Alexander Shaknovich doesn't break for lunch. A Harvard-MIT trained cardiologist, his career includes a position as Chief of Interventional Cardiology at New York Hospital-Cornell Medical Center. He is currently in private practice and divides his packed 12 hour-plus workday between seeing patients and doing procedures.
Who: Alexander Shaknovich, M.D. Where: Ritz Diner, 1133 First Avenue, New York
On the Menu: Lox, bagels and cream cheese and planning for a full, active life.
Instead of a lunch, Shaknovich agrees to have an early breakfast at the corner diner down the block from his East 61st Street office. Even ordering the top item on the menu, a bagel with cream cheese and lox, he is by far the cheapest guest since this column has been in existence.
And probably the most matter-of-fact one. We just have time to sit down and accept a splash of black coffee into chipped diner mugs, before he gets right to the point.
"Cardiology has been a major beneficiary of the immense resources this society devotes to medical care. Cardiovascular disease is still the No. 1 killer in this country, but now it can be managed. The secret among cardiologists is that their patients can now pretty much live forever."
Forever may be an exaggeration, but life spans reaching well into the nineties and beyond have become routine. A hundred years ago, Shaknovich points out, living a long life was largely a matter of chance. If you assign values to three major factors in longevity -- patient's behavior, physician's skill, and fate -- fate would have probably been responsible for 95 percent of the outcome. By "fate" is meant not only genetics, geographic location and exposure to infections, but diet and exercise, since little scientific evidence existed until recently linking fat, salt and cholesterol to heart disease.
Today, fate still plays a role -- since there are incurable diseases -- but physicians have been given technological tools to prevent, diagnose, treat, cure and manage a wide range of previously fatal diseases. Patients can now live with chronic medical conditions such as diabetes and cardiovascular disease.
Only recently, Shaknovich asserts, blood pressure readings of up to 140 over 90 were considered normal. Now, the ceiling for normal has been lowered to 120 over 80, because medicine has the wherewithal to bring the patient's blood pressure into this range permanently.
"When patients ask me what is the difference," says Shaknovich, "I tell them it is a new game plan. The old game plan was to live to 70. The new game plan entails a much longer life span, so you have to adjust how you get there."
When I tell him that longevity, and more specifically concern about outliving one's savings, has become a major issue in the financial planning industry, he leaps on the analogy.
"When you go to a financial advisor, you don't expect him to perform miracles. He has the training and the technological tools at his disposal to manage your portfolio within certain parameters. He gives you the kind of investments that meet your financial goals."
An advisor diagnoses your financial condition, helps you formulate your goals and develop a strategy that will help you achieve them -- within the parameters that are acceptable to you and taking into account your limitations.
"It is not only about extending life expectancy," says Shaknovich. "Life is defined not only in a physiological sense, but it has to be a full, active life. With longer life spans, planning is essential."
According to Shaknovich, this is how the role of the physician is gradually shifting. Gone are the days when a doctor, armed with a stethoscope and some very general understanding of what goes on inside the human body, had to make a diagnosis and then use very imperfect tools to treat what he believed was wrong with you. Whether he was right was often discovered only by autopsy.
Now, as medical technology has become more sophisticated, it is not only that diagnosis becomes more precise, but less now depends on the traditional skills of the physician.
"When weapons are limited to fists," says Shaknovich, "the skill of the fighter is paramount. When you have heat-seeking missiles, you don't have to be a good marksman."
At the same time, as medical care shifts from responding to acute symptoms and handling emergencies to more routine disease prevention and management, the relationship between doctor and patient changes as well. The role of the patient is increasing. Shaknovich, who is clearly fond of metaphor, puts it this way:
"In the past, the patient was a passenger in a boat and the physician was in charge of ferrying him across. Today's medical advances have provided a second oar, for the passenger to make the journey more successful. But if only one person keeps rowing, the boat will just spin in place."
While there are plentiful strategies on how to manage chronic illness, they have to be adapted to the patient's individual circumstances, preferences and choices. Extensive exercise may be useful, but if the patient for some reason is unable or unwilling to devote time to it, it will not be an effective strategy. The physician, then, needs to work with the patient, to determine both what this particular patient's needs are and what his circumstances will realistically allow him to do. In other words, the physician has to be a life coach -- just as so many financial advisors are now becoming.
Shaknovich doesn't believe that the patient should become as well-versed in medicine as his health care provider. Nonetheless, he also bridles at the idea that patients should be sheep in the hands of the physician.
"When you make a routine purchase, when you buy a washing machine, you do at least minimum research about available models and prices," he says. "When you go to buy jewelry, you don't automatically assume that every corner store is Tiffany's. Yet, in medicine [that] is often the case, even though there are many ways of delivering relevant information to the patient about his medical professionals."
If the patient takes time to educate himself, his partnership with his health care provider will be more effective and the outcome is likely to be more successful. To return to the three longevity factors, the patient's involvement in his own treatment should become increasingly important in the future.
Education also includes rating health care providers. Just as in the case of financial advisors, there are benchmarks by which physicians can be judged. How well your cardiologist is performing can be assessed by such numbers as your blood pressure and cholesterol. Unlike financial advisors, doctors' financial rewards are not based on the quality of health care they provide. Insurance companies and government insurance such as Medicare and Medicaid reimburse doctors the same amount regardless of success rates of the individual practitioner. Which wastes an opportunity, Shaknovich asserts, to use market tools to reward successful health care providers and punish unsuccessful ones.
Alexei Bayer runs KAFAN FX Information Services, an economic consulting firm in New York; reach him at email@example.com. His monthly "Global Economy" column in Research has received an excellence award from the New York State Society of Certified Public Accountants for the past four years, 2004-2007.