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Grandberg Lecture in Primary Care

Beth Israel Deaconess Medical Center

I want to thank Joe for his kind introduction; even more I want to thank Joe on behalf of everyone here for his work over the last three years in fostering closer and more collegial relations between Harvard University and the teaching hospitals that enable our Medical School to work. We are very much aware at Harvard that our success – our success as a Medical School and our success as a community – depends on what happens in teaching hospitals like this one.

I want to thank Bob Moellering and Tom Delbanco especially for the invitation to be here. I want to applaud their commitment to primary care as a crucial aspect of the academic hospital’s mission. I’ll say a little bit about that later.

I want to acknowledge the Grandberg family, and acknowledge Sarah and Arnold Grandberg’s vision in being prepared to support primary care and thought about primary care. It is easy to support renal disease research if you have renal disease; it is easy to support cardiac research if you have heart disease. It is more rare and more of an act of imagination to support primary care, and it is just that kind of support that will become ever more important in the years ahead.

I see someone here in the audience who I don’t think I’ve seen in roughly 45 years – by the way, I’m 47 – and if I know anything about what I’m talking about today, it may be because of what was infused into me by Frank Epstein, a partner of my father’s in a babysitting cooperative. That was back in the mid-1950s. I learned a lot – Frank may have learned a little bit, too. My father was an economist, and the other participants in that babysitting co-op were economists, and the whole thing worked through shadow prices and game theoretic allocations of babysitting burdens. I don’t know whether it’s really true that he got double credit for taking care of me, but that’s what my parents said to make me feel bad. It’s good to see you again, Frank.

I’d like to reflect this morning on three related topics: First, Harvard medicine from my perspective and the University’s perspective; second, primary health care and the health care system from my perspective – both my perspective as an economist, as well as from the perspective of one who has served in government; and third, I want to reflect on the special and important work of doctors in our society from my perspective as a patient.

I’ll start with Harvard medicine. I got my first sense as President of the importance of all of this in one way in the first few hours after I had been named to my current position. I was seated with Joe and a number of the other Deans at lunch, and I asked them a number of questions including, “How many professors are there in your school?” And one said 150, and another said 62, I think the largest was 600. And then I said to Joe, “How many people are there in the Medical School who are full-time researchers on cancer?” And Joe, as I’ve now learned to expect when I ask him questions about the Medical Area, replied “Do you mean the Quadrangle? Do you mean teaching hospitals? Do you mean researchers? Do you mean Ph.D. students? Do you mean MDs? Do you mean fellows?” And so on. I tried to answer Joe’s first couple of questions, and then decided that I really had no clue what I meant. So I said, “I mean guys who put on coats, who go and work with petri dishes and pipettes and such and have the word Harvard in their title.” And Joe thought for a minute, and he said, “For that disease, 800.”

Subsequently, I learned that there were some 3,500 Harvard medical affiliated faculty. And I realized that, in a sense, the modern University can be thought of as a medical complex with some classrooms for other fields that are attached. That’s not always how we see it in Cambridge. (Laughter)

And I realized the scale of Harvard’s work in the medical area. But as I have reflected further, I have come to see the centrality of Harvard’s medical work in all three of the University’s missions: scholarship and research, teaching, and service.

I’ll start with scholarship and research. We are on the brink, or maybe we are just past the brink, of what is a once-in-human-history opportunity for progress in the life sciences and their application. Life expectancy in the United States just a century ago – less than a third of the way back through Harvard’s history – was my current age, 47. Today, if current trends continue, with the promise of what is going on in the laboratories here actually playing out, if things actually work out as we hope they will, it is not unreasonable to expect that my daughters, or certainly my daughters’ children, will live to be twice that age. That growth in life expectancy that lies ahead of us is something that has never happened before in human history, and it is something, given at least our current understanding of the relevant limits, that is likely to never again happen in human history. And it is a reflection of science, and it is a reflection of its application.

From what little I have been able to glean, the progress in the years ahead is going to be in part a reflection of something I would imagine that teaching hospitals or primary care physicians will come to be very much involved in. And that is the transformation of the scientific research enterprise from an effort that is largely reductionist in focusing on individual reactions within individual cells, to a process that is far more systemic – or to use some jargon from my field – from a micro process to a macro understanding.

It is that transformation of the research enterprise that will drive the progress that is being made in clinical care. I believe it has been one of the great strengths, of what has happened in this medical community in the last few years that we have seen far more emphasis on translational research – taking the results of science directly to patient care. There has been unprecedented intellectual opportunity and progress. It doesn’t matter, if people don’t understand what it is that is happening. It doesn’t matter, if that progress isn’t translated to the next generation of medical scientists, of medical practitioners.

We have seen a basic change, that we are only beginning to appreciate fully the implications of, in what is understood about how people learn medicine. I believe it is becoming increasingly clear, that two of the least efficient means of how people learn is sitting passively and reading, and sitting in a large group and being talked at. It does make one wonder about the enterprise in which we are now engaged – but I will be relatively brief – and I will not give a quiz afterwards. (Laughter)

What we are increasingly seeing, whether it’s in business education or in legal education or the liberal arts, is that people learn best when they are learning actively. When they are challenged to solve problems. When they work interactively as teams. When there is an important stake in their failure or their success. When there is direct and immediate feedback from their effort.

What I was most struck by in the half day I spent at the Harvard Medical School and in the Harvard Medical Area doing rounds and other things was that all of the learning seemed to be active. Whether it was making rounds with patients, whether it was using the very realistic patient simulator, or whether it was working in groups solving problems, the New Pathway really has at its center the concept of active learning.

So in addition to the centrality of the scientific enterprise, I believe that here there is a model of the type of learning that is going to be important in every walk of life in the future.

What about service to the community? Starkly put, there are tens or hundreds of thousands of people in Boston walking around today who would not be walking around today without the care that was provided to them at the Beth Israel Deaconess or the other major hospitals in this region. There are many more people whose good health depends all across this country on the training that people receive in this Medical Area. This Medical Area has been a leader in reaching out to serve all who need health care.

There are two other things that impressed me in the conversations I had with Joe Martin and his colleagues and students. One was how many of the students were engaged in service to the community in the afternoons or during their off hours. Now medical practice is many things, but it is not something that leaves one with much leisure time. The fact that so many students, so many young physicians, take extra time to serve their community is very impressive, indeed. That, frankly, is something that I remembered from the time that I was close to this community 20 years ago.

There is something else I learned about that I think is enormously exciting. And that is the transformation of academic medical centers from places to which people come with problems into places that export their knowledge, their learning, their expertise all over the world. The other statistic that surprised me was that one of Joe’s students estimated that more that a third of medical students at some point during their training spend time in a Third World country dealing with the very different health care issues that arise in those contexts, and those numbers are very steadily increasing.

Service, Teaching, Research. Some part of what I’ve said really venerates and supports the tradition of academic medical centers everywhere. And I believe we as a country have an opportunity – an opportunity so great it constitutes an obligation – to support those academic medical centers, and to ensure that they are able to continue to improve and strengthen their work.

What I also learned is what all who are here know, what all who have chosen to support this hospital know, and that is this: for a combination of reasons – some historical, some of which people in this room can take credit – we have a remarkable opportunity in Boston in representing the leading center of biomedical research and thought. Not just in our country, not just in the world, but given the progress that has been made, the leading center that there has ever been in these areas. It is a matter of the greatest importance and it is more important than any other trust that I hold to ensure that this excellence is retained and strengthened in the years ahead.

It’s important in one other way. Harvard is increasingly recognizing its obligation to the broader community. And here’s one way that I think the biomedical research area will make a very big difference in the years ahead. You know, Silicon Valley happened around information technology and computer science and it didn’t happen here, though many would have expected it to. I am convinced that the next Silicon Valley, with all that it means and all that it brings, will happen in the biomedical area, will happen in the technology and in the products that relate to extending and improving the quality of human life. And it will happen where the most knowledge resides and where the best systems for its application exist. I believe that can be, should be, and will be here in the Boston area.

Now, it occurred to me as I had that thought and subsequent thoughts, that there is an interesting paradox in the way Congress and others talk about health care. And that is this: If the computer industry, or the travel industry, or the steel industry, come to be a larger share of the economy, that is thought of as a good thing. They are expanding, they are selling more of their products, they are employing more people, and they are making greater contributions. And yet it is often suggested that when the health care industry becomes a larger share of the economy, that it is somehow a bad or wasteful thing. I’m here to tell you as an economist that this idea is bad economics.

Of course it is essential that we supply adequate inputs to the health care system so that their prices do not rise excessively. Of course it is crucial that resource allocation decisions be made wisely and that there not be waste. But if the fountain of science produces more and more capacity to do more and more things to help people, and as a consequence, more and more is done to extend people’s lives, to allow grandparents to know their grandchildren longer, to allow more people to live more fulfilling, more satisfying lives for longer periods of time, to allow happy marriages to continue for more years, that is a good thing. We as a country need to recognize this in the years ahead.

I believe that whether or not we recognize this, and in what way we recognize this, will depend very crucially on primary care physicians. It is a paradox in many areas that as specialization increases, as knowledge becomes more complex, the ability to deploy the integration function, the ability to take a holistic view, becomes that much more important. And so it is in medicine.

If as advanced as science and technology become, primary care professionals are able to perform this function well, it ensures that the health of patients and the diseases of patients are looked after. That what is brought to bear is what should be brought to bear, that which can make a real difference in people’s lives is not simply that which is available or interesting. We will see a growth in the application of health care technology with enormous benefits to the patient and enormous benefits to the American economy.

But if that function of managing the health care system on behalf of patients is not performed well by primary care physicians, it will be performed by others. And I would suggest to you that it would be performed less well in the interests of patients.

So I am very much convinced that the kind of discussions that you will have at this 30th anniversary symposium are not the last gasp of the generalist as the world moves on to be more specialized, but are indeed pointing us toward what I believe will be an ever more important role for primary care physicians in the years ahead.

I believe that in the practice of medicine something very similar to the process I described earlier – the transformation from micro to macro approaches – from reduction to holistic approaches – will go on precisely because specialists will be able to do so much more. The task of assuring that those specialists are working together, of assuring that patients are on their way to the right specialist, of assuring that patients carry out their treatment regimens in effective ways, will be far more important in the future than it has been in the past.

Primary care physicians will also see an increase of what in many ways is the most important plane in medicine and that is the special relationship between doctors and patients.

I have not had the opportunity, and I hope the opportunity won’t come too soon, to be a patient at the Beth Israel Deaconess Hospital, but I was treated at one of Harvard’s other teaching hospitals – the Brigham – 18 years ago for advanced Hodgkin’s disease. There was a time that went on for several years when I didn’t go two hours without thinking about my condition and what it could mean for me and what it could mean to my family. But it is a reflection of the progress of medical science, probably a reflection of the fact that I came along when I came along, rather than 20 years earlier, that before I thought about the talk I was going to give this morning, I hadn’t reflected on that condition for several months.

I want to share a few reflections on that experience with you and in particular with the house staff and physicians who are here this morning.

I have been fortunate to have had a fair variety of experiences in life, both good and bad. And of the dozen most memorable non-family conversations that occurred in my life, probably a half-dozen of them occurred during that period when I was being treated – when I first learned that I had a serious condition, when I learned the nature of that condition, when the lab tests came back positive, and so forth. In each of the cases, I remember the person; I remember the place; I remember the words. And yet when I have reflected on those moments, which were so searing and striking for me, what I have realized is that these interactions were actually very ordinary to the physicians who were treating me. They were part of the everyday life of the residents who shared test results with me. They were part of the everyday life of the oncologists who discussed treatment plans with me. They were part of the regular work of medicine.

It seems to me that it speaks to the special opportunity that physicians face, but also one of the special challenges of being a physician. It is so often the case that your routine and ordinary work are some of the most important moments in the life of the people with whom you are interacting. It speaks to the satisfactions that I suspect drew many of you to medicine in the first place. It also speaks to the special burden and special obligation that you must feel as physicians.

I think this type of consideration is going to be increasingly important here in the years ahead. When David Rosenthal, the head of the University Health Services, who was my physician at that time and has been my physician ever since and who is here this morning, treated me, he was always on top of every laboratory test, every aspect of a lot of different kinds of cells prefaced by letters. But he also was very much aware of the fear and apprehension that I was feeling and was focused on the fact that he was treating me as a person with a disease rather than treating a disease.

As I went on rounds this past week, I was struck that the danger that people would be reduced to numbers and test results has become ever more real with the tremendous progress that in a very real sense was enabling their conditions to be more effectively reduced to numbers and test results than has ever been the case before. It seems to me that if medicine is to be everything that it can be, we cannot fail to take advantage of every bit of artificial intelligence, cannot fail to take advantage of every bit of measuring and understanding to promote the accurate diagnosis and accurate targeting of cures. But we cannot allow the hardness and the rigor of that science to divert us from the underlying human condition. And that, it occurs to me, is likely to be a challenge for all doctors, but it is a challenge for which it is very clear for those primary physicians who are on the front lines.

From time to time I encounter someone who has been recently diagnosed with a serious condition and I repeat that story of how years earlier I believed I would never have had a sustained hour-long thought about any subject other than my condition. I tell them what is true, which is that I haven’t thought much about my own condition in a long time. But if there are many, many people like me, who once thought only about the immediate threat and don’t any longer, it is because of the people in the health care system. Nurses and orderlies, residents and attending physicians who are thinking every day – and looking at the red eyes on the part of the house staff, I’m reminded, every night – about how people can be made healthy again.

You know, after September 11th, I think all of us, each in our own way, in very different ways, in very different settings, are led to think about how we can be part of something bigger than ourselves and how we cannot just sacrifice for ourselves but make a contribution to the broader community. And that is done in many different ways at Harvard University. But none, I believe, more important, more significant, or more fulfilling than those involved in the work that takes place in this hospital and others like it.

I salute primary physicians and their work, I salute the Beth Israel Deaconess; I salute the next 30 years that I know will be even greater than the last 30 years. And I salute the work of promoting and maintaining health here in the Harvard Community. Thank you very much.