Demystifying Medicine One Month at a Time

Tag: NPR (page 2 of 4)

The Inflection Point(s) of Aging

A new column of mine has been posted on NPR’s website about “de-prescribing,” the art of pruning medications from older adults that take too many of them, a condition we refer to as polypharmacy.

Katherine Streeter for NPR

Katherine Streeter for NPR

It’s well-known that being on too many medications can lead to more side effects and drug-drug interactions, so anything medical professionals can do to minimize such negative outcomes is welcome. Thus we revert to our Hippocratic doctrine: First, do no harm.

Contrast that with the competing ethical imperative toward beneficence — to do good for patients. Medical science teaches us that many (though far from all) of the medications we prescribe for chronic illnesses (e.g. cardiovascular conditions) lead to fewer ‘events’ (think heart attacks & strokes), which prolong lives.

As a result, doctors wind up prescribing a lot of stuff — and decades of medical practice and now guidelines and quality metrics push us to do this even further.

One area I’d like to see science help us is in identifying “The Inflection Point of Aging,” which I define as the point in a person’s life when we can pare down ‘aggressive’ treatment of chronic conditions because it becomes counterproductive: when taking the “medically proper” action is likely to cause more harm than good.

This whole notion arises out of recent discourse: As I recently blogged, the SPRINT Trial, which was stopped early because it showed that treating blood pressure even more aggressively than we’d previously thought leads to fewer bad ‘events.’ How low, I wonder, is too low?

Also, an article in the Atlantic by medical pundit Ezekiel Emanuel titled “Why I Hope to Die at 75” emphasized this idea.

Emanuel is a known iconoclast, but I appreciate his efforts to stir up dialogue and get us talking about important issues that we are otherwise reluctant to discuss. In this case, I think his editors at the Atlantic did him a disservice, because the provocative headline of the article caused a furor and detracted from his real message, which was simply this: There comes a point where undergoing standard medical practices no longer makes sense. That point is different for everybody and is dependent on a person’s values as much as their physiology. Emanuel never said he wants to die at 75, merely that he plans to stop seeking medical interventions at that age — two very different ideas.

If you click over to the NPR column, you can see that anecdotally, we care for patients for whom physiology does change — and it therefore doesn’t make sense to keep doing the same things over and over. It’s trite to say it (and you’d be amazed at how challenging it can be to fight medical inertia), but we must think about each patient individually and truly weigh the risks and benefits of adhering to population-based norms and recommendations when goals and bodies change.

Doctor, Don’t Treat Thyself. Or Family Members.

The day I started medical school, I called home to tell my parents about it. My mother, a hypochondriac, didn’t want to hear about the class schedule or the amount of work.

“I have a new rash I need you to take a look at,” she told me.

What did she think? That after one day, I’d suddenly been imparted all the knowledge I’d need to treat her? (As you’ll see later, I would come to wish that had happened.)

Silly Mom. As if I’d been admitted to some special club.

This comes up more often than you might think in medical practice. The ethics are fairly clear — it’s not illegal to treat family members or friends, but it’s unethical because those friends and family members cannot exercise their full autonomy when making medical decisions.

Just published on NPR’s Shots blog is a column I wrote about our experience caring for our daughter during this past winter’s flu season, and a couple of stories of familial ethical challenges from other doctors. Please click over and take a look. Thanks to Katherine Streeter for great collage art.

Gotta get me one of those “Dad” hats, but I’m not much into argyle.

What Really Makes People Sick

Medical science has evolved rapidly. With the newest computing and laboratory technologies, the pace of knowledge generation only increases. Our biggest challenge today is in processing data, and finding the patterns within that can unlock more secrets of life and health.

sep2011_AWSI_03 bigPublic health improvements in the 20th century like sewer systems and a clean water supply, coupled with childhood vaccinations and the advent of antibiotics radically increased the human life span to its all time high–roughly 80 years for men and women in the ‘industrialized’ western world.

Some in the scientific community think an achievable human life span is closer to 120 years; that if we can alter some of the problems caused by senescence and aging, more of us will live past 100. It’s at about 120 years that current science guesses that cellular and tissue breakdown is genetically programmed to occur to such an extent that further life as we know it is near impossible.

As the list of causes of death in the U.S. has changed dramatically over the 20th century, you can now see that much of what kills us is chronic disease. Interestingly, our ability to make inroads on this list has not been as successful as it was in fighting the original infectious causes of death. We manage chronic conditions like diabetes, heart disease and cancer; very rarely do we cure them. This despite a nearly half century “war on cancer” and billions of dollars spent on research and development in heart disease.

What we’ve come to understand in the medical world, by listening to our social science colleagues, is that social factors have a profound impact on our health — such that the World Health Organization estimates that medical care (over which we spend $3 trillion annually in the U.S.) only impacts about 10% of our health. It’s the social (non-medical) factors that play an outsize role in our health as individuals and communities.

NPR Health ran a short series of radio stories and web posts called “What Shapes Health” that looked at these phenomena. They’re well worth indulging in if you didn’t catch them when they aired. Among the highlights:

  • What is an adverse childhood experience (“ACE”) and how does it impact your future health? Take a short quiz and get your own ACE score.
  • Survey research showing that people with lower incomes perceive that they pay a price with poorer health. Not surprising news, but important knowledge of the effects of inequality.
  • Housing impacts health…in a big way. If you don’t have housing, can’t afford it, or live in housing that is unsafe or substandard, in all likelihood you will die younger than others in your age cohort.

Each of these social factors (and another HUGE one: education) lead to that amorphous concept we call “stress.” It has real impact, and quite frankly we’re only in our infancy of being able to quantify what it does to us. Stay tuned.

“Everything’s Fine.” [Not.]

npr_alzheimers_final_wide-1b09fc6b3928be310d8acbe0f86a53047a7b100f-s800-c85Over the years, I’ve cared for many patients that come to the doctor because a loved one has urged them to.

Asked why they are visiting, they’ll often reply “My _____ made me.”

Most often, that blank is filled with “wife,” though not always.

Click over to NPR’s Shots to read about one such patient I cared for and what I missed.

Thanks to Lucinda Schreiber for gorgeous artwork that accompanies the piece.

Stories of Hope and Miracles

christmasgiftartHolidays can make us…sentimental.

Sometimes in spite of a worldview that prioritizes scientific rationality above all us, we see things that aren’t easily explained.

Its important to be open to wonder. Even for docs.

Post by NPR.
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