The Heroism of Incremental Care | The New Yorker
Instead of once-a-year checkups, in which people are like bridges undergoing annual inspection, we will increasingly be able to use smartphones and wearables to continuously monitor our heart rhythm, breathing, sleep, and activity, registering signs of illness as well as the effectiveness and the side effects of treatments. Engineers have proposed bathtub scanners that could track your internal organs for minute changes over time. We can decode our entire genome for less than the cost of an iPad and, increasingly, tune our care to the exact makeup we were born with.
Our health-care system is not designed for this future—or, indeed, for this present. We built it at a time when such capabilities were virtually nonexistent. When illness was experienced as a random catastrophe, and medical discoveries focussed on rescue, insurance for unanticipated, episodic needs was what we needed. Hospitals and heroic interventions got the large investments; incrementalists were scanted. After all, in the nineteen-fifties and sixties, they had little to offer that made a major difference in people’s lives. But the more capacity we develop to monitor the body and the brain for signs of future breakdown and to correct course along the way—to deliver “precision medicine,” as the lingo goes—the greater the difference health care can make in people’s lives, as well as in reducing future costs.
This potential for incremental medicine to improve and save lives, however, is dramatically at odds with our system’s allocation of rewards. According to a 2016 compensation survey, the five highest-paid specialties in American medicine are orthopedics, cardiology, dermatology, gastroenterology, and radiology. Practitioners in these fields have an average income of four hundred thousand dollars a year. All are interventionists: they make most of their income on defined, minutes- to hours-long procedures—replacing hips, excising basal-cell carcinomas, doing endoscopies, conducting and reading MRIs—and then move on. (One clear indicator: the starting income for cardiologists who perform invasive procedures is twice that of cardiologists who mainly provide preventive, longitudinal care.)