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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