to meet quite a few faculty, many of them dedicated to improving both access to and the quality of care—which, you won't be surprised to hear, was the subject of my remarks. (I did my best to stay non-partisan, although I couldn't resist a few broccoli references.) Based on a handful of conversations with graduating students before the ceremony, plenty of them share those interests. I gather more than a few already have experience serving the undeserved via the university's clinics and missions to the Caribbean and Latin America.
The address I gave mentions a few people whose work has influenced me over the years, including David Cutler, Jonathan Gruber, and John Wennberg. For ideas and inspiration, I'm particularly grateful to Atul Gawande, whose speeches on these subjects are the stuff of legend, and to one person I did not get to mention: Howard Markel, a pediatrician and historian of medicine at the University of Michigan..One final note: I spoke from prepared text but improvised in places. What you see below is my best recollection of what I actually said. I'm sure the translation isn't 100 percent faithful. - JC
May 27, 2012
Thank you President Hanbury, for the kind words and for that recognition of our nation’s veterans. Thank you faculty and guests, particularly those of you who have come a long distance. And thank you, especially, graduates.
It’s a privilege to address you at this critical juncture in your lives, here inside this sacred temple of professional hockey and flying rats. I’m particularly honored to stand on this stage, following in the footsteps of two of our nation’s greatest intellectuals: Katy Perry and Jay-Z.
Thank you also for the honorary degree, which means a great deal to me. But I’ll be honest: It means even more to my mother. She’s been waiting her entire life to say these words: “Have you met my son the doctor?”
But this day is about you, the graduates of the health professions schools. Over the last few years, you’ve accumulated a staggering amount of knowledge – and ingested a staggering amount of caffeine. Exam all-nighters pushed your bodies to the limit. Textbook purchases pushed your credit cards to the limit. You’ve learned about pharmacology and histology, kinesiology and, of course, anatomy.
You survived cardio-physiology with Dr. Merevetz and ocular disease with Dr. Reed. You can describe erythromycin’s mechanism of action. You can sketch out the exact path of the Trigeminal nerve. You can describe interactions between the Trapezius and Levator Scapule.
Did I pronounce that right? Yes, I looked it up on Wikipedia.
As I was writing this speech, I couldn’t help but think of my own commencement day. And an image popped into my head—everybody in their bright red gowns, so anxious about the future and so excited about what it might hold, hugging, crying, dancing, singing….
Then it hit me. It wasn’t my commencement I was remembering. It was the season finale of “Glee.”
Truth is, my commencement was more than twenty years ago and a lot has changed. The president was George Bush. The first one. Pluto was still a planet. Madonna was still young. And, of course, the Miami Dolphins were still a good football team.
I don’t remember the ceremony, or the speaker, or even thinking the speaker was a big deal. If you’re thinking the same thing, don’t worry. I’m not offended. Graduation speakers are like mixed seasonal vegetables. When you go to a restaurant, you expect them on your plate. But they’re not the reason you went there and they’re not what you remember about the meal.
So as I stand before you today, like some forgettable but hopefully tasty mix of broccoli, snow peas, and summer squash, I will try to be quick. But I do want to send a message—and I hope you’ll forgive me if it’s not the kind of message you were expecting.
Commencement speeches are typically full of hope and good cheer—about congratulating you on the work you’ve done and the world of opportunity you are about to enter. You’ve earned that kind of send-off and, if you were almost any other crowd, at any other school, at any other time, I’d happily give it to you.
But you’re not any other crowd at any other school at any other time: You are new members of the health professions at a moment when our health care system is near collapse. You will be on the front lines of one of our society’s greatest challenges—finding some way to reorganize that system into something that takes better care of us, and does so at a price we can afford.
Yes, graduate school was hard. What comes next may be even harder.
It's a bit unfair to ask this of you, because merely by selecting these fields—and enduring the academic gauntlet you’ve just completed—you’ve assumed enormous responsibility.
In some respects, health is a great equalizer. Injury and illness affects everybody. At this moment of ultimate insecurity, people will look to you for help. And you will be able to provide it, in ways that no generation before you has.
It’s a little staggering to consider how far health care has come in what is, in the grand scheme of things, a very short time. In the 19th Century, healers treated infection by bleeding the patients. It didn’t kill the germs. It did leave the patients a few quarts short in the tank.
A favorite treatment for gastrointestinal disease was a tonic called Calomel. It didn't make you better. It made you dead. That’s because the active ingredient was mercury.
Towards the end of the 19th century, doctors seized on a new miracle drug that, they swore, could cure morphine addiction. The drug was called cocaine. Yeah, that didn’t work out so well either.
Today, we diagnose gastrointestinal disease with scopes and scans, and treat it with procedures and drugs, that the caregivers of the 19th Century could scarcely imagine. We have devices that allow doctors to operate deep inside the body, via incisions just a centimeter long. We have medicines that can turn HIV, not so long ago a certain death sentence, into a livable, chronic condition.
Tomorrow will bring still more advances and I don’t simply mean new drugs and devices. You’ve trained as health professionals, but you’ll probably spend a great deal of your time as data engineers, absorbing and manipulating real-time information about your patients and whole communities. Someday soon, a smart phone or tablet as essential to your jobs as a stethoscope or a torsion balance was to your predecessors.
Right now, on some university campus, the next Mark Zuckerberg isn’t inventing the next Facebook. He’s inventing the next great health care app.
Sorry, I don’t who he is or if he can give you a job.
But progress can’t simply mean figuring out how to provide care. It also has to mean providing care to the people who need it. Progress on this front has been much more halting.
As health care left the dark ages of the 19th Century, it didn’t simply become more effective. It also became more expensive. Our efforts to deal with that challenge produced a hodge-podge of private insurance and public programs such as Medicare. Although that system worked for a time, it has faltered. The human toll is all around us, in stories like the ones I’ve encountered over the years.
As newly minted health professionals, you know that we can treat cancer—in the best of cases, to save lives and, in the worst of cases, to make those lives a little more comfortable. So how do you explain what happened to a man named Gary Rotzler, a father of three from New York, who lost health insurance when he lost his engineering job, lost his wife to a cancer that went undiagnosed, and ended up declaring bankruptcy?
You know that adult-onset diabetes is eminently treatable disease—and that routine eye exams are part of the standard regimen. So how do you explain what happened to Tony Montenegro, a security guard in California, who never had that exam because he had no way to pay for it – and who ended up almost totally blind, disabled for life?
You know that children born with cerebral palsy face extraordinary challenges—but that, with the right kind of physical therapy, they can walk and be happy, productive members of society. So how do you explain what happened to Elizabeth Hilsabeck, a housewife in an affluent Texas suburb, whose efforts to get her baby boy’s treatments ran into a brick wall of bureaucratic denials, depleting her savings and eventually destroying her marriage?
One of the most illuminating experiences I’ve ever had as a reporter was about ten years ago, during a tour of a clinic serving the uninsured of Los Angeles. Staff members were proud of their work but, on this day, they were particularly eager to show off their dental clinic. Like a lot of people, I hadn’t put dental care in the same mental category as pediatrics or emergency room care. But I quickly learned that I was wrong.
Dental care has also come a very long way in the last hundred years. It’s also become a lot more expensive. When parents can’t pay for it, their kids miss out on prevention and they don’t get treatment for decay. The cavities they get hurt. And they hurt a lot. They can’t concentrate in school and, in the worst cases, they can’t get to school at all. These kids—five, seven, nine years old—already had it tough. Now, because they couldn’t get to a dentist—something a lot of us take for granted—they have it even tougher.
Addressing this problem has been a national preoccupation for nearly a century. Two years ago, elected officials in Washington passed a new law designed, among other things, to improve access to health care. The verdict is still out, literally, with a Supreme Court ruling expected next month. And the public remains deeply divided. Some people like the law. Some people don’t like the law. Some people think the law is actually about broccoli.
In the interest of full disclosure, I should tell you that I’m among those who like the law—which is to say, I don't think it involves broccoli. But I also know, understand, and respect people who think otherwise. This is an issue about which serious thinkers can have honest disagreements.
But there is something on which nearly all of us who follow health policy agree: The problem with American health care isn’t simply that too few people have insurance. It’s also that the system as a whole costs too much, making it more difficult for all of us to afford—as individuals and as a society.
You’ve heard that before, I know, so let me be clear about what I mean. There is no iron law of economics that says we can’t spend more than a tenth, or a fifth, or even a third of our income on health care. And, in some respects, we get quite a lot for what we spend.
David Cutler, an economist at Harvard, famously calculated how much people value extra years of life—and used that calculation to show that some of our most expensive interventions are more than worthwhile. Yes, health care is a lot more expensive than it was in the 1950s. But, as another economist, Jonathan Gruber of MIT, likes to ask, if you could have 1950s quality at 1950s prices, would you make the trade? Very few of us would.
Still, it’s one thing to say we’re getting something for what we spend. It’s another thing entirely to say we’re getting enough for what we spend. That case is much harder to make, particularly if you look overseas. No other nation on the planet comes close spending what we do. And while there are some things we do as well if not better than any other country, there are plenty of things we do worse.
We throw a ton of money down the drain on administrative waste and profiteering. A sane health care system would reduce both. In addition, international comparisons suggest that the prices we pay for many services, including some you guys will be providing, are higher than necessary. A sane health care system would do something about that too.
But we also spend a ton of money on care that is unnecessary, duplicative, or downright harmful. And you don’t have to go abroad to see this phenomenon. You can look here in this country, right in our own backyard. Some of the best research on this topic comes from John Wennberg of Dartmouth University. One of Wennberg’s first studies looked at nearby towns in Vermont, alike except for one thing: In one town, 7 percent of kids got tonsillectomies. In the other, 70 percent did. And the 70 percent kids were no healthier.
Later Wennberg and his team compared Medicare spending in Miami and Minneapolis. The cost here in South Florida was twice as high. The outcomes did not appear to be twice as good. In fact, they appeared to be basically the same.
A few years ago the federal government audited hospitals and found institutions all over the country doing back-to-back CT scans, which doesn't reveal much extra information but does expose patients to potentially dangerous levels of radiation.
Does that mean we should change something about the way we pay for medical care? Is our system full of the wrong incentives, encouraging overtreatment in some places and under-treatment in others? Probably. But those changes won’t be enough, because it’s not simply a matter of changing incentives. It’s a matter of changing the way people think. And that’s where you come in.
A generation ago, it was enough to learn what you could do to help people. Now, you have to think about what you should do. Will an invasive or painful test actually sharpen a diagnosis? Will a new drug actually work better than an old one? Will this therapy actually lead to a better quality of life?
Health care is inherently personal and intimate. Every person has the right control his or her care, according to his or her own values. But very few of us can make these decisions without guidance and information—and we’ll be asking you to provide it.
So you’ll have to be prepared. And that's not going to be easy. I know you’ve just completed years of grueling study, but your learning can’t stop today. You need to keep up with what works and what doesn’t—and in those many cases when care will work sometimes and not work other times, you need to learn why.
The best caregivers have always done this. My father is a doctor—he practices right down the road here, in Plantation. I still remember him bringing home videos of new surgical techniques and watching them before dinner.
Yeah, it was a real appetite-killer.
But those data tools I mentioned earlier will make learning easier and harder for you than it has been for him—easier, because you’ll have so much more information at your fingertips; harder, because you’ll be expected to be much more current than health professionals are now.
You also must be prepared to see health care in a way that we haven’t before—not as a series of episodic interventions when somebody is sick, but as an ongoing, constant effort to keep people from getting sick in the first place. It’s not your responsibility to make sure people stay healthy. It can’t be. But it is your responsibility to help them understand the importance of maintaining health and, when they ask, helping them to achieve it.
I feel a bit sheepish giving you orders like this. After all, I don’t have a graduate degree in health like you do. But you’ll hear the same thing from people who are bona fide experts, like Atul Gawande, the surgeon and writer for the New Yorker who, in a great commencement speech not long ago, talked about the need to “corral cowboys” and operate like “pit crews,” and said that “making systems work in health care … is the great task of your and my generation of clinicians and scientists.”
Still, even that won’t be enough. There’s one more thing—and here we get closer to my area of real expertise. I mentioned before that public policy can’t, by itself, fix what’s wrong with our health care system. But that doesn’t mean it can’t or won’t play a big role. If the last few years are indicative, we’re going to be arguing about health care policy for a long time.
That’s a good thing. It’s a cliché to say we have too much bickering in American politics but I don’t think that’s quite right. These are important questions, involving some of our most cherished values. We should argue about them—loudly, vigorously, relentlessly. But we should argue about them intelligently, or at least more intelligently than we have. A recent survey by the Kaiser Family Foundation showed that the majority of Americans don’t actually know what’s in the new health care law. If we don't even know what's in the law, how can we possibly know what to think of it?
Blame the politicians if you want. Or blame the media if you prefer. People hate us almost as much as they hate lawyers. But there’s only so much we can do. Just like pharmacists can’t make people take their medicine and therapists can’t make people do their exercises, journalists and elected officials can’t make people pay attention to the facts.
Of course, many people don’t have time to learn the facts. They’re busy making a living, feeding the kids, keeping the house—and it’s damn near impossible to remember who said what about which bill. But somebody has to do it and, I’m afraid, that somebody has to include you
...because you actually understand how the health care system works.
...because you have influence, via the friends and neighbors and customers and patients who will ask you what you think.
...and because the feedback you give, directly and indirectly, will help the people making policy in Washington—or, in my case, writing about it.
So pay attention: Read a daily newspaper or do what the kids do and follow some good RSS feeds. Listen to long-form radio shows and crack open a book once in a while.
And while you’re doing that, keep an open mind. If you’re a liberal, turn on Fox News and read the Wall Street Journal editorial page. If you’re a conservative, turn on Jon Stewart or read Paul Krugman. Or, better still, read me.
At worst, you’ll hear nonsense that will strengthen your convictions. At best, you’ll hear things that cause you to re-examine some of your own positions—and lead you to better understanding of other people, even if you don’t agree with them.
Have I scared you? Have I challenged you? I hope I've done both. I know most of you figured you were headed to careers in the private sector. You are. You're also being drafted into public service.
It's a heavy burden—one unique to your time and your chosen professions. But it is also an opportunity.
You don't just get to heal your patients. You get to your heal your country.
Thank you, good luck, and congratulations.
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