The good old days?

Medical Knowledge and technical savvy are biodegreadable. The sort of medicine that was practiced in Boston or New York or Atlanta fifty years ago would be as strange to a medical student or intern today as the ceremonial dance of a !Kung San tribe would seem to a rock festival audience in Hackensack. – Lewis Thomas

When in medical school (and after) a common quote is that 50% of what you learn in medical school will be obsolete in 5 years. Sometimes it even feels like things come and go out of fashion however. I’m old enough to have seen theophylline come in and out of the lineup for treatment of asthma/reactive airway disease (at least to some degree) a few times. When I come across quotes like the one above, several thoughts come to mind.

One thought is what my grandfather would think of medical practice in the twenty first century. He went to medical school in the 1930s and got interested in Urology while serving in the Army during World War II. He retired in the mid 1970s. He lived until the 1990s, long enough to see me graduate medical school. When he started, there essentially no antibiotics, no antihypertensives, no real way of treating cancer other than surgery (I would have to check to see when radiation began to be used for treating certain tumors). Some early antihypertensive medications actually had to be started in the hospital for patients’ safety. Vaccination for smallpox and for Rabies were the only (or two of the few) vaccinations available. Diseases such as Polio, Measles, Mumps, Rubella, Influenza and  tetanus killed/disfigured/disabled thousands of people if not tens of thousands or millions worldwide yearly (this is something people who are anti-vaccination seem to forget as Smallpox has been eradicated, Polio, Measles, Mumps and are thankfully rare. I have never seen someone affected by pre natally affected by Rubella).  I have a whole host of medications to treat hypertension, diabetes, varicella, bacterial infections and so forth that my grandfather’s generation of health professionals could just dream about.

Secondly, the business of medicine has changed drastically as well. I have heard stories as to how patients paid him with vegetables they grew in their own gardens. Though I won’t say much more here (it’s not germane to this particular blog post).

Thirdly,  sometimes people will say that we can’t seem to make up our minds as to what’s good for people or bad. For example, for years eggs were made out to be bad for us because of the amount of cholesterol in them. Now, they’re ok to eat as part of a balanced diet (though like many things, you can have too much of a good thing…). It’s just that as we learn more, the message about things gets more nuanced. Eating fats in your diet isn’t bad, though you can have too many of the ‘bad’ kinds of fat. Not all carbohydrates are bad: Too much refined sugar is bad, complex carbohydrates (as in FIBER) are good. This also can be seen in what medications are considered first line for treatment of certain diseases, sometimes a new(er) medication is better to start with than an old, more established medication. Other times, an old medication can treat a disease just as well as a newer one.

Secondarily to this several thoughts come to mind. One is that with all the
medications available for almost every conceivable disorder, we  – and I mean both doctors and patients – forget that we shouldn’t rely on a pill to fix everything. In the case of things like Type 2 Diabetes, prevention by diet and exercise will do far more than pills or injections can. Of course there are people who’d still develop Type 2 Diabetes, so for those who’d say “well my uncle/father/neighbor/etc did everything right and still developed DM-2 (or hypertension or whichever disease you’re talking about that can be prevented/delayed or modified by diet)…” I would use this analogy. We lock our car doors when we park them. When we leave our homes we lock the doors. In both cases peoples’ cars and homes still get stolen or broken into. Sometimes we  forget that some of the tools available to my grandfather’s generation are still just as valid and useful today: it’s that  we know more about how diet and exercise  work than they did. I think, however, doctors and patients sometimes miss that for the allure of taking a ‘new or improved’ medicine because its “more modern” than the old fashioned way of doing something or that it’s just easier to take a pill than it is to count calories and exercise more or do some exercises to help reduce a symptom such as back pain.

When I was in medical school my grandfather remarked how everything in the New England Journal of Medicine was about immunology and antibodies. As I read the the New England Journal, I am beginning to get the same feeling, though  now I’d say it’s all about genetics as there are more articles about DNA and genetic mutations. In several cancers, specific mutations and chromosomal changes have been targeted as they lead to a gain in function (or lead to a protein being produced constantly rather than being produced in a regulated fashion). Knowledge of this has led to some medications being developed that are less toxic than what’s usually used for cancer. How this will affect the treatment of other diseases remains to be seen. Will Asthma, Hypertension and Rheumatoid Arthritis be treated someday with medications that block whatever the root cause is, or perpetuates the disease? Only time will tell.

If someone were to ask me if I’d rather be a doctor now or when my grandfather started his practice, I’d have to say now. I can do a lot more for my patients than he could when he started. It also means however, that keeping up with changes in what we know or think we know about how best to treat patients I think is harder because of the sheer volume of things to read and keep up on is larger. Even if it means I’m accused of ‘flip flopping’ because new recommendations and papers seem to point in a different or opposite direction from what was said before. This is why physicians keep up with what’s new in whatever specialty they’re in. It’s the price we pay for 50% of our knowledge becoming obsolete every few years.

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