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

Friday, November 21, 2014

Unscrambling our eggs

I recently saw a patient in my clinic who made me think about the many other patients like him I’ve treated over the years. He had a rather dramatic family history of heart disease, and had himself undergone coronary bypass surgery before his 40th birthday. He had, of course, seen many doctors before me, including all those directly involved in his surgery. But nonetheless, he traveled a considerable distance to see me and get my advice.

We may reasonably leave out the particulars of pharmacotherapy, and merely state the obvious. Since he was very overweight, he needed to lose weight. Since he didn’t exercise, he needed to start. Since he didn’t eat especially well, he needed to eat far better. In other words: well, duh.

While both you and I might understand why someone already working very hard to eat well and be active might seek out expert guidance on how to do even better, I trust you see the anomaly in this case. Why would anyone need expert guidance to start using what essentially all of us already know about lifestyle as medicine? More fundamentally, with a compelling family history of heart disease, a host of very obvious risk factors, and even an entry-level understanding of the link between those risk factors and their potentially calamitous consequences, why wait until after bypass surgery to consider doing something about it all?

This patient, as noted, made me think of other patients like him; in particular, one whose story I tell, calling him by the pseudonym “Doug,” in the first chapter of Disease Proof. But this patient, and Doug, and all the others like them, made me think of Ebola. In their cases, it was a body in danger. With Ebola, it is the body politic. In both cases, a penchant for attempting to unscramble our eggs is on display.

As noted in a column by Dr. Steven Osofsky, executive director for wildlife health and health policy at the Wildlife Conservation Society, published yesterday by CNN, we know a lot about the origins of Ebola outbreaks, just as we know a lot about the origins of heart disease. Unlike virtually all of the Ebola coverage inundating us at present, half of which is telling us not to panic and the other half telling us why we should, Dr. Osofsky looks beyond the current outbreak to its root causes. There is a proud history of that very method in preventive medicine. Root causes tell you what you can and should fix not just now, but so that the current crop of bad news isn’t replicated any time soon. That’s the benefit of getting to the roots.

The roots of the Ebola outbreak reside not with the arcane biology of exotic viruses, but the mundane behavior of hungry people on an overcrowded planet. In parts of Africa where other food sources don’t meet the need of populations swelling ever more into wildlife areas, hungry people wind up catching and killing wild animals for food. Their choices can be rather indiscriminate, and include both bats and primates. Such exposures are how Ebola first infected humans. Much the same is true of HIV.

I won’t repeat here the insightful, clear recommendations Dr. Osofsky offers for addressing this problem at its origins; I commend his column to you for that. I will note, as he implies, that failure to learn from the follies of our history may well destine us all to endless repetition of them. There are many other animal viruses we have yet to encounter. In a world of business as usual, where bush meat is the only way to fill the bellies of hungry people in rural Africa, we will inevitably find them, in the worst way possible.

So, at the moment, it is Ebola. It was once the high waters of hurricane Katrina on the low ground of New Orleans. Or the mostly undefended stretches of Jersey Shore in the face of Super Storm Sandy.

It could also be the high temperatures of global warming. Or the high threat level on our color-coded scale of terrorism. It might just as readily be the low rainfall in California, and the desiccation of aquifers.

It might also be Doug’s many risk factors for heart disease; or your own.

The common theme? The risk of crisis portended by warning signs all too often neglected. In the case of wayward biomarkers such as cholesterol, only somebody is harmed by that neglect, although that’s small comfort if the somebody is you or anyone you love.

In the case of Ebola and Katrina, it is the body politic. In all such cases, bodily harm tends to ensue from willfully mindless neglect of the obvious.

That’s what we do, bodies and the body politic alike: wait for catastrophe, then scramble.

So it is that Ebola, a preventable catastrophe like so many before it, is upon us. Even as we address it, we should be considering the root causes, and directing resources there to prevent the next outbreak, potentially, of something even worse. At the roots, ounces of prevention will do. Once the next calamity germinates, even pounds of cure may not suffice.

The best treatment of any disease is its prevention. The best response to any crisis is its aversion.

Alas, we, anybody and the body politic, alike, seem to harbor an aversion to just that approach. We are forewarned again and again, but never quite manage to be forearmed. We wait for the inevitable fall, then dash in madly to unscramble our eggs.

By all means, let’s do what we always do: call in the King’s horses and the King’s men, at the customary high cost in dollars and human potential. And why not, while we’re at it, go ahead and cross our fingers.

As for those good eggs lined up atop that wall over there, wavering in the wind, well, pay no attention to them. I’m sure they’ll be fine.

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.

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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