In late 1979, while working for the University of Chicago Medical Center administration, I witnessed an exciting new surgical technology up close and personal: total hip replacement for severe arthritis. Scrubbed in with an enthusiastic young orthopedic surgeon, I watched over his shoulder as he methodically cut through layers of muscle in the patient’s posterior with an electric cautery, laid the joint bare, removed the ball and replaced it with a metal prosthesis and a new plastic socket in a 4½-hour procedure. The 80-something-year-old patient stayed in the hospital for about three weeks and expected a lengthy and arduous six-month-plus course of rehabilitation.
Flash forward 36 years, and on Nov. 19 I went under the knife at Martha Jefferson Hospital (part of Sentara Healthcare in Charlottesville, Va.) to have my own left hip replaced. Same problem: a painful, severely arthritic hip joint. Basically, the same technology: a (much smaller) ceramic ball and a much more durable plastic socket. Access was from the front, facilitated by a special table that held me up on my side. Yet, how times have changed.
For one thing, my surgeon was a young woman, a member of a tiny female vanguard in what remains the most robust fraternity in medicine. For another, not a single muscle was severed; she employed an anterior approach, which simply pushed the muscles aside to lay bare the joint. Cautery was mostly limited to blood vessels in the dermal layer. The procedure took a little over an hour. (Some surgeons today perform total hips in 45 minutes!) I was awake and walking on the joint within 90 minutes post-op; walking stairs, albeit gingerly, the next morning; and discharged to home within roughly 24 hours of waking up.
Physical therapy began at home less than 24 hours after discharge and 48 hours post-op, as did a week of home health visits to make sure pain was being managed effectively, as well as the risk of blood clots, infection and other potential post-operative complications. Thanks to the full court press of scripted visitations, managed by what my surgeon called a “rapid recovery protocol,” there weren’t any complications. My surgeon was hovering continuously in the background, connected to me by text messaging. The biggest problem I faced: the lack of pain — leading to overexertion, consequent swelling and risk to the incision. I was walking without a limp in two weeks and driving my manual transmission car in a month. “Rapid recovery” was exactly what I got.
Progress Without 'Breakthroughs'
Much is made in medicine about the need for technological breakthroughs. That wasn’t what I experienced when I had my hip replaced. The “breakthrough” took place in the mid-1970’s. There has been no cure for arthritis since and, sadly, none appears even remotely likely. Rather, the real progress in total hip replacement came from continual refinement by the orthopedic community not only of hardware but also of clinical processes inside and outside the operating room.
Nor is this seemingly invisible progress through collective learning an isolated instance confined to orthopedics (see chart). Much has been made of the continued frustration in the search for a “cure” for cancer and of the high cost of new cancer medications. The popular press neglects to mention that while we’ve been waiting for a “cure” for cancer, there has been a nearly 25 percent decline in the age-adjusted death rate from cancer in the U.S. since 1990. The result is that there were nearly 14.5 million cancer survivors among us in 2014, according to the American Cancer Society.
Though the disease remains scary for patients and their families, cancer treatment today is much less a “one off” search for solutions than it was even a decade ago. Cancer care is increasingly protocol-driven, informed by a comprehensive and growing cancer registry maintained by a network of National Cancer Institute-designated community cancer centers. There has certainly been therapeutic progress for some forms of cancer, including a vaccine for cervical cancer, but the real progress has been an immense and largely invisible collective effort by the cancer community to harness the power of big data and clinical practice experience across millions of cases.
Strokes used to be the third leading cause of death in the U.S. Since 1970, the age-adjusted death rate from strokes/cerebrovascular disease has fallen by 76 percent. Death from strokes is now the fifth leading cause of death in the U.S., eclipsed by both lower-respiratory infections and accidents. Stroke care today begins in the ambulance on the way to the hospital, and hospitals are publicly rated on the number of minutes that elapse between the moment the patient reaches the hospital’s front door and the time that catheter-driven therapy (coils or stents) addresses the cause of the stroke (e.g., bleeding or vascular blockage). Strokes are still a scary health risk, but a massive amount of suffering and brain damage today is avoided by more systematic and focused care.
Though it is still the nation’s leading killer, deaths from heart disease have declined by two-thirds since 1970. This is despite the escalation of cardiac risk created by the obesity epidemic and the resulting sharp rise in the prevalence of diabetes. Absent these two linked developments, one suspects the decline in cardiac mortality would have been even more striking than what we have seen. Twin revolutions in invasive cardiac care — bypass graft surgery beginning in the early 1970’s and cardiac stenting in the 1990s — helped alleviate symptoms, while marked improvements in cardiac intensive care saved hundreds of thousands of lives after cardiac events.
But the decline in mortality continued during the decade of the 2000s despite a pause in technological progress in heart care. The facts that cardiac bypass volumes fell by more than a third in the decade after 2000 and that catheter-driven interventional cardiology volumes are also declining suggest that something significant has happened to the demand for cardiac care. The wide use of statin drugs as well as drugs to manage hypertension have reduced the prevalence of the underlying disease.
The same pattern of process improvement that we saw in orthopedics, cancer and stroke care appears in cardiac care: incremental but not revolutionary improvements in underlying technology, better education and communication with patients, tighter care management protocols and, most important, an evolving professional conversation leading to consensus on standards for best clinical practice. These are the ingredients of more effective care for complex illnesses.
Are We Getting Value?
This progress never enters into the national “conversation,” if you can call it that, about the rise in health costs. There are unquestionably waste and inappropriate care in our health system as well as an inflationary bias in how we pay for care. There also remain troubling disparities in health outcomes and access by race and income. And our care system is by any international comparison the most expensive in the world.
But the argument that we have not received societal benefits that parallel the rise in health cost is difficult to defend. The steady decline in mortality rates for the major killers of Americans suggests we are improving our health system’s performance. I do not know many patients who would willingly opt to return to 1970’s medical practice standards, were it possible for them to do so, because the care was cheaper. The care our parents and grandparents received was also a good deal riskier and less effective. The real question might be: Is the return on societal investment in basic and applied research in medicine adequate?
While publicly funded research at the National Institutes of Health and private research and development investment in our medical device, pharmaceutical and biotech sectors continue to seek cures for the complex chronic diseases, we should accord more respect to the benefits of professional collaboration that produce better organized care. Hospital management teams can materially assist in this collaboration and use it to improve their results and patient satisfaction.
Jeff Goldsmith, Ph.D., is the president of Health Futures Inc. and associate professor of public health sciences at the University of Virginia in Charlottesville.