Medicine has come a long way since the early days of bloodletting, humor balancing, and spiritual exorcism. The field has undergone several major revolutions in the course of reaching its present state. Medicine in this country is once more at a crossroads, poised to undergo major changes. Widespread demand to lower the cost of medical treatment, to improve quality, and to deliver decent health care to as many people as possible, have made the current state of American health care a critical one.
Always a leader in change, the Duke University Medical Center (DUMC) is playing a major role in influencing the way medicine will be practiced in the future. The spectacular growth experienced by the DUMC over the last several decades has earned it a position of prominence in the national and international medical communities.
![[Photo: Duke Hospital North]](DukeNorth.gif)
Ralph Snyderman, M.D., Chancellor for Health Affairs and of the Medical Center and Dean of the Duke University School of Medicine, describes Duke's tremendous progress: "From 1965 to1985, the Medical Center had undergone a lot of growth. A revitalization of the basic sciences took place in the late 60's and early 70's, and then a lot of emphasis from mid 70's to early 80's was placed on building North Hospital. A tremendous amount of energy was put into revitalizing clinical facilities to make for a first rate hospital." These efforts culminated in the opening of Duke Hospital North (see photo at left) in 1981.
At the same time, the advent of genetic engineering and advances in biomedical research were propeling the field of medicine towards an unexpected transformation. "In the mid 80's," Dr. Snyderman explains, "it became apparent to many people here that we had missed being at the cutting edge of the genetic engineering revolution...it had occurred at MIT; it had occurred at Stanford; it had occurred in a lot of places other than here, and our basic research, while it was very good, was not outstanding, not superlative...we were not making the degree of discoveries that a place like this ought to make...."
In an effort to insure Duke's preeminence among American medical institutions, a number of new departments were created: Cell Biology, Neurobiology, Genetics, Cell Growth Regulation, and Oncogenesis (Molecular Cancer Research.) Dr. Snyderman directed each of these expansions. "These were all conditioned by the faculty in the mid 80's, who gave me a blueprint for the direction of basic sciences in the medical center when I got here. Over the last four years there has been a renaissance of science in the medical center...focusing it on cancer research, genetics, neuroscience, and cell activation research. These are the areas in which we believe the major discoveries will be made in the next 10-20 years."
In addition to having reformed its programs in medical science research, Duke is also initiating changes to lead the way in the increasingly important field of health care delivery. "We're undergoing the greatest change in the health care delivery system in the history of anybody's life. We are about to embark upon substantial health care reforms" Snyderman explains that it is one of the Medical Center's primary goals for the next few years to become more of an integrated health care delivery system. "What we are trying to do is to develop a health care network, so Duke is no longer a hospital or clinic in Durham, North Carolina, but a health care apparatus that reaches throughout the state and throughout the region." As in the past, Duke will strive to provide the highest quality health care services to patients throughout the state.
In the crunch to make the delivery of health care more efficient and cost-effective, more and more emphasis will be placed on primary care. According to George Parkerson, M.D., Professor and Chairman for the Department of Community and Family Medicine, general practitioners can care for a larger segment of the population (approximately 80-90% of all medical cases) at a lower cost than specialists can. For example, in an under-served area, one or two general or family practitioners can handle more patients than even 10 to 20 specialists put together. Thus, since cost-effectiveness is such a major concern, the role of the general practitioner will most likely continue to expand.
Duke has anticipated and prepared for this trend by establishing programs that expose medical students to the field of primary care. For example, in 1972 the DUMC established the Family Medicine Residency, and instituted the requirement that all students in the School of Medicine participate in a two-month internship with a family doctor in a rural setting. Foreseeing the need for a greater emphasis on primary care, Duke University Medical Center initiated these and other programs, such as the Family Practice Department, the General Medicine Department, the General Internist Program, and the General Pediatrics Program, years before most other major medical institutions. This foresight and oppenness to new or unconventional programs is an attribute that will most likely continue to serve the DUMC well in these times of rapid and monumental change.
In order to meet the increased demands for affordable, quality health care, American medical practitioners are beginning to broaden their emphasis, often expanding their practice in the area of preventive medicine. In contrast to rehabilitative medicine, which seeks to treat patients after their health has already faltered, preventative medicine encourages individuals to maintain a positive state of health by making lifestyle changes which minimize the risk of future illness.
Preventative medicine actually costs less than traditional medical treatments in the long run. It also helps to insure a healthier population, thereby reducing the strain on the medical establishment. As people continue to take increased responsibility for their own health--in the forms of both prevention and treatment--the field of holistic, or alternative, medicine is likely to play a larger role in health care. Holistic, or alternative, medicine refers to the various forms of medical treatment which consider the whole individual rather than just the area of illness in determining what medical treatment measures to take. Biofeedback, acupuncture, and nutrition therapy are all relatively common forms of holistic medicine.
More and more individuals both within and outside the medical community are beginning to question whether some of the problems with the American health care system have their roots in the medical philosophy underlying it. Western medicine emphasizes cellular pathology, looking at illness as a physiological malfunction and prescribing treatments to remedy the malfunction. A potential consequence of this approach is that health care providers will often view the human body as a mere collection of cells, rather than as part of an integrated mind-body-environment system.
The essence of holistic medicine is an attempt to treat the individual as a whole, in terms of psychological, social, and physical factors. Illness, viewed through this lens, can be seen as the result of any number of subtle factors (not all quantitatively observable) that together cause physiological malfunctioning. Holistic medicine, strongly influenced by Eastern Philosophies, views the patient in terms of mind and body, and respecting the interplay therein, seeks to prevent and treat physiological malfunctions by poromoting the well-being of both mind and body.
An integration of the science of Western medicine and the more global perspectives offered by holistic medicine may strike a successful balance in the current health care system. The preventative nature of holistic medicine offers a relatively promising solution to the problem of cost-effectiveness. Nonetheless, there are a number of doubts among those in the medical community regarding the legitimacy of alternative therapies.
One stumbling block on the road to the acceptance of certain unorthodox holistic therapies is the fact that modern Western medicine places a great deal of emphasis on empirical scientific evidence. Since it is difficult to demonstrate scientifically the validity of holistic medical treatments, it is likely that the American medical community will be slow in accepting holistic therapies.
Still, based on an examination of the history of medicine, there is a relatively strong case to be made for the validity of holistic therapies. In the past, certain treatments were considered mere folklore; in many cases, however, these treatments were later validated by scientific research, and they have since been incorporated into mainstream medicine. One striking example is that of Foxglove, a common wildflower. Described in old English texts as possessing special healing properties, it has been discovered only recently that it contains Digitalis purpurea, an effective heart stimulant now widely used in the treatment of arrhythmia. Holistic medicine as a whole may, in the near future, experience a similar sequence of events; certain treatments and therapies considered unorthodox today may in actuality have solid scientific bases for their effectiveness.
The Duke University Medical Center has, in a sense, been practicing holistic medicine throughout its history via its emphasis on family care. A family practitioner, knowledgeable of a wide spectrum of diseases and illnesses, treats an individual by focusing not only on the illness, but also on lifestyle factors, psycholgical issues, patient attitude, and other aspects of the individual's life; this is an inherently holistic approach. The DUMC has always acknowledged the importance of an holistic approach in treating the individual, and has thus welcomed the growing interest in alternative, holistic therapies.
As an example of the DUMC's effort to evaluate fairly alternative forms of medical treatment, Dr. Snyderman relates the story of the team of doctors sent by the medical center to East Asia on a mission to investigate acupuncture. The team returned with a scientific report on their findings and the conclusion that acupuncture is an effective supplement to traditional forms of treatment. The Duke University Medical Center has combined a strong scientific medical program with an eagerness to investigate any form of medical treatment that may prove to be of value.
With its history of rapid and effective growth and a visionary medical philosophy, the Duke University Medical Center is poised to lead the way through the dramatic changes that are sure to sweep the American health care system over the next decade. Boasting a strong foundation in the major specialties, general medicine, and biomedical research, as well as a faculty that is willing and eager to explore scientifically new routes in health care -- including holistic and alternative therapies -- the Duke Univeristy Medical Center is poised to lead the way through the dramatic changes that are sure to sweep the American health care system over the next decade.
Winter 1994 contents
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