The two biggest problems for future physicians (part 1)

It's time that we took a trip back to the questions that I posed back in my first post: What makes/is good medicine and what makes/is a good doctor? Making good medicine and being good doctors in the future is going to, in my opinion, revolve around tackling two big problems here in the US.


1) Equal access to health care.


2) Obesity

As far as equal opportunity to obtain health care goes, I think that the underlying problem has to do with the consumerist nature of our country. There is a desire for "McMedicine", quick, cheap, and easy fixes. Unfortunately, the most quick fixes aren't cheap. Even the ones that are, when overused, have a rapidly mounting cost. This cost isn't just a monetary one, there is a detrimental effect on the health of the entire country by over use of quick and easy fixes. We are addicted to interventional medicine. Preventative medicine? Bed rest and chicken soup? No way! Who has time? I'll just pop some antibiotics (gee, hope I remember to take them all!) and be on my way. The simple truth is as long as we abuse the powers of intervention, we will never have guaranteed health care. Any system that is overused with be toppled by the pressure. Money is finite, therefore health care is finite. And yet, how can we stop people from overusing medical treatments.

At the same time, we are only setting ourselves up for bigger, badder bugs. Overuse and misuse of pharmaceuticals is directing evolution towards multi-drug resistant diseases. Evolution hasn't stopped just because we discovered its properties. It's amazing how much medicine has changed in the last 100 years. I don't mean just the equipment, science, and treatments. I'm talking about the whole concept of medicine, and who it should serve. 100 years ago, you could be imprisoned on an quarantine island in order to protect the public from whatever disease you had. Your rights were utterly revoked for the good of the population. That was good medicine back then, even though it might bother us now. A doctor's purpose was to rid humanity of disease, not a person. The medical community was at war with disease like TB, Typhoid, Dengue Fever, and many others. It was a battle that focused on the disease within people, not diseased people. If a few patients had to be trampled in the process, it was worth it for the greater good. When small pox was eradicated by global vaccination efforts, the fact that 1-2% of those vaccinated were going to die was worth defeating a disease that had a mortality rate ranging from 30%-90%. Now adays, we have people who refuse the vaccinations offered to their children, and are allowed to send those children to public schools. In many states, we can't even arrest an HIV patient who willingly infects people. I'm not saying that we need to go to the extremes that were once acceptable at the dawn of Modern Medicine, but I think we need to take some lessons from their book. Preventative medicine, especially vaccines, are what save lives. Sanitation and vaccines are what has resulted in the increase of our average life span, not normal interventional medicine. Certainly, surgeries and medications save individual patients here and there, but overall interventional medicine has been most effective in the relief of suffering, where as preventative medicine has resulted in the massive extension of human life. It is still a wonderful calling, but most doctors improve lives more than they save them. The exception are those involved in public health programs that emphasize prevention.

So I want more preventative medicine and less interventional medicine, what's my plan do you ask? Education. I personally believe that a physician's calling to educate spans both his students and his patients. We must integrate once again into the mainstream psyche that medicine heals and medicine hurts, and that prevention is the best way to healthy living. Washing hands does a lot more good, in the long run, than taking a pill. It's ok to be sick! Sickness, nine times out of ten, makes you stronger. It's good for you to have a fever and need to be in bed for a couple days, your body is flexing its lymph muscles!

At the same time, though, we can't blame patients for the health care crisis without taking some of the responsibility on as well. It is up to us as future physicians to resolve the one of the biggest medical issues of our time, how to reconcile the needs of the individual and the needs of the population. How much care is good medicine? Is it good medicine for the patient, or for the population. Is it possible to have good medicine for both at the same time. Is increasing the life span of HIV patients good for the population? Can we ethically not try and increase their life span as much as possible? Fun stuff, I just hope there is an answer. The rallying cry of today's medical world is "individualized care". The ultimate break from the population focus of the past century. The benefits to individuals stand to be immense. At the same time, though, we can't forget that our duty is to the community as well as our specific patients. There must be a compromise for optimal health.

Another thing that we as physicians must do, is never forget that we are treating people, that we must be very careful with concepts such as "acceptable losses". As more and more machines and tests are placed in between doctors and patients, one of the most important parts of medicine is at risk. There is healing in medical Art as well as Science, and when we stop interacting as people caring for people, we degrade our profession. I honestly believe that one of the main reasons that Complementary and Alternative Medicine has become so widespread in our culture, is because of the fact that it is a result of an imperfect system of medical treatment. As science has come to be held above all other things, many physicians seem to have lost the time necessary to treat using the Art of medicine. The success of many alternative practitioners is based on the fact that they CAN practice the art. They have the time that a busy physician with 40 patients to see in the next hour does not. They can listen to worries, have time to discuss them. The members of the CAM community can make friends with and present themselves as people to their patients at a level that most physicians are to busy to do.

Not all patients who come to a doctor are physically sick. We, as humans, have a tendency to fear the unknown. When a new dimple or pain appears on our body, we begin to fear that it is worse than it usually is. It gnaws at us, and we seek comfort in the vast knowledge of medical practitioners. The reason that we revere Hippocrates and his style of medicine, rather than his rivals', the Cnidians, is because the school of Cos was well aware of the need to be caring, friendly, and truly concerned with the patient. They could not cure much, but they were very good at predicting what was going to happen and identifying the disease. They cut through the unknown and brought knowledge, even if it was knowledge was death. Regardless of the outcome, they did their practice with caring and understanding. I have seen old ladies be brought in on ambulances because of a toothache. They would talk to the doctor for a few minutes and then leave happy with no medication. Sometimes, people just need a few minutes of a doctors time, a few minutes of someone who is concerned with their well being. Some people, having received knowledge of their illness, leave almost proud of their new found knowledge. If we are to fix medicine, we must understand this simple fact of human nature: Being sick scares us. Knowing why excites us.

I was shadowing my father a long time ago, and we visited a man complaining of knee pain without any visible cause of it. My father knelt down, felt the knee, and told the man that he was going to be fine and to ice it. He left happy. I asked my father if he really needed to feel the knee, and he said "No, but that was the cure." He then proceeded to give me some of the best advice I will probably ever get on the Art of medicine:

Always find an excuse to touch your patient.

I'll talk about the second biggest problem, obesity, on another occasion. Now go touch some patients!