Seven years have passed since I started this blog.
In that time…
I have learned some basics about writing. (I almost wrote, “I have learned to write,” which would have been foolish, since, writing-wise, I have plenty to learn.)
I have learned to stay upright on the bicycle. Concussions made me understand that the joys of criterium and cross racing don’t outweigh their risks. I still ride nearly every day; I’m a pretty fast bike commuter now. And I’ve shifted my endurance-sport goals to running, which is a far safer sport for the brain. My goal is to run 10k in less than 40 minutes.
The main thing that has changed about me is my views as a doctor, especially when it comes to dealing with people who complain of nothing.
Medicine is most pure when we treat people with illness. The infirmed come to us with a problem and we use our intelligence, experience and procedural skills to help them. It’s immensely gratifying. The joy of helping people still negates the stifling burden of administrative nonsense. I’ll do your damn corporate safety modules one more year because helping sick people get well feels so good.
But when people complain of nothing, our first job is to do no harm. I know prevention of disease is better than treating it, but the process of prevention gets dicey. When we prescribe things (screening tests, statins, aspirin, diabetes drugs etc) to people who complain of nothing, we should have the highest evidence these therapies deliver benefit. Too often, we cite eminence rather than evidence.
I’ve come to believe the medical profession is too paternalistic, too arrogant. I fear the medicalization of the human condition. These days, I order fewer tests. Medical tests put people into the “system,” on the metaphorical train of healthcare. This train accelerates quickly, and it’s often hard to get off. Even a simple echo scares me. I could tell you stories.
More often than not, I tell patients to stop checking their “numbers.” If they insist on health numbers, I favor three–the scale, the belt size and a Timex to measure walking speed.
A 2002 article from Dr. David Sackett (a pioneer of evidence-based medicine) perfectly captures my views on preventive medicine.
It’s called The Arrogance of Preventive Medicine. It’s worth a look, now more than ever.
Shortly after I tweeted the Sackett article, Harvard economist and professor Amitabh Chandra chimed in with this:
https://twitter.com/amitabhchandra2/status/810481941111828480
JMM
P.S. For a longer and more polemic view of preventive medicine, see also, Piotr Skrabanek’s… The Death of Humane Medicine. Be warned; you can’t unsee this stuff.
10 replies on “I am changing…”
The ultimate horror of preventive medicine in that it has made millions unwell, is the “standard” dietary advice scientifically based on no science at all. And, despite the obvious sickening of the population, the response is more of the same etc etc. The prospect of the advice being the actual opposite of what would benefit the population is too awful to the “anointed ones” to be even mentioned. Yet, it is so. I, upon retirement, began to study this stuff and it eventually led to my cutting my carbs and increasing the my fat consumption a lot and losing all my excess weight and keeping it off for three years so far. Not only that, but my feeling of well-being on this regime is, still to me, an amazing and much-welcomed surprise.
Hi Dr Garry
Although I am a like minded person, we should be using sound arguments for our positions, or we risk weakening them. There is no good evidence that I am aware of that “the population is getting sicker”. Life expectancy stats (probably the most reliable stat) in my country (Australia) show the opposite and in the US show a slow improvement over time which may be stalling but not going backwards (source: World Bank). And I’m afraid your own personal experience, as valid as that is for you, is not a sound basis for making decisions about population health.
I regard the % of population with diabetes, obesity, CVD as a better indication of population. The fact that life expectancy may have increased through better medical care (stents. Limb amputations etc) should not be taken as better health. I’m firmly with Dr Gary on this one.
This is great, but there is an entire industry (workplace wellness) devoted to “overscreening today, overscreening tomorrow, overscreening forever.”
Until we get someone to expose these scoundrels (I can’t call them “quacks” because they aren’t licensed as clinicians), workers will continue to have the stuffing screened out of them.
Until then, keep up the good work…but visit http://www.theysaidwhat.net to see what you’re up against.
Among your excellent posts, this one stands out as a special gem. All of us are keen to help patients in the classic sense. But addressing poor lifestyle habits with medication is not only ill-advised, but actually enabling, not to mention the ADE et al.
An even greater sense of urgency now exists, with the recent report of reversal of CHD mortality and negative effect on lifespan. The moment of truth, predicted for some time, is now here, and yet public powers that be still do not “see” the problem.
More evidence of this self-defeating filtering is the proportion of the health budget destined for prevention through lifestyle improvement. We should be mounting a campaign on an unprecedented scale–one that dwarfs the anti-tobacco movement–to motivate healthy behaviors and make good choices the default. Such a movement needs strong administrative leadership.
Only 1-3% of Americans attain ideal CV health, and the number has not improved since its definition. Combine this with Geoffrey Rose’s writings and the trajectory of our national corpulence, and the full picture becomes painfully apparent.
All the best for the sub 40min 10k time. A solid goal. Let us know how you track with your training. Merry Xmas.
Thank you for your thoughtful writings.
It would be valuable to me to know more clearly what you mean by “preventive medicine “. I consider lifestyle counseling to be PM.
Do you consider those who have no symptoms, to be well?
Do you not consider the following numbers to be of importance in symptom-free individuals: blood pressure, heart rate variability, glucose, insulin, vitamin D?
You forgot to mention the book, “The Last Well Person: How to Stay Well Despite the Health-Care System,” by Norton M Hadler, MD. This book made me re-evaluate my perceptions of health care in the United States.
I think for most conditions it is wise to avoid testing in the asymptomatic. I have written about the dangers of the routine ECG, the routine echocardiogram and the routine stress test on my blog. However, there were 326,000 cases of sudden cardiac death in 2014 and many of these are the first symptom of any cardiac problem. For the prevention of these sudden, unexpected deaths in the patient with no symptoms who, in fact, may be following optimal lifestyle recommendations I think tests to identify early, advanced atherosclerosis (coronary calcium, carotid plaque/IMT) are warranted.
What if preventive medicine is getting a bit more time outdoors in the sun and nature without shoes? https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3576907/