Good Medicine Makes Good Drama
By Marcia C. Landskroener
First there were "Dr. Kildare" and "Marcus Welby, M.D." Then there were "Saint Elsewhere," "ER," "Chicago Hope" and "Gideon's Crossing."
Now, on the rising tide of reality television and on the heels of Johns Hopkins' "24/7" comes "Hospital," a documentary television series airing this fall on Discovery Channel.
The 13-part series filmed at Duke University Medical Center during a four-month period provides a sometimes graphic view of intense and complicated medical procedures and situations. From episode to episode, viewers follow real-life characters and the stories of doctors, patients and their families as they grapple with an array of medical problems. An elderly patient with an aortic aneurysm is brought back from the brink of death, to be surrounded by loving family. A man with brain cancer and remarkable religious faith undergoes surgery while he is awake. A woman with a complicated pregnancy delivers an infant daughter who undergoes open-heart surgery to correct a genetic defect. The fear, the heartbreak and the hope of these people are real.
Americans have long held a fascination for medical shows that dramatize the strength of the human spirit and the miracles of modern medicine. But until just recently, viewers have been treated to antiseptic versions of the truth--that sickness, violence, trauma and ultimately, death are very much a part of living. "Hospital" takes a good hard look at what goes on at one of the world's most renowned teaching hospitals and in all that disease and dying finds something uplifting and hopeful.
When a documentary filmmaker asked Dr. Ralph Snyderman '61  if his crew could capture the real-life dramas that occur every day at Duke University Medical Center, the chancellor for health affairs at Duke considered it good medicine for what ails the American health care system.
"There are certain individuals who dedicate their lives to the care of others who are in crisis," says Snyderman. "We feel it is important for the public to understand exactly what goes on in teaching hospitals, to see the tremendous commitment of our doctors, nurses and staff, and the level of service we provide. The series also demonstrates the enormous economic and societal challenges facing America's teaching hospitals. The more the public understands about the implications of federal budget cuts in Medicare, for instance, or the uninsured, the more they will pay attention to this important political issue."
Snyderman, a clinical physician, research scientist and respected medical leader who recently joined Washington College's Board of Visitors and Governors, is also the chief executive officer of a business that employs 13,000 workers. When he took the helm as chancellor for health affairs and dean of the School of Medicine at Duke University in 1989, he vowed to make Duke one of the finest medical institutions in the world. It soon became clear, however, that teaching and research are money-losing propositions. Now, as CEO of the sprawling Duke University Health System, Snyderman is seeking to create a thoughtful, proactive and economically viable health care delivery system for the Durham-Raleigh region of North Carolina that could be profitable enough to subsidize Duke's missions in academic medicine. Until that battle is won, however, one of Snyderman's tasks is to deal with the economics of providing the best possible health care to everyone, whether they can afford it or not.
After filming open-heart surgery on a baby girl, the removal of a malignant brain tumor and a teenaged car crash victim opting for amputation of his arm, the "Hospital" crew paid a visit to Snyderman's office. He was in a meeting, deliberating with another physician lobbying to establish an Emergency Room residency program. Duke's ER sees 60,000 patients a year. Snyderman and the ER chief discussed the ground rules of establishing such a program, and then the producer asked Snyderman to describe what it was like to run the business end of a hospital.
"The analogy I made was this," Snyderman says. "It's like having an extremely upscale restaurant open to anyone who walks by. When the diners come in we bring them a gourmet meal, vintage wine, the finest champagne. Only after they have indulged do we ask them if they have any means to pay for the meal. Most reply that they can only give us a small percentage of the bill, and some cannot pay at all."
The scene may not be as visually compelling as Duke's Life Flight team rushing to the ER with a trauma patient, but the message is equally as dramatic. What happens if hospitals as renowned as Duke can no longer afford to treat patients?
"Hospital" walks a fine line between graphic reality television and a public information documentary, says Snyderman. "The series had to balance the need for interesting stories with the importance of the message to society. I clearly was interested in the greater picture. The producer was interested in getting greater viewership. Some of the graphic scenes push the boundaries, but I believe we found an appropriate balance, mindful of issues of patient privacy and matters of taste."
The bigger picture is that America's health care system is in crisis, and that Snyderman and Duke are in the fray. "We have not had political leaders with the courage to stand up and say we have a health care system that is broken," Snyderman says. "We need to step back and consider, 'Do we need to have a system in which 44 million Americans have no insurance; a system that provides a catastrophic policy, but only in the emergency room; a system in which the insurance companies create an arm's length relationship between the patient and the one who delivers health care?' It's not working. Having managed care controlled by the insurer doesn't make much sense. We need to put more responsibility on the individuals as purchasers of health insurance."
Snyderman believes there is a better way, and he is directing his energies toward developing models of health care delivery at Duke that make more sense. By giving people the tools and resources needed to prevent or manage chronic disease, the catastrophic costs associated with treating advanced illnesses can be avoided. "The problem is economics. The good things that we want to do--health care planning and disease prevention, things that affect chronic disease, are financial disincentives. We lose money by doing the right thing."
With the creation of the Duke University Health System, Snyderman says, the delivery of health care in the region has improved. Durham Regional Hospital, Durham's only other community hospital, could have gone under without a relationship with Duke, he says, and that association has allowed Duke to become more proactive in the community. Children are being immunized, and the poor and undereducated are being taught to manage diabetes and high blood pressure through proper diet and exercise.
"We're doing a lot of the right things," Snyderman says. "Whether the economics will support it remains to be seen."
New medical knowledge and advances in medical technology emerging from Duke's academic environment and research and clinical labs also present tremendous potential for bringing astronomical health care costs back to earth. "Through genomics and the evaluation of health risk, lifestyle and genetics, we can develop methodologies of managed health care for individuals that can actually decrease the cost of care over their lifetime."
Managing health care appropriately is the great hope for the future, Snyderman believes. Under his leadership, Duke has launched several pilot projects in developing models for delivering health care that could revolutionize the cost-effectiveness of medicine. In a model for treating chronic heart disease, patients working closely with their physician and a nurse practitioner develop their own individualized therapeutic plan for disease management. "Given intense instruction, patients tend to follow what needs to be done," Snyderman says. "Most physicians erroneously think that patients do what they tell them to do. But without planning, the best intentions fall short."
Snyderman has a vision for the future of health care in America. In that vision, where medical research and clinical practice meld, Duke has the starring role.
"Duke is in a position to become a national model for delivering the very best of what academic medicine can provide to the public. As good as Duke was 12 years ago, it didn't have the clout or the visibility to be a mover in creating models of health care, generating new knowledge, developing new clinical practices and enhancing research. There is a tremendous amount still to be done. Yet as an institution, we've made a lot of progress."
Marcia Landskroener is senior writer and managing editor of the Washington College Magazine.
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