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Monday, December 17, 2012

Forewarned is forearmed, except when it isn't

Those who don't learn from the follies of history, we are famously told, are destined to repeat them. One of the oft-repeated follies is to ignore vulnerability, and wind up dealing with the consequences of that neglect.

Our vulnerability arguably comes in two flavors. There's the kind we can't do much about except recover from it afterward. Perhaps earthquakes are an example of this kind, since we can do nothing to prevent them. Hurricanes may be an example as well, since they have long occurred with no help from us, although they are almost certainly getting help from us now.

But even hurricane damage can be pre-empted to some degree. The need for protective measures taken in New Orleans after Hurricane Katrina was well recognized before. Had such measures been taken in advance, the catastrophe would have been much diminished, if not averted. A similar case has been made about the calamitous effects of Hurricane Sandy along the Northeast coast.

And while we can't prevent earthquakes, we can build infrastructure to withstand them. So it may be the kind of vulnerability we can do nothing about doesn't really exist after all, or is very rare (as in, a-giant-asteroid-hurtling-toward-Earth rare). Most of the time, forewarned should be forearmed.

Which brings us to the other kind of vulnerability, the kind we can do much to alter. That kind prevails.

It may prevail with regard to monster storms, but that's not my field. So I can only repeat what I've heard experts say: Power lines could run in reinforced pipes underground, rather than between poles and among trees. Storm surges can be anticipated, confronted, and diverted in harbors and coastal lowlands. Such things are being done in parts of the world more inclined to look at vulnerability as an opportunity for self-defense than we seem to be.

Regardless of the causes of our severe weather, the consequences are clear to us all. It is penny wise and pound foolish to let infrastructure get destroyed and pay the costs of cleanup again and again, when better infrastructure would resist such destruction. But such investments need to be made before disaster strikes, and that's the dilemma.

It is a dilemma that bedevils the medical field, and particularly my specialty of preventive medicine, where I may rely on my own expertise and experience for insights. It is, in a word, silly to treat hundreds of thousands of myocardial infarctions annually while knowing how to eliminate almost all of them. Silly, and, of course, tragic.

It is silly and tragic to treat type 2 diabetes, formerly known as "adult-onset diabetes," not only in ever more adults, but ever more children while knowing how to prevent the condition in 90% of adults and eradicate it in children. After all, we invented type 2 diabetes in children within the span of just the past generation.

Prevention produces far better outcomes and costs less than treatment. But like hurricane-proof shorelines and earthquake-proof buildings, it requires up-front investments for returns over time. We tend to be bad at that. But we need to get better, because lives are at stake.

As may be the fate of the nation. The Centers for Disease Control and Prevention is projecting that by mid-century, should current trends persist, 1 in 3 American adults could have diabetes. Devastating though it is, the toll of Hurricane Sandy is small in comparison to this brewing storm.

The first message in these winds is that current trends cannot persist, because the dollar and human cost of that are apt to be unbearable. We currently have roughly 27 million diagnosed diabetics in the U.S., and struggle to pay the health care bill. When 1 in 3 of us has diabetes, that will be well over 100 million. There is no bank account big enough to write that check.

The second message may matter even more. Guess who those adults will be, burdened with more diabetes than the world has ever known? Our children and grandchildren. They will be the adults in 2050, dealing with the crushing burden of chronic disease we bequeathed them.

The trouble with even temporary neglect of vulnerability is that the longer you wait, the worse your options. At the individual level, if you address vulnerability after the onset of diabetes, or after a first heart attack or stroke, your health will simply never again be as good as it could have been. Chronic disease can be managed, but the adage about not being able to unscramble an egg applies to health. That's what Humpty Dumpty was supposed to teach us.

At the collective level, the more vulnerability converts to consequences, the more resources are diverted to deal with those consequences. Whatever search and rescue costs, we have no choice; the money must be spent. Whatever emergency angioplasty or coronary bypass costs, the money must be spent. The more often money is spent that way, the less likely allocations to prevention become because the money is already gone.

One tends not to hear any clamor for pinching pennies and shrinking government when it's time to send in the National Guard, bring helicopters into flood zones or over forest fires, or mobilize the Coast Guard for search and rescue. In contrast, in moments of calm and far better options, those voices gain volume. When there's time to make investments to prevent the next costly calamity, we are heeding the call to cut the deficit.

The trouble is that catastrophes are enormously expensive. Vulnerability to them is the quintessential case of a "pay now, or pay later" scenario in which the latter costs dwarf the former. Neglecting vulnerabilities we can fix is penny wise, pound foolish. The deficit grows.

When Ozymandias, king of kings, invited lesser sovereigns to look on his works and despair, he may have had intimidation in mind. But what is truly indelible is his vulnerability. As told most famously by Shelley, the kingdom of Ozymandias fell to ruin in the desert sand. We are misguided to think we are too mighty to do the same. Signs of our vulnerability abound.

The choice to take on vulnerability is never easy. Building a levee when the ground is dry may seem unnecessary, even frivolous. But of course, it's the only time to build a levee that will reliably prevent catastrophe, rather than one that might not be enough to mitigate it. Making a serious commitment to eating well and being active may not seem worth the effort or time before you are on your back staring at the roof of an ambulance or riding next to your child doing so. But afterward, the investment is larger and the return smaller.

We are vulnerable, and we know it. That knowledge is only power if we put it to use before the costs of that vulnerability come due. Forewarned is forearmed only if we take up the requisite arms against a sea of looming troubles, and by opposing, end them before ever they begin. Again.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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