American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, December 26, 2013

Gaia and snake oil

My older brother is also a doctor, but not a primary care provider like me. He’s a specialist: a limnologist. If you have problems with blue-green algae in your lake, he’s the man to see. Limnology is the study of lakes, and fittingly, Bill works in the “Land of a Thousand Lakes” as a professor in fresh-water ecology.

I’m not sure he’s thinking of switching over to direct-care limnology. I’ve been afraid to bring it up.

We do have a lot in common in our professions, as we both see a mindless assault on the things we are trying to save (patients for me, lakes for Bill). My frustration with our health care system is matched by his anger toward those who deny global warming and the harm humans are causing on our world. Just as he can get my blood pressure up by asking if his child will get autism from the immunizations, I simply have to suggest this week’s cold weather as proof against global warming to raise his systolic pressure.

So it was notable when I heard a rant against an unexpected target: “You know the Gaia hypothesis?” he asked. ”They think the world is a ‘living organism’ that works toward a ‘balance’ to maintain life. They believe that humans act against nature, and so are responsible for everything that’s wrong with ‘mother earth.’”

“It’s total bullshit,” he went on to explain, not waiting to hear if I knew what he was talking about. ”Do you know that when trees appeared on the earth, they caused a mass extinction (called the Permian Extinction)! Trees! There’s no mystical ‘balance of nature;’ it’s always in a constant state of flux, of imbalance.”

Let me make this clear: Bill is not saying that it’s OK that we are harming the earth, nor is he trying to absolve us of our responsibility for what we are doing. His beef was with the notion that there is some kind of “balance” of nature, when the evidence clearly points to the contrary. The result of this belief is that that there is somehow an imputed moral goodness from this “balance” (resulting in the idea of “mother earth”), and a subsequent implied immorality to any assault on our mother’s sacred “balance.”

This has come to mind as I have had significant changes to my thinking about giving good care my patients, especially as it applies to the area of “wellness.” Since leaving my old practice, which was immersed in a world of ICD (problem) codes and CPT (procedure) codes, I have shifted my thinking away from a medical world where every problem demands a solution. I have moved my thinking away from reacting to everything that is going on at the moment, and toward the bigger picture. I am focusing less on problems and more on risk. I am focusing less on solutions, and more on responsibility.

American medicine is obsessed with identifying problems and then finding solutions so we can cross those problems off of the list. We are obsessed with cures. We seem to think that anything that departs from “normal” should drive us to push it back toward “normal.” If “wellness” is the natural state of things, then health is good; sickness ends up being a wrong that needs to be righted.

But this is not necessarily the case. For example, if someone gets an upper respiratory virus, we often/usually consider this a “problem” which requires fixing. The idiom: “finding a cure for the common cold” reveals this underlying belief. To “fix” this problem, people take vitamin C, zinc, or “drink plenty of fluids” (if they are from the “avoid medicine” camp), or they take decongestants, antihistamines, or visit their doctor looking to get an antibiotic to “keep this from turning into sinusitis/bronchitis/pneumonia/etc.” The reality is, however, that simply by allowing their T-cells to do their job, they will get better 99.9% of the time without any intervention. In fact, it is reasonable to suggest that this may even be the equivalent of exercise for their immune system. Studies suggest that infants in daycare who are exposed to the germ cesspool that is a daycare center are actually less likely to get sick when they are older than children who are kept at home. It may actually be good when people get sick.

The idea of a “balance” to be disturbed flies in the face of the reality easily seen in this world: few people get through the year without getting sick, and none ultimately avoid getting some terminal condition. In short, fighting sickness is always a losing game.

I am not suggesting that we shouldn’t treat illness; I am simply suggesting that the “every problem deserves a solution” put forth by society, modern medicine, and (especially) our payment system is, to use my brother’s words, total bullshit.

Why get so bent up about this? It does, after all, give me job security, right? There are several bad outcomes when we approach health and wellness in the “Gaia” approach:
• We tend to look for blame when there are problems. What did I do to get sick? What could I have done differently? Was I not eating properly? Did I not get enough sleep? People are constantly looking for things they did wrong when they get sick, when the real cause is that they are simply humans.
• We look for problems to justify our solutions. Why check cholesterol in low-risk people in their 30’s? Why do a “routine blood panel” on people every year? To identify problems requiring intervention. This, despite the fact that these tests (and their matching interventions) don’t prolong life or improve quality of life. In reality, there’s no good clinical motivation to do a lot of what we routinely do, but there is a huge economic motivation to do it.
• The system becomes obsessed with definitions. Is obesity a disease? There has been a recent dispute over whether or not it is classified as such. Why bother? Because disease gets a diagnosis code (for which you can bill) and allows for justification of procedures to “fix” the problems (bariatric surgery, medications, etc). What about Attention deficit disorder? Is it a “problem” (disease) or is it simply an immature kid or absent-minded adult? These types of debates will on ly increase as long as we keep the disease/cure mindset.
• We look for solutions to things that aren’t actually problems. What is a “bulging disc” on an MRI? Normal, it turns out. What is “bronchitis?” A loose cough. But the most common use of the term “bronchitis?” A justification for antibiotics.
• We look for “magic” solutions to problems, and we as health care providers feel pressure to give people “their money’s worth” when they come to the office. This leads to a whole lot of unnecessary tests, medications, procedures, and cost. Sick? Take a pill. Obese? Get surgery. Not feeling well? Get a bunch of lab tests done. Feeling anxious or down? Take another pill.
• Many of our interventions end up creating their own problems. ”Fishing” for abnormal lab tests is far more likely to lead to more lab tests and unnecessary worry than it is to help someone. Medications can have side effects, cause harm, and (in case you hadn’t noticed) cost a lot of money.
• People are much more prone to snake-oil salesmen. Whether that snake oil comes from a pharmaceutical company (Adipex for weight loss, treatment of “low T” for men getting older), neighborly advice (“drink this juice which is loaded with anti-oxidants”), or a true huckster (“bathe your feet in this water and when the water turns color the ‘toxins’ are removed from your body”), our drive to fix every problem leads us to throw our faith and money at anyone who can solve our problems.
• Many patients avoid getting care because they have bought into society’s practice of pointing a finger of blame for every problem, and so are ashamed of their blood pressure, diabetes, or their child’s asthma. Others are harmed by providers (both in my profession and outside of it) who promise “miracle” cures. Still others spend huge sums of money striving for the generally elusive (and always temporary) goal of “wellness.”

So what’s the alternative? We need an approach that accepts our human frailty and rejects the reflex toward fixing every problem.
1. Understand that sickness is inevitable, and stop blaming yourself (and others).
2. With any symptom, disease, or condition that comes along, first address the issue of risk. What is the risk? What is the worst thing that could happen? How likely is it?
3. When considering any intervention to reduce risk, be it medication, lab test, or procedure, first address the issue of risk. What does this do to lower the risk of the condition? What is the risk of this intervention? What is the likelihood that this could reduce risk, and what is the likelihood it will cause more harm? When in doubt, do nothing.
4. Once risk is determined, then address impact: what is the impact of this condition on the quality of life? What can be done to reduce the impact, and is doing so really necessary? You can treat a fever for the comfort if you want, but it doesn’t impact the ultimate outcome.
5. When considering an intervention for symptoms, first address the issue of risk. Since the treatment doesn’t reduce risk, any significant risk of treatment should be weighed carefully.
6. When a person is not having problems, consider risk. What are conditions that this person is at risk of developing? How serious is that problem? Is it heart disease? Diabetes? Gout? Chronic pain? Rectal itch? And how likely is it?
7. When considering an intervention to reduce risk in a healthy individual, first consider the risk of that intervention.

In reality, health care is not about achieving wellness in people; it is being responsible in our approach to people’s medical conditions and doing what we can to avoid them in the first place. When a person does develop a disease or experiences symptoms, good care is focused on understanding the person’s risk and taking only actions that give the best chance of giving them the best, longest life. It is irresponsible to expose people to more risk in our interventions. It is irresponsible to pay thousands of dollars for something that has marginal benefit. Just because insurance pays for the stent in the 40% heart lesion doesn’t mean it’s the responsible thing to do.

This should be medicine 101. Why is it that it seems so radical? That, I believe, is a huge problem.

Oh yes, if you need any help with your blue-green algae, I know a good doctor who can help you.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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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.

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 Iowa City, IA, 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.

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.

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.

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).

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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