American Medicine: Closing of the Frontier?

An edited version of this op-ed ran in USA Today on November 7, 2013

In the 1930s, the United States gave birth to the most innovative health care system in human history. In every decade since, American doctors continued to introduce medical miracles of greater and greater significance to the rest of the world. Now it is 2013, and every young health care professional ought to ask, “Are our laws, regulations, institutions, and politics bringing this age of innovation to a close?”

My parents always had an endearing and ingenuous habit—innocently inflating the importance and accomplishments of their friends. A friend who was moderately well-to-do would rise in their description to the level of Aristotle Onassis. A second vice president at some company would be just a notch or two below the CEO. I donned perhaps the biggest smile when my father told me that our small-town family doctor essentially invented the idea of stem-cell therapy. Imagine my smile decades later when I discovered that Dad was pretty much correct. The case of Milton Ende, M.D., is iconic—a reminder of the importance of physician autonomy and a warning against the rigid, centrally driven homogenization of medical practice. 

A well-known and colorful figure in Petersburg, Va., Dr. Ende grew up with my mother. In an era of sedate menswear, he sported brightly colored jackets and enormous, 150-decibel bowties. We knew him to be an astoundingly fine diagnostician. When an aunt with chronic health problems was critically ill, he quickly asked a question no one over the years thought to ask, “Has anyone ever tested her for multiple sclerosis?” They hadn’t, and his keen eye spotted that key diagnosis in an instant. 

In the early 1960s, Dr. Ende wondered why infants rarely contracted cancers. He and his brother Norman, also an M.D., thought that perhaps something in the infants’ blood inhibited cancer growth—and they wanted to see whether transplanting blood from infants to cancer sufferers might have therapeutic benefits. Ethically, they couldn’t extract blood from infants for this purpose, but they realized that they could use infant blood cells from the umbilical cords (and later placentas) of newborns. Cord blood, we now know, is rich in stem cells.

The brothers transplanted cord blood into cancer sufferers whose cases were deemed hopeless. Their experiments cured none of the patients, but some exhibited temporary and at times substantial and prolonged improvement—enough to give the doctors hope that they were onto something.

Funders and major medical journals routinely rejected the Endes’ work, so in 1972, they first reported their findings in a regional publication, “The Virginia Medical Monthly.” In medicine, credentialism is real and, sometimes, a real problem. In the early 2000s, some finally recognized the importance of the Endes’ work, describing them as the earliest of all pioneers in stem-cell therapy. And all of this occurred in a small, quiet town whose primary contribution to medical science had been Civil War field hospitals a century earlier. While the Endes never received their full measure of recognition, the medical frontier in those days was wide open, and other pioneers gave rise to a vast array of stem-cell research and therapies.

Could the Endes’ experiment occur today? Physicians have told me “almost certainly not.” One, a cardiologist, reminisced about grass-roots-level innovation in his field 40 years ago. In that time, a burst of new surgical procedures emerged via improvisation and experimentation—almost on the fly. Today, physicians have to run their innovations through an expensive, slow-motion gauntlet of attorneys, accountants, and bureaucrats. 

Of course, we must balance our desire for experimentation against the need for patient protection. But young medical professionals ought to ask whether our quest for safety and deference for credentialed insiders is unnecessarily snuffing out potential sources of life-saving treatments. In our era, Big Science and Big Government are deeply intertwined, with the capacity to discourage heterodox research and treatment. Such intellectual ossification can occur through outright prohibition or reimbursement policies. (If Medicare doesn’t pay for Treatment X, no one is going to do Treatment X.) With too much central control, medicine slows to an uninspiring, unaffordable stasis.

We see such control in various ways. Malpractice law sends physicians quivering into lockstep practice patterns. Excessive red tape ends small practices, forcing doctors into large groups. Comparative effectiveness research shifts from useful gauge to mechanistic autopilot—homogenizing medicine toward “best practices.” Medicare’s reimbursement formula gives primacy to conventional wisdom and barricades the path of innovation. The Affordable Care Act worsens matters by tightening Washington’s bureaucratic grip through such unaccountable institutions as the Independent Payment Advisory Board. The ACA’s focus on Accountable Care Organizations will further consolidate physician groups and hospitals into larger combinations.

The most important question in American medicine ought to be, “Why is there no Steve Jobs of health care?” Why is there no visionary who brings us undreamt-of quality care and sends prices plunging? Are we snuffing out health care innovation altogether? Both ends of the political spectrum have failed to answer these questions, if indeed they have even bothered to ask them.