The ancient Germanic legend of Faust has been retold numerous times and in many forms since it first appeared. The most famous early rendition was Christopher Marlowe’s 1587 play, The Tragical History of Doctor Faustus. As has been the case with the natural history of the practice of medicine in this country, Doctor Faustus’ origins were humble, but he became a learned man via his studies:
Now he is born, his parents base of stock… Of riper years to Wittenberg he went, whereas his Kinsmen chiefly brought him up, so soon he profits in divinity, the garden of scholarship being adorned by him, that shortly he was grac’d with doctor’s name.
At the outset of the play; however, he is not at all happy with his accomplishments, and feels that he has gained all of the personal benefit and gratification possible from knowledge. In all arrogance, he also suggests that he has used this knowledge to achieve all that is humanly possible (and somewhat more, seemingly). He relates that he no longer finds any enjoyment in the somewhat boring business of things such as curing the plague, and that the only thing that could perhaps make practicing medicine at this point worthwhile for him is resurrection of the dead – an achievement that he stops just short of claiming…
“The end of physic is our body’s health. Why Faustus, hast not thou attained that end? Is not thy common talk sound medical maxims? Whereby whole cities have escap’d the plague, and thousand desperate maladies been eas’d? Yet are thou still but Faustus and a man. Couldst thou make men to live eternally, or being dead, raise them to life again, then this profession were to be esteem’d. Physic, farewell. – Where is Justinian? A petty case of paltry legacies.”
What Doctor Faustus admits to himself in the opening scene, after cataloging his displeasure, is that through the use of magic, and the knowledge that magical powers will bring to him, he could potentially enjoy the worldly rewards that he considers of value. So… you know the rest of the story, and if you don’t it should sound fairly familiar to you. Faustus conjures up Mephistopheles, a demon in the employ of Lucifer, and sells his soul in exchange for these things.
As I alluded to earlier, and similar to Doctor Faustus, the origins of the practice of “modern” medicine in this country were humble, consisting mainly of mystic and traditional practices ungrounded in the terra firma of either objective scrutiny or proof. Over time; however, as the science progressed, it came to be a learned and somewhat effective undertaking. In time as well, medicine moved from a populist, “home-based” endeavor, to a professional, “clinic-based” enterprise. It moved away from the practices of agrarian self-sufficient individuals isolated from physicians, or adjacent to those that had nothing effective to offer, and eased into an industry that would become an incredibly powerful social and economic force.
As this transition occurred, the initial focus of medical practice and care was effectiveness – disease outcomes. Competitive advantage, in the eyes of both the general public and among hospitals and physicians themselves, was based on efficacy. Now it is true that efficacy – defined as the “ability of an intervention to produce the desired beneficial effect in expert hands and under ideal circumstances” – was hard to measure in previous times, and still is. One might compare it to the task of measuring a large snake as it rapidly slithers by, angered by your efforts to apply the measuring tape. However, despite these durable difficulties, word, as they say, got around. There was money to be made in the practice of medicine, most certainly, and for the most part, doctors “did well”, but revenue generation was not the goal, it was a byproduct. The origins of this industrial and corporate transition antedated the Flexner Report of 1910, but there is no doubt that the after-effects of that report – a retooling of the medical education enterprise to ground it in fact rather than tradition and quackery, and the advancement of professional societies, boards and peer review, galvanized the process. So the enterprise became both more expert, and more effective, but at some point during the past one-hundred years, Mephistopheles was conjured up by American medicine, as by Faustus. There was a gradual realization that “magic”, in this instance a metaphor for “money”, could provide much more than the coarse benefits of a medical job well-done. We gradually made the decision that we should compete not on the basis of medical outcomes, but on the basis of revenue, because this must be a surrogate measure of success, as it is in other industries, and besides, there is only so much you can do anyway, right? it was impossible, after all, to “make men live eternally, or being dead, raise them to life again… Physic, farewell!” Faustus suggested that there were rewards well beyond knowledge and outcome:
“These metaphysics of magicians, and necromantic books are heavenly; lines, circles, scenes, letters and characters; Ay, these are those that Faustus most desires. O, what a world of profit and delight, of power, of honour, and omnipotence, is promised…”
Before you start shaking your head and murmuring that “this guy is a zealot”, I will admit that this metaphor is a little overwrought. The point that I am trying to vividly illustrate; however, is that we did make a gradual decision over the past century to compete in medicine for revenue rather than outcomes, and that has had significant and perverse consequences. I am not, in fact, criticizing the concept of “profit motive” in health care, as many have done. The provision of medical care is incredibly expensive, and if physicians, hospitals and systems cannot make a profit, there would be no way to reinvest sufficiently to keep the endeavor afloat. I could most definitely condemn the wholesale application of an open market philosophy to health care, and do indirectly here. The market and its competitive forces do indeed drive innovation, but to what end in health care? There has perhaps been no more innovative area of human endeavor than American medicine over the past century, but a great deal of that innovation, and certainly how much of that innovation has been deployed, has been directed at the generation of revenue, and not directly at improving disease outcomes.
One obvious example is the cephalosporin antibiotic story. There are around fifty of these drugs on the market. Did the development of each of these drugs require innovative thought and process? Yes. Do we need fifty cephalosporin antibiotics to improve disease outcomes? No. A defender of the history of the development of this class of drugs would be tempted to tell you that there are “five classes of cephalosporins, each with a different profile of effectiveness on various types of bacteria”, and that would be true. What he or she would not perhaps admit is that for four of those classes there are ten to twenty drugs each, with near-identical effectiveness. Why would that be? The answer can’t be found rummaging around in the closet of boring medical outcomes, but in the open market – the market for these types of drugs is tremendous – millions and millions of dollars. As it turns out, if you can grab two percent of a one hundred million dollar market – that translates to a good business investment, and generates revenue. Oh, by the way, drugs come off patent protection in time, and the market forces the price down when that occurs with generic equivalents. Might it pay to slightly change the molecule and put another one out in the same class as that time approaches, if you can market it and convince just enough providers to use it?
So, what are the downsides of this approach? It is a “free and open market country”, correct? What’s the harm if society benefits from the added productivity associated with the realization of good return on investment? As it turns out, there are downsides. One downside is that research and development dollars are not spent on “truly” innovative antibiotics necessary to combat future resistance, and another that we learned painfully in retrospect is that pushing “me too” drugs out, and encouraging providers to use more and more of them leads to the development of drug resistance in the first place. “Magical powers” are no doubt realized (money is made), in these endeavors; however. Make no mistake – big pharma competes on the basis of who can generate the most magic.
How about another example? How about the development of small volume open-heart surgery programs in community hospitals? If created and resourced with any degree of sophistication, an open-heart program that performs between fifty and seventy-five cases per year can be profitable. There are a lot of programs in small and medium-sized hospitals around the country that are working with these sorts of volumes. Interesting; however, research suggests that the number of cases that an individual cardiac surgeon needs to perform in a year’s time to be proficient is minimally in the one-hundred to one-hundred fifty range. Now it is true that many surgeons practicing in these sorts of arrangements perform cases at more than one hospital, but their teams do not. How “good” are they if they do fifty per year, versus five hundred? That, as it turns out, has been heavily investigated as well. There is a direct correlation between volume, quality and cost in complex clinical care. Sure, some very small programs “look” good in comparison to larger programs, but that can often be explained by “cherry-picking” the types of cases that are performed, or frankly not having enough data to make an educated assessment of overall quality. The latter concept, one that statisticians call “type II error” is well known – the failure to reject a hypothesis (ie “our program is safe and effective”) due to a small sample size. What are the downsides to this approach? There are several. Over time, the likelihood of a small program to cost more per case, and to have poorer outcomes, is high. Second, this competition for revenue drives up the overall cost of care for the health system, and can actually paradoxically at times lower access.
The way to understand that latter point is via another cardiac surgery example – in 2008, the city of Chicago had five heart transplant programs. In an article authored by Judith Graham, in the Chicago Tribune, she stated that:
“Policy experts debate the value of competition in health care, and in this case competition appears to have backfired, leaving local heart transplant centers operating below capacity. Paradoxically, even with local hospitals’ vast investment, fewer severely ill patients here receive these potentially lifesaving surgeries than in other major urban areas.”
Each of those five transplant programs had the same overhead cost – millions, and theability to be cost-effective, and have optimal outcomes goes down as your volumes are diminished for a complex endeavor such as this, as suggested earlier in the open heart program example. Why might access suffer when there are such programmatic riches available? If you are you are low volume, one bad outcome can make your overall statistics go south quickly. Transplantation, due to regulatory oversight, is one of the few areas where at least someone is scrutinizing results for continued certification. So, you might be inclined to take fewer risks. Why do organizations start transplant programs in crowded markets? There is “ripple effect” money to be made from the endeavor, even if you aren’t high volume. Each cardiac transplant recipient represents a much larger number of heart failure patients that come to your center for evaluation and care, not to mention the aura that such a program can generate, potentially attracting other patients to your facilities, and into your highly reimbursed hospital beds.
Try to go online and ferret out the five-year survival rate for colorectal cancer for an individual physician, or health system program. How about the five year admission rate for congestive heart failure, or the number of times patients are admitted with exacerbations of chronic obstructive pulmonary disease, or the percentage of women that are disease free of breast cancer after ten years? Perhaps you would like to know the percentage of diabetics that have avoided the ravages of retinopathy, or peripheral vascular disease? There are a few data points out there, but it is very, very sparse. Want to find out how many patients were seen, or how much revenue was generated? That’s pretty easy. Ask most health system CEO’s to describe their enterprise, and the first proud words uttered are quite often “we are a ‘X’ billion dollar health care system”.
Take a moment and consider the question – what is our “product” in health care? I suggest that unlike many other businesses, even those that sell something tangible, but must generate increasing profits as a real “product” for shareholders, that revenue generation is not the end game for us. The end game is what our patients care about – disease outcomes. What they care about is “will I be alive in five years?” “Will you be able to cure me?” “Can you relieve my suffering?. There are indeed nurses to be hired, aging technology (ideally technology that brings tangible disease outcome benefit – all of it does not unequivocally – think “surgical robot”) and other infrastructure to be replaced and upgraded, and providers of actual care to compensate. It is not the “making” of money that is ill conceived here, or the seeking of profit per se, it is the focus on that aspect of the business above and beyond the actual product. Pay us for our outcomes, and pay us more if they are better. Innovation will come without competing for revenue in that scenario, and what will be sought is innovation that changes outcomes, not innovation that simply generates revenue.
In the Marlowe version of Faustus, the good doctor was not able to repent of his unsavory agreement with Mephistopeles and Lucifer and suffered dire consequences, as catalogued by some that were present at his demise:
SECOND SCHOLAR: O, help us, heaven! see, here are Faustus’ limbs, All torn asunder by the hand of death!
THIRD SCHOLAR: The devils whom Faustus serv’d have torn him thus; For, twixt the hours of twelve and one, methought, I heard him shriek and call aloud for help; At which self time the house seem’d all on fire With dreadful horror of these damned fiends.
SECOND SCHOLAR. Well, gentlemen, though Faustus’ end be such as every Christian heart laments to think on, yet, for he was a scholar once admir’d
In a later 1805 version by Wolfgang Geothe, the play entitled simply Faust, the ending of the story is much different. In this version, our protagonist’s soul is spared as a result of the fact that although he has been compromised by his previous deal with the devil, in the end he still sought redemption via his actions:
THE ANGELS (Soaring in the highest atmosphere, carrying the immortal part of Faust.) He’s escaped, this noble member of the spirit world, from evil, whoever strives, in his endeavour, we can rescue from the devil. And if he has Love within, granted from above, the sacred crowd will meet him with welcome, and with love.
So, perhaps it is a little too late to “go back” on our own pact with Mephistopheles and his master Lucifer. But maybe it isn’t too late to change our ultimate fate. Every schoolchild, even if he or she doesn’t know the actual literary underpinnings of the concept of “selling your soul” knows that this type of deal is never quite “clean” – the devil frequently gets the much better end of the bargain, and that all deals like this are time-limited. In the case of Marlowe’s Doctor Faustus, Lucifer agrees to give him twenty-four years to enjoy his “magic”, and then he was committed to hell. Many would argue that the time on American medicine’s Faustian deal is running out.