Chapter 11: Today’s Medical Paradigm Shift

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Chapter 11: Today’s Medical Paradigm Shift

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In this segment, Dr. Rodriguez provides perspective on what she calls “the medical paradigm shift” that currently challenges everyone in healthcare. She begins by sketching how landmarks in the history of research into causes of disease created paradigm shifts in the pass. She begins with the long period in which doctors learned their craft through apprenticeship to other individual physicians. She then explains that a paradigm shift occurred in the 19th Century, when hospitals became the primary setting for acquiring this training. She notes that the growth of nursing also had an effect on the practice of medicine. She then talks about the technical developments of the 20th century that led to another paradigm shift. Dr. Rodriguez explains that the current paradigm shift is not focused on technology, but on how care is delivered and diseases managed. She stresses that the new paradigm focuses not merely on the doctor-patient relationship, but on the management of relationships between teams of providers and the institution to deliver optimal care. Dr. Rodriguez says that MD Anderson is still in the investigational paradigm and may not have the skills to engage patients in being their own health care advocates. She explains that there is a great deal of data available to help individuals prevent cancer and that nearly seventy percent of patients survive for five years. Dr. Rodriguez cites several MD Anderson initiatives that focus on prevention.

Identifier

RodriguezA_02_20150306_C11

Publication Date

3-6-2015

Publisher

The Historical Resources Center, Research Medical Library, The University of Texas Cancer Center

City

Houston, Texas

Topics Covered

Overview; Understanding Cancer, the History of Science, Cancer Research; The History of Health Care, Patient Care; On the Nature of Institutions; Technology and R&D; The Healthcare Industry; Understanding the Institution; The Institution and Finances; Research, Care, and Education

Creative Commons License

Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 License.

Disciplines

History of Science, Technology, and Medicine | Oncology | Oral History

Transcript

Tacey A. Rosolowski, PhD:

I have another general question. When I was doing my background research, I read somewhere that you had said that medicine—the entire environment of medicine and healthcare was really poised for what you referred to as a “paradigm shift.”

Alma Rodriguez, MD:

Yes.

Tacey A. Rosolowski, PhD:

And I wondered if you could talk to me about what that involved, and how it connects up with this issue of physician leadership that we’re discussing.

Alma Rodriguez, MD:

Yes. OK. Well, so I’m going to digress for some time—

Tacey A. Rosolowski, PhD:

Sure.

Alma Rodriguez, MD:

Just so that we have the perspective of what I’m speaking of today. So, up until the 1800s, for example, when scientific inquiry began to revolutionize, truly revolutionize medicine and to make a scientific inquiry into the cause of diseases, and we discover microbes, and we discover principles of immunization, for example, and principles of hygiene and epidemiology, and how those are very critical in illness, up until that point, throughout history and up until the middle ages in Renaissance, medicine was taught pretty much as an apprenticeship, you know. Yes, there was a period or a face of didactic learning, where the physicians would go to a university and learn about anatomy, and whatever was known at the time about physiology, was a great deal of herbology, and techniques of how to excise tumors, etc. But truly, it was an apprenticeship, and one would seek a practice, a Physician in practice; one would go and be mentored by that individual, who would take the young Physician under their wing, and the Physician would then learn through the older individual and learn their practice. In the 1800s, hospitals became a reality. And by the way, hospitals, for a long time, were place to go die, not places to go live. And it was the revolutionary changes, again in the 1800s, that were brought about by nursing, you know, when nursing was developed finally as a distinct, professional pathway, if you will, a distinct profession that helped to sustain patients staying alive after surgery, and it was not just, you know, removing their waste and bringing them plates of food when it really became a care profession. Then physicians and nurses could partner, and then hospitals became the training, the better training places for Physicians to learn acute medicine. So this is the period of the 1800s into the early 1900s, when we see, if you will, the scientific basis of medicine begin to take root. So medicine transitions from an apprenticeship, really, to a more systematically learned practice. I mean, that’s where the term “intern” comes from; an intern was somebody who would literally live in the hospital. They never left. They were left twenty-four hours to take care of the patients. And that’s where the word resident comes in as well, because one would reside in the grounds of the hospital to be available to the hospital. And so that was the paradigm shift, from an apprenticeship to a truly learned profession, in given environments with a more scientific basis. And then we transition, then, in the twentieth century to highly technical developments; to the introduction of hemodialysis that allows people with chronic renal disorders to live. Heart bypass and organ transplants, bone marrow transplants. So the twentieth century was like an explosion of technical and further scientific evolutions. In fact, medical oncology, as a discipline, isn’t really born until the mid-twentieth century. So we’re a relatively young profession, or arm of medicine. So that’s yet another paradigm shift, you know, our ability to manipulate physiology and technology in such a way that we are now transforming the life expectancy of individuals. But the new paradigm now is no longer focused so much on the technology, but actually how we deliver care, because for the longest time, again, the assumption has been that medicine’s about the patient-doctor relationship. But the truth is that health and well-being and the management of illness which, by the way, are different issues—everyone thinks that healthcare is health care. No. There are different paradigms and faces within that, as well. There’s the health maintenance, there’s the chronic illness management and then there’s acute illness management. They’re all different. So, but in any one of those faces, it really is no longer about just the patient-doctor relationship. It really is about the patient and medical team, or clinical team relationship.

Tacey A. Rosolowski, PhD:

And about an institution.

Alma Rodriguez, MD:

And institutional relationships.

Tacey A. Rosolowski, PhD:

Yes.

Alma Rodriguez, MD:

And so, what is now, if you will, under what really should become the important analytical—let me backtrack. What really we need to look at critically now, what we need to learn about now, I mean, we were learning—in the 1800s, we were learning about microbes. In the twentieth century we were learning about how to manipulate technology and alter human physiology. This time, we need to learn how we manage ourselves and our systems; how we best deliver in a system. How do we deliver the most optimum care? So medicine itself, the delivery of care itself, is now the subject of inquiry, in my opinion, that’s most fascinating and most challenging. I understand that MD Anderson is still under the paradigm of let’s investigate illness down to the genetic level; but frankly, that is not what’s going to solve the problem of cancer. And I don’t mean that disrespectfully. That is going to solve the problem of certain cancers. But the problem of malignant disease in the larger community is going to be solved by how we address population behaviors, how we address education of individuals, how we engage the individuals to be accountable and to manage their own health most optimally. I truly cannot be at the bedside, or at the table, I should say, in the home of my patients watching to be sure they don’t eat carcinogenic foods. I can’t do that. That’s not possible. I can’t be watching them while they sneak out to have their cigarettes, right?

Tacey A. Rosolowski, PhD:

Yeah.

Alma Rodriguez, MD:

That’s not possible. So the most meaningful preventive health measures are entirely within the domain of individual control.

Tacey A. Rosolowski, PhD:

It sounds like in in some ways you’re revisiting the scenario you confronted in San Antonio, I believe it was, when you were interested in diabetes.

Alma Rodriguez, MD:

In diabetes. Correct.

Tacey A. Rosolowski, PhD:

Yes. And it really now providing mechanisms to support management of individual behavior—

Alma Rodriguez, MD:

Which is another health disorder that is within the scope of individual—largely. Not entirely. There are some individuals who, unfortunately and regretfully, the pancreas just quits working.

Tacey A. Rosolowski, PhD:

Right. Right.

Alma Rodriguez, MD:

But for most people it’s not that the pancreas doesn’t work at all, it’s just that the metabolism in their body has been so altered by their dietary and lifestyle habits.

Tacey A. Rosolowski, PhD:

So what impact—I mean, how is MD Anderson engaging what you see as this new paradigm in any way?

Alma Rodriguez, MD:

Well, we are to some degree. I mean, so remember that I said that, you know, within what people consider to be healthcare, there really are different—there are different domains of healthcare. There is true health management where one does what I just spoke about, one motivates and engages one’s patience as partners in the care delivery. And that’s predominantly a primary healthcare issue, and frankly, I don’t think Physicians are necessarily the best at that. I mean, I think that nutritionists, exercise experts, even behavioral medicine specialists are far more expert at doing that. We’re not trained to do that. We’re not trained to maintain health. We are trained to take care of disease. We are trained to be disease management experts. So for Physicians, chronic illness management and acute illness management are the domains of our education. So to answer your question, how do we engage people? Well, we don’t do that very well. Nonetheless, we have accumulated a large body of evidence that supports our moving, if you will, the needle towards the domain of prevention, progressively more. And we can do that at two ends. We can do that before people get cancer, but we can also—we also need to do it after people get cancer, because actually, we’re getting so good at the management of cancer that if you look at the statistics for the American Cancer Society and the National Epidemiology Database, the SEER [Surveillance, Epidemiology and End Results] database, you will see that nearly seventy percent of patients who are diagnosed with cancer today will be alive five years or longer from today. So these people are going to have further opportunities for other cancers, OK, so it’s equally important, not just for the people who are pre-survivors, that terminology is now being used, previvors. Previvors, I think, is the actual term. Previvors. And then the survivors of cancer. So how do we influence those groups, is now coming into our consciousness. There are people who now—you know, there are fellowships now that are being focused more towards prevention, as well as post-cancer management. We are, in fact, engaging with Baylor University to develop a residency program for along the track of internal medicine with a focus on cancer management. And that means helping patients manage their illnesses, such as diabetes, heart disease and so on, probably go through the challenge of being treated for cancer, but then post-cancer as well. So those are changes that I foresee in the future. So one of the ways in which as an organization we’re doing that, for example, is that, you know, we are committed now to the—we have been for a long time committed to a tobacco-free environment, but we didn’t necessarily require that our employees were tobacco-free.

Tacey A. Rosolowski, PhD:

Right.

Alma Rodriguez, MD:

Now we do. We have—

Tacey A. Rosolowski, PhD:

And that was instituted when? Was that earlier this year, or was it last year?

Alma Rodriguez, MD:

Correct. I think it was—well, probably it was last year.

Tacey A. Rosolowski, PhD:

Yeah.

Alma Rodriguez, MD:

Sometime last year. You know, we’re also taking that message in our international relationships, that coalition that was established with the National Institute in Mexico, National Cancer Institute in Mexico for prevention of tobacco-related illnesses and tobacco-related malignancies. I mean, sadly, worldwide, the rise of tobacco-related illness and malignancies is rising. But one country at a time, I guess.

Tacey A. Rosolowski, PhD:

Yeah.

Alma Rodriguez, MD:

So that’s another strategy. But I think, going back to the larger community, we also collaborate with other institutions across the state in what is called the Texas Cancer Control Plan and, you know, our cancer prevention program is part of that. And we assume a leader—we have, I don’t know exactly how many years, but I know that Dr. Lewis Foxhall, who’s in the Cancer Prevention Department, has a leadership role in that initiative. So those are some of the ways in which we are starting to take some responsibility for that. And then, of course, on the post-cancer arena, we are developing, or we have over the last several years, been developing the survivorship program. And we are—we make ourselves available to anyone who wants to reach out to us who wants to learn how we’re doing it, we freely share our lessons learned. We’ve been developing the program, we share the model that we’ve developed.

Tacey A. Rosolowski, PhD:

I mean, I know that that’s been a major initiative since 2006, and probably even—maybe even earlier, that was also part of your role as Director of the Office of Medical Affairs.

Alma Rodriguez, MD:

Yes.

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Chapter 11: Today’s Medical Paradigm Shift

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