Thanksgiving is a time for family. When I sat down to write this morning, I remembered a conversation I had with my oldest son that changed the way I look at medicine in an instant. He was in his first year at West Point, and I asked him what he was studying. “The Civil War.” I was amazed. “Why would you study that? That war happened over one hundred years ago”. He explained it this way. “Studying the Civil War teaches a valuable lesson. Generals get their troops killed by using tactics that were appropriate for the last war. Tactics lag technology.”
Almost instantly I recognized the valuable lesson he was talking about, and it has completely changed the way I look at medicine. When the Civil War started, the armies fought as they had for 2,000 years. As the battle was about to begin, the troops would get in formation, the regimental bands would strike up a tune, and the two armies would march towards each other. When they got close, they would spread out across a line two or three miles long facing each other. They were about 40 yards apart. Then they would fire by volley at the enemy troops. That was possible because they were using muskets, which were not very accurate—especially if the distance was over 40 yards.
All that changed when the armies got rifles which can reliably hit a man-sized target at 300 yards. That was new technology. The defenders also started using trenches and stone or brick walls as cover—more new technology. From that moment on all the advantage was with the defense. The shoulder-to-shoulder attacks over a broad front became madness. But that did not stop them. General Longstreet begged General Lee not to attack federal troops behind a stone wall at Gettysburg. When Lee ordered Pickett to attack, an entire division evaporated when it was only halfway to the target. These attacks were more like the movie “Saving Private Ryan” in their violence than the sanitized films about battles in the Civil War era. They were horribly violent.
Nearly a year later, General Grant ordered frontal assaults against entrenched Confederate troops repeatedly and suffered 60,000 casualties in the month of May 1864 alone. The fire was so intense at the battle of Spotsylvania Courthouse that a 22-inch-thick oak tree behind the Confederate trench was cut down by rifle bullets. Troops were shot to pieces. Still nothing changed. The Union troops continued with frontal attack after frontal attack and over 500,000 young Americans were killed in that war. Still, fifty years later nothing changed in WWI. Allied troops in France made frontal attack after frontal attack against entrenched German soldiers with machine guns, repeating rifles, barbed wire, mortars, and breech-loading artillery. When the British attacked German defenses in the first day of the Battle of the Somme, there were 60,000 casualties. The leaders still did not learn. More attacks continued and by the end of that one battle, 500,000 allied troops were killed, wounded, or missing. Ten million of the finest young men were killed in WWI. Old technical paradigms die hard. Even with that level of madness, that is not the most important lesson.
After WWI, junior officers who would become critical leaders in WWII, recognized these tactics as madness. Dwight Eisenhower and George Patton were friends and they helped develop lightning war or blitzkrieg tactics. Rather than marching soldiers into machine gun fire and spreading heavy weapons over a front extending miles, Patton and Eisenhower advocated focusing on the weakest point in the enemy line and concentrating tanks, artillery, bombers, machine guns, and infantry in a coordinated and integrated attack that simply chewed up the defense. The concentrated, mobilized forces would pour through the breach. A breach at two points made it easy to quickly encircle the defenders, and that happened repeatedly in WWII. In an instant, the impregnable defense gave way to the irresistible attack. Combat was changed forever.
Here is the punchline. This is the whole point of this article. Senior generals in the American army found these new ideas threatening. Eisenhower published articles about these tactics in the military literature of the day. “Eisenhower’s writings in the Infantry Journal found disfavor with the Chief of Infantry, MG Charles S. Farnsworth, who told young Eisenhower that his ideas were wrong and dangerous. Farnsworth added that if he published anything further incompatible with “solid Infantry doctrine,” he would be hauled before a court-martial.” The new ideas were a threat to the old order. The infantry was the “Queen of Battle”, and Farnsworth was king. Once the role of air power, armor, infantry, and artillery changed, anything could happen. That change was a threat to the money and power of the leadership then existing.
Tactics lag technology is an idea that changed my life and I have thanked my son many times. The parallel with medicine is almost exact. The organization of medicine is very little changed in the last 50 years although the problems requiring action are dramatically different. Chronic disease is the dominant problem now. It generates 86% of healthcare costs. Our understanding of chronic illness was very limited 50 years ago. We were fighting with muskets. We did not have ACE inhibitors, ARBS, statins, metformin, SGLT2 inhibitors, or eplerenone. We did not understand disease at the molecular, genetic, and epigenetic level. Our impact was very limited in those days.
That is all changed now. Now we have very effective weapons against chronic disease. We can develop the medical equivalent of mechanized infantry divisions and combine these weapons and tactics in integrated, coordinated attacks. We can create advanced medical home teams in primary care using new science, new systems, and new payment models. Advanced medical home primary care teams using protocols, population health tools and other modern systems are the medical equivalent of mechanized infantry divisions in the army. We can combine our heavy weapons against chronic disease to produce longer, healthier lives now, but the barrier is still the same. Change is a threat to the finances and power of current medical leaders, and they are fighting it tooth and nail. Make no mistake. Current practice is the medical equivalent of marching young men into machine guns. Americans are dying and becoming disabled daily because we have not adopted new tactics to take advantage of the new technology and science. There are dozens of medical professionals working to bring medical practice up to date, but they are in the same position as Eisenhower just after WWI. I think we would all agree, marching shoulder-to- shoulder into machine guns is madness. I hope you agree that failing to update our systems to address chronic illness is equally crazy. Join us in pressing for updated tactics to make the most of the advances available. What do you think?
Further more, better and cheaper diagnostic tools, evidence based science, and patient-centered ethics, and moral principles which have taken a backseat for way too long in the name of “fee for service” unscientific, baseless American Medical Kabuki Dance is the reason why people have completely lost trust and faith in the medical industrial complex and its practitioners, and the Ivy Leaguers elite profiteering “experts”.
Yeah, not to mention to costs of the legacy 19th Century practice of American medicine: it costs $4.5 trillion dollars, plus another $3.5 trillion dollars in loss of productivity and premature deaths, in addition to bear the disreputable distinction of becoming the third cause of deaths following cardiovascular diseases and cancer. Time to wake up and change this failed corrupt system, before it bankrupts American economy.