I was at an interview for medical school a few weeks ago, and was asked the question:

What do you think is the greatest problem facing healthcare today?

In the following paragraphs I outline the gist of my response, and some embellishments on the topic.

While I was in college, I can remember attending a lecture by the former United States Surgeon General Dr. C. Everett Koop. While Dr. Koop is best known for his monumental work in enhancing public awareness about the dangers of cigarette smoking (indeed, he is the one responsible for the warning labels prominently displayed on all packs of smokes), he actually spent most of his career pioneering the field of pediatric surgery at the Children’s Hospital of Philadelphia. He is a most distinguished graduate of Dartmouth College (class of 1937), and, more interestingly for the non-Dartmouth readers, he was interviewed on the Ali-G show, so clearly he merits profound respect.

At the time of this lecture, Dr. Koop was almost 90 years old. I was expecting to hear a speech from a elderly man whose wisdom would be sadly muffled by his frailty. It turned out that he still spoke with a loud and penetrating voice, with which he spoke extemporaneously for over an hour. And his words were agile and keen. Needless to say, I was listening very closely to what he had to say, as he spoke with the wisdom of nearly a century.

Dr. Koop said that the most severe, costly issue facing modern medicine is that we have effectively transformed acute illness into chronic disease. He recalled the scenario from 50 years ago: “If you got sick, you either died right away, or you got better and went home. There was a finite toll on the healthcare system” (paraphrased).

In today’s medicine, we have developed elaborate treatments that can extend the life of a human body almost indefinitely. And that’s a true statement: patients who have no electrical activity in their brain, and thus no breathing or cardiac activity, can receive full body perfusion by drastic life support devices (like ECMO and cardio-pulmonary bypass machines). And the only thing more astounding than the ability to keep a clinically dead person alive is the cost: a day in the ICU can run a bill of thousands of dollars (1). Additionally, Dr. Koop spoke of illnesses like cancer, which pharmaceutical advances have rendered a livable disease, in some cases. But once again, the lifetime cost for chemotherapy and/or radiation therapy can cost into the millions (2).

The result is a healthcare system that is stretched to its limits. Now that people live with their disease, instead of dying right away, there is a massive fiscal burden. The United States spends over 15% of its GDP on health care, a number that few other countries even approach (3). Dr. Koop warned that the transformation of acute illness into chronic disease is further compounded by an aging population — the baby-boomers — who are now reaching retirement. And, concerning the baby-boomers, he said, “They’re a hedonistic bunch, who believe they deserve only the very best care” (I couldn’t make that up…).

The point is that, while the science of medicine has accelerated at incredible speeds in the past few decades, there is a real cost to our improved health. And hold onto your pants, because there’s no sign of it slowing down.

And a disclaimer, before anyone gets the wrong idea: I do not mean that critically ill patients are, in any way, undeserving of life-saving care. In fact, I rejoice at our predicament, where we have the ability to do so much good, but must also find a way to pay. I do believe, however, that we must consider the quality-of-life when making these kinds of decisions (in medical speak, QALY). Sound economic choices need not be independent of a heart to help.

(1), (2), (3)