I do think, however, that the future contribution of medicine will have to be distinctly different from that of the past. For one thing, medicine will have to give more than lip service to its responsibilities in the broadening field of prevention. In order to contribute to improving the quality of life, medicine will have to shift from its traditionally passive roleproviding care when the patient asks for it, an essentially remedial role-to one of active involvement in seeking to address conditions in society that give rise to the very health problems that medicine is expected to solve. I am not suggesting that every physician become some kind of social activist or instant expert on problems of the economy, community planning, education, or any of the other societal factors that influence health and the quality of life. Not all of us are cut out for such things, and certainly no practicing physician can place some other concern ahead of the needs of his or her patients. But it does not make sense for the medical profession as a collective force to remain aloof from the very etiologic factors that cause a great many patients to seek help. Where once medicine had to concern itself with microbes, now it must focus on a new class of societal pathogens, one perhaps no less strange and baffling, and certainly no less important, than the invisible organisms that our predecessors learned to identify and to cope with. There will always be room, I hope, for further advances in diagnosis, treatment and rehabilita-

tion. We will find better and better ways to treat cancer and heart disease, to ease mental illness and to arrest the degenerative diseases. And every time such measures are brought to bear, the

4 . . . medicine will have to give more than lip service to its responsibilities in the broadening field of prevention."

quality of a life will be improved. But improving the quality of all our lives and of the lives of future generations will demand more of medical science and practice, more of medical training, and more of the profession itself than the gradual accretion of new weapons and new skills. It will require a new perception of the role of medicine in society, a perception toward which I believe we are beginning to move-and none too soon.

A More Effective, Efficient and Equitable System VICTOR R. FUCHS, PhD, Stanford Professor of Economics, Stanford University Vice President, National Bureau of Economic Research, Inc.

MEDICINE HAS MADE many important contributions to the quality of life in America. During the past half century mortality has declined significantly for infants, children and young adults. True, part of this decline is attributable to non-

medical factors such as a higher standard of living, but in my opinion most of it stems from great advances in medicine's ability to prevent or treat infectious diseases, to deal with trauma and to intervene surgically with greater safety and efficacy. THE WESTERN JOURNAL OF MEDICINE

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In addition to raising life expectancy, medicine has contributed to a fuller, more satisfactory life for millions by correcting or reducing a wide variety of disabilities involving the senses, reproductive function, physical movement and organ failure. Finally, medicine has continued to provide sympathy, reassurance and caring. Most of these contributions are now taken for granted, and the dominant public mood is "What have you done for me lately?" The scientific advances have often been closely associated with increased specialization-which frequently has negative implications for access to, for continuity

". .. the dominant public mood is 'what have you done for me lately?"' of and for personal quality of care. Moreover, many of the advances (and pseudoadvances) of the past 15 years have been very expensive, so that each additional reduction in mortality or morbidity now requires a massive diversion of resources from other purposes. Some technologic advances, which are viewed not so much as extending life as prolonging dying, may actually adversely affect the quality of life. Another negative factor is the growth of iatrogenic disease. Powerful drugs and radical surgical procedures are two-edged swords in the battle to improve the quality of life. The increasing complexity of modern medical and surgical interventions is making it more and more difficult for physicians to heed the ancient injunction, "do no harm." Even "relief of anxiety," a staple item in every physician's output, often enters the qualityof-life equation with a negative sign because of the proliferation of diagnostic tests with numerous false positives. What of the future? Significant breakthroughs in the treatment of arteriosclerosis, cancer and mental illness could contribute greatly to the quality of life-although much would depend on the nature of the treatment. Even as the search for such breakthroughs continues, it seems to me that medicine should consider the possibility of contributing more by doing less. Lest this sound paradoxical, recall that while physicians regard medical care as a good thing, most lay persons Refer to: Fuchs VR: A more effective, efficient and equitable system, In Medicine and the quality of life-A forum. West J Med 125:3-5, Jul 1976

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JULY 1976 * 125 * 1

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