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Thursday, February 27, 2014

Obesity and oblivion, or what I've learned under general anesthesia

I am going to tell you what I’ve learned under general anesthesia, but I ask you to bear with me kindly and wait a few paragraphs for that revelation.

I am a rambunctious guy, pretty much always have been. I have always loved active recreation and was one of those kids who had to be reeled in for dinner from outside play with a winch and a cable. As an adult, I placate the restlessness of my native animal vitality with about 90 minutes of exercise every day. In addition, I hike whenever I can, and pretty much share my dogs’ attitude about it: the more miles, the better. I studied the martial arts for years. I am a lifelong, avid alpine skier, and an ardent equestrian, privileged to share that latter brand of rambunctiousness with my beautiful horse, Troubadour, who seems to enjoy running and jumping as much as I do, and is far better at it.

This is all part of family tradition. Women in the family are generally quite active, and some have their share of perennial restlessness. But the guys are a case apart. My son’s rambunctiousness is, quite literally, famous of song, story, and program. The ABC for Fitness™ program Gabriel directly inspired is now reaching hundreds of thousands of kids around the country and world, and paying forward the benefits of daily exercise in schools. Gabe helped me appreciate the importance of asserting that the proper remedy for rambunctiousness in our kids is recess, not Ritalin.

And then there’s my father, whose restlessness is the granddaddy of all, and the stuff of legend, or at least family lore. We celebrated his 74th birthday last summer with a hilly, 56-mile bike ride.

By and large, the effects of this rambunctiousness are extremely positive. My animal vitality is spared the constraints of leash or cage, and rewards me reciprocally with energy, stamina, and vitality. But everything has a price. My particular brand of rambunctiousness has involved pushing limits, and limits have a tendency of pushing back. The result is several concussions (I am now a consistent helmet wearer), too many stitches to count, roughly 20 broken bones, and general anesthesia to restore the mangled anatomy of some joint or other not fewer than a half dozen times.

Which leads, at last, to what I’ve learned under general anesthesia: Nothing. Nada. Zip.

Nobody learns anything under general anesthesia. General anesthesia involves unconsciousness, oblivion.

And on that basis, I consider it a societal travesty that hyperendemic obesity and the metabolic mayhem that often follows in its wake are treated ever more frequently, in ever younger people, under general anesthesia. Our answer to obesity is, it seems, oblivion.

True, bariatric surgery is effective. But it is also expensive, and subject to all of the potential complications of surgery. We don’t really know how long the benefits last, particularly for the children and adolescents who are candidates in growing multitudes. We do know that lasting benefit requires ancillary lifestyle change, and that there is often some, and sometimes a lot, of weight regain despite the rewiring of the gastrointestinal tract.

And we know as well that we are relying on scalpels in the hands of others to do what forks in our own hands (and feet in our own shoes) could do better, at dramatically lower cost and risk, if our society committed to empowering their more salutary use. We have evidence to suggest that schools and aptitudes acquired there could do for weight what scalpels applied under anesthesia do. But in my experience, they could do so much more. As a medical advisor at Mindstream Academy, a boarding school producing weight loss to rival bariatric surgery, I have been far more impressed with what the kids find than what they lose, impressive though the latter may be. They find pride and proficiency; confidence and competence; skillpower and self-esteem. They learn, in other words -- as nobody ever does under general anesthesia.

Our society’s tendency to “over-medicalize“ has been chronicled by others. The consequences extend to expecting from our clinics what only our culture can deliver. Among the most vivid illustrations of this is the lifelong work of my friend, Dean Ornish. Dr. Ornish was involved in groundbreaking work that showed the capacity for a lifestyle overhaul to rival the effects of coronary bypass surgery. With evidence in hand that feet and forks (and a short list of other priorities attended to) could do for coronaries what scalpels could do, Dr. Ornish set out to make his lifestyle program a reimbursable alternative to surgery. He succeeded, earning Medicare reimbursement after—wait for it—17 years! I don’t know that Dean has the patience of a saint, but he apparently does have the patience of a cicada.

It took 17 years to gain reimbursement for lifestyle as a cost-effective treatment of coronary artery disease, whereas surgery was reimbursed from the get-go. That’s how we roll, and then wring our hands about the high costs of health care.

With that in mind, I ask my fellow parents reading this column. I ask the grandparents, godparents, aunts and uncles to contemplate this: How many of our sons and daughters, nieces, nephews, and grandchildren will have passed through the O.R. doors if it takes us two decades to establish lifestyle intervention as a culturally sanctioned alternative to bariatric surgery? However many that is, I can tell you exactly what they will all learn while under general anesthesia: Nothing. Nada. Zip.

Knowledge and experience are the foundational elements of culture itself. Culture derives from the capacity of our species to learn, and pay forward our learnings to our contemporaries and our children. Among the impressive manifestations of effective school-based approaches to adolescent obesity is the capacity, and proclivity of the kids to pay their newly acquired skillpower forward. When last I visited Mindstream Academy, one of the young girls there, who had lost some 80 pounds, was most proud to tell me about her father back at home who, courtesy of her long-distance coaching, had lost about 40. There is nothing to pay forward following the oblivion of general anesthesia.

Bariatric surgery is effective and should be available to those who need it. I have referred patients for such surgery over the years. But our culture will be defined by what we learn and share. We could learn and share the skill set for losing weight and finding health, and make that our cultural norm. That remains unlikely so long as we put our money preferentially where our medicalizations are. The AMA has proclaimed obesity a disease, but that’s just symptomatic of our culture tendencies. It is more a disease of the body politic than of the often healthy bodies that succumb to it in a culture that propagates its causes.

The healthiest, happiest, leanest, longest-lived populations on the planet do not attribute such blessings to the proficiency of their surgeons or the frequency of their clinical encounters. They attribute them to the priorities and prevailing norms of their culture.

Nobody learns anything under general anesthesia. General anesthesia is oblivion. If we keep prioritizing the medical over the cultural, oblivion over enlightenment, my friend Dean Ornish will remain a lonely pioneer. And the cicadas, when next they emerge, will see nothing new. They will have cause to roll their protuberant eyes at us and trill out: same as it ever was.

It doesn’t have to be that way. We could choose oblivion a bit less often, and stay conscious instead. Conscious, we would have a chance to think outside the box of surgical gloves, and perhaps thereby perceive a new world of opportunity.

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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