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Americans love toys. Even better than toys we love new toys. We are a nation that encourages and rewards invention. Perhaps to a fault, we seek technological solutions to our problems – and we frequently find them. We foster a sense of optimistic determinism – that which is new must somehow be better; that which is technologically more sophisticated must clearly be an advance. What we are capable of doing to a large extent sets the agenda of what we feel we must do.American medicine reflects American society – resource-intense, technologically sophisticated … and very expensive. America spends twice as much per capita on healthcare as any other nation in the world. If one were to study the number of CT scanners or MRI machines per capita (more than twice as many as the average for economically advanced nations), or the number of advanced procedures performed per diagnosis (approximately twice as many coronary PCI’s/million population as the second “busiest” nation) – even though we support many fewer physicians per capita than many of our economically advanced “colleague” nations – one would begin to appreciate the dimensions of our national love affair with technological advances (as well as the price tag that we pay for it.)
America is the land of opportunity – of potential. And we Americans are famous for understanding potential, even if we are somewhat less successful with the patience and painstaking diligence required to bring those opportunities to fruition. In 1967, the first technically successful human heart transplant was performed. The operation gained incredible public support and spread rapidly throughout the world. The initial burst of enthusiasm was doused with the realities of immunosuppression – scientific understanding had not caught up with surgical technique. The procedure was promptly abandoned throughout the world. Abandoned, except for those dedicated to research, who were able to recognize the discovery of cyclosporine as the key to making this therapy a clinical reality.
The completion of the Human Genome Project brought with it the promise of instant and obvious cure for all disease. Bold new projects resulted in many bold new failures. The promise of discovery is still to this day in its very earliest phases, as the associations between genetic fingerprint and human disease turns out to be much more complex than previously imagined. It is only through years of patient and thorough study and analysis that research will be able to begin to bring the fruits of this knowledge to bear on understanding and curing human disease.
Genetics turns out to be more complicated and boring than anticipated? No problem. Stem cells will cure everything and anything. Maybe. But the first round of clinical experimentation in the use of various preparations of stem cells have been unimpressive at best. Yes, the knowledge is increasing incrementally – the heart does have some regenerative capacity; cells of various types can be reprogrammed to perform like other cell types; new layers of intracellular control mechanisms are being unraveled. Once again, it is the army of researchers who go through all the exhausting steps to weigh and evaluate different strategies and hypotheses who will move this field forward at an inexorably slow but steady pace.
Perhaps it is the lessons of science. Perhaps it is the constraints of the budget. But, for the first time in this bold nation of ours, medical technology is actually being introduced in a rational and somewhat controlled fashion. The discovery that a diseased aortic valve can actually be replaced without transthoracic surgery – a percutaneous system that deploys the valve without ever opening the chest – has revolutionized the field of cardiovascular medicine. However, unlike the case of percutaneous interventions for coronary artery disease, where an entire array of technologies were introduced (and abandoned) without careful analysis of comparative advantages relative to surgery or medical therapy, the field of percutaneous valves is being explored in a rational and careful manner. Carefully constructed prospective randomized trials are being conducted at leading medical centers. As technology is released, approval is contingent upon strict demonstration of operator expertise and competence, as well as upon participation in a clinical registry which is designed to evaluate outcomes. It seems as though this time, we’ve got it right. Whether it is because we are growing wiser, or because we are learning from our previous indiscretions, or even because we are merely trying to survive on a tighter budget, we are finally learning from the many lessons which research has to teach us. It is this dedication to research which defines the Florida Heart Research Institute’s critical role in shaping the medicine of our future.
