Pancreatic surgery. A paradigm for progress in the age of the bottom line
A. L. Warshaw
Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston.
The past few decades have seen great change in the capabilities of medical
care. The next decade will emphasize great change in its delivery, driven
mainly by the necessity of containing costs presently running at more than
13% of the gross national product. The current perception is that two of
the principal causes of the excessive cost of medical care in the United
States are the price of new technology and the fact that much of the care
rendered is by specialists. In fact, most surgical care can be rendered by
general surgeons, and the coming changes will revitalize the demand for and
self-esteem of general surgeons. Managed care will recognize this by using
general surgeons and keeping patients "down on the farm," a line drawn from
the World War I era song entitled "How can you keep them down on the farm
after they've seen Paree?" But some things are still unique to the medical
equivalent of Paris, perhaps including more complex forms of treatment, the
acquisition of knowledge, and teaching. The questions are: what should we
decentralize and how do we discriminate what should remain decentralized in
the community for economy, and what might be concentrated to good advantage
in the centers? I would like to offer the pancreas as a paradigm in
thinking about these issues.
