some interesting thoughts

JAMA Network | JAMA Internal Medicine | A 300-Year-Old Solution to the Health Care Crisis.

Of note, I think when you click on the link above, you will have to download  the PDF.

I remember reading this article abut the time it came out. Though I don’t think it necessarily has all of “The Answers”, it does bring up some interesting points. I’ve often why some health insurance plans won’t pay for some preventive care when it would benefit the patient. When I’ve asked colleagues this the answer I  often get is “because the patient will be on different insurance [ie, medicare or  a managed care product from a private insurance].”

However many private insurances also have a managed care product for seniors. people may not ‘graduate’ into a plan from insurance they have while working. However there are people that might go from  Having Harvard Pilgrim Health Care to AARP’s program (through united health care). however, some might go fro United healthcare to HPHC’s product (or an equivalent insurance in a different part of the country). This might even things out a bit.

Anyhow, I sugges you read the article and make your own conclusions.

The Prevention Prescription, part 1

I suppose this is going to have some overlap with some of what I’ve already written. Even though I treat adults, I am routinely (every month or two)  giving people vaccines against various preventable diseases. Tetanus, diphtheria and pertussis being the most common vaccination I give, though I think perhaps only vaccination against influenza could be as or more as that in absolute numbers.  By the time most people get to me, they’ve had a majority of their vaccinations (except perhaps for those that didn’t exist when they were growing up or weren’t recommended outside of certain high risk groups).  Most people don’t seem to have a problem with getting a Tetanus/Diphtheria/Pertussis booster. Influenza vaccination seems harder to take for some people.

Other folks seem to take offense at getting any immunizations at all. Perhaps if we went back in time to an  era when people died of polio (1952 saw what is reported to be the worst epidemic in U.S. history: 57,628 cases,  3,145 died and 21,269 people were left with paralysis of some degree). People developed rubella while pregnant (between 1962 and 65 when there was a worldwide pandemic – an estimated 12.5 million rubella cases occurred in the United States.  There were a resulting  2,000 cases of encephalitis, 2,100 neonatal deaths, and 20,000 infants born with Congenital Rubella Syndrome).

I could go on about how vaccination has either eliminated disease (the last case of smallpox was in 1978) or vastly reduced the number of affected people. In some countries, vaccination has eliminated diseases (the U.S. has been polio free for the past 30 years) or vastly reduced the rate (only 223 reported cases worldwide in 2012 with only three countries being considered endemic for polio).

One might ask why an internist is writing about vaccinating against “childhood diseases”.  Viruses and bacteria do not know the ages of the people they infect. A lot of diseases are mild(er) in children but have higher complication rates in adults. Varicella (the chicken pox virus) can come back in adulthood and cause shingles as well as an encephalitis. Varicella is also a worse disease in adulthood and not everyone gets the disease in childhood. It’s now routinely recommended that if one is going to be around young children (I.E. infants) or in healthcare that people get vaccinated against Pertussis to prevent it spreading. People forget or don’t know how many lives have been spared because of vaccination and that a lot of diseases that caused death and disability are thankfully gone or almost gone. Part of my job is not just to treat illness but try and prevent it as well. With vaccinations it’s important not to forget them even in adults. It’s a matter of public health (preventing pertussis spreading to one of my patients’ children, grandchildren, nieces and nephews, etc): prevention of disease in my adult patients as well as those they come in contact with.  I also am trying to prevent disease on the individual patient level as well. If my patients aren’t getting the natural ‘booster shots’ of exposure to their (grand-)children while they’re infectious for varicella, there is the potential for waning immunity which puts them at risk for reactivation (I.E. Shingles in the case of varicella).

As time goes by, I think there is, and will be an appreciation that vaccination isn’t ‘The Answer” for everything. There is an appreciation that immunity wanes for some vaccinations, eg tetanus and diptheria, which is why it’s recommended to get boosters. It may be the case for the MMR vaccine as well. That immunization doesn’t always prevent a given disease is not  a reason to avoid vaccination. If we thought that way in other areas of our lives, we would not lock our car doors, the doors to our houses, look both ways before crossing the street because “doing these things don’t prevent cars being stolen, houses broken into or being run over by a car”.

Sometimes convincing people of the power of prevention is the hard part.

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.

Related articles