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Thursday, November 13, 2014

Softer care for harder cases, of Ebola and everything else

The evolving Ebola outbreak is very disconcerting, to say the least. The situation in West Africa is, obviously, truly dire, with projections of the toll escalating from terrible to calamitous day by day. A dreadful, transmissible disease in a part of the world where access to clean water can be elusive is a very bad and volatile mix.

But the situation in countries putatively far more capable of confronting this kind of problem effectively has provided little comfort to date. Transmission in Spain apparently owed something to the ravaging of public health resources in an austerity economy. Here in the U.S., we are navigating through an embarrassing sequence of public health blunders. We, too, have routinely raided the never copious public health coffers whenever economic challenge came calling. Even so, we should certainly be able to do better than this.

So, yes, even as someone formally trained in epidemiology, I find the situation, not just in Africa, but right here at home, disconcerting. I rather wish I hadn’t recently watched Dawn of the Planet of the Apes, much as I enjoyed the movie, because a virus catching a plane and going global has life imitating art a bit too closely for comfort.

That said, I hasten to note that there are still some important differences in perspective attached to formal training in public health.

First, Ebola is bad enough as a quasi-natural occurrence, compounded by a series of unfortunate events (or actions). There is no basis for the conspiracy theory nonsense all such crises propagate.

Second, the risk of Ebola transmission to any one of us in the U.S. or Europe is, until or unless truly dramatic and very unlikely changes occur, vanishingly small. There have been 24 deaths in the U.S. from lightning strikes so far this year. National Geographic tells us that 5 people die from shark attacks every year.

OK, you are not worried about lightning hitting the shark that’s eating you. Let’s move on.

Third, while new, exotic, and seemingly scandalous threats for which we can hold someone else accountable fascinate us, we routinely dismiss, disparage, and neglect the vastly greater risks we have the means to manage. I have lamented this many times myself, but now have the excellent company of Frank Bruni, who did so masterfully in this week’s New York Times. Globally, measles kills over 100,000 people annually. Even as we eagerly await news of effective Ebola vaccines, we forgo use of those we have, invoking a toxic blend of paranoia and complacency. So measles is back.

These points have all been made before. There is, however, another consideration in all of this, a connection I have not yet seen others make. We need all of our care, clinical and public health alike, to be more holistic.

Holism may evoke butterflies and wildflowers, as the term has taken on a New-Age, touchy-feely kind of glow. Holism suggests not so much the rigorous analytics of applied epidemiology, as the soft touch of doting humanism. My argument here is that if holism is indeed “soft,” then the softest of care may best suit the hardest of cases.

Consider that the origins of the Ebola crisis relate not directly to public health, but to ecosystems, native diets, and biodiversity. We have known for a long time that bats and primates were prone to harbor viruses that could infect humans, Ebola included. A failure to think holistically, however, precluded culturally tailored approaches to modifying traditional diets, providing for ample alternatives, and sparing the world its current catastrophe. It’s not too late, however, to prevent the next one.

As for Ebola containment, holistic thinking is clearly essential. Control of an outbreak is not limited to treating the sick, but managing the social network of every index case. Hospital care becomes the workings of a village, with the comings, goings, tasks, and interactions of providers inextricably tangled up with the patient’s requirements, and the vulnerabilities of us all. The social contacts of a hands-on caregiver, both in the hospital and beyond, suddenly have clinical relevance.

The lesson here is that they always do. The nature of care and social interactions influence the propagation of heart disease, too. That some populations are so much more prone to diabetes than others isn’t about biological distinctions, but social ones. Type 2 diabetes is, fundamentally, a social disease.

We will spend a fortune on a global Ebola response. We might have spent much less, proactively, on the source of the problem, and saved both lives and money. There is nothing unique to Ebola in that. We spend billions on after-the-fact treatment of chronic disease and obesity every year, and pitifully less to address them at their origins, use what we know, and add a bounty of both years to life, and life to years as a result.

Imagine for a moment if we thought heart disease were “infectious.” In a sense it is, since families tend to share vulnerability, and it runs in social networks. But we take this to be due to behaviors and exposures we can ostensibly control, not some virus we cannot. So we are complacent about it. The result is that millions are diagnosed with heart disease every year in the U.S., and it kills some 600,000 of us prematurely. Ebola, of course, terrible as it is, is a very long way from any such toll.

We know heart disease to be preventable 80% of the time, if not more. But we just keep treating cases as if each man and woman to succumb were an island, and the carnage goes on.

The ramifications of more holistic thinking extend to medical enigmas. Patients suffering from what they are apt to call “chronic Lyme,” for instance, have a choice between clinicians who endorse the condition and treat with antibiotics often long after the last spirochete is dispatched, or those who renounce the condition altogether. What about a likely truth in the middle? Bodies exposed to a serious infection and then antibiotics may suffer long-term symptoms as a result of either or both, whether or not active infection is “chronic.” More holistic thinking about such cases expands treatment options, and obviates the need to tie symptoms warranting attention to a specific, controversial diagnosis. There is more to the patient than the name of their pathology.

Effectively addressing the Ebola crisis, now and in the future, can’t just be about infectious disease. It also needs to be about hunger and diet, poverty and culture, ecosystem management and biodiversity. Different, but related ripples spread out from every case of diabetes, and heart disease; depression and chronic fatigue.

Holism tends to bespeak the touchy-feely end of the medical spectrum. And indeed, thinking and treating holistically does tend to result in softer, gentler, more caring care. But there are ways to operationalize holistic care that involve rigorous thinking, and invoke systematic methods. That would serve us well now, as ever. For it may be that in the hardest of all medical situations confronting individual patients and populations alike, the seemingly softer aspects of care are just what the doctor ordered.

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 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.

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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