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

Friday, September 9, 2016

Politics, propaganda, and perspective: how preventive medicine pertains

In any political campaign season, fidelity to facts is often sacrificed for the persuasiveness of propaganda. In this campaign season of roiling discontent, that is only all the more so. In particular, the identification of every act of terrorism or violence as a systemic failure of the current power structure is as specious as it is seductive. Preventive medicine can lend some very relevant perspective.

As a board certified preventive medicine specialist, I know full well the major liability of my field. No one gets much credit for what doesn't happen.

There are no tears of gratitude from family members because father or mother, sister, or brother did not have a heart attack. There are no cards on your office wall expressing abiding thanks for the stroke that never occurred. No crayon drawings of adulation from children who grow up without type 2 diabetes because of some policy or program. There are no philanthropists eager to support you in any way you ask because you saved their life, or the life of someone they love. Perhaps you did just that, but if you did, they certainly don't know it happened, and you may not even know it yourself.

Such is the thanklessness of prevention, but it's a price well worth paying. The field of preventive medicine has brought us cancer screening programs that save thousands upon thousands of lives, and immunizations that save millions. Luminaries in this field are why we need no longer fear such one-time ubiquitous perils as smallpox, and polio. And, of course, in the modern era the relevant efforts continue to address immunization and infectious disease, cancer screening and interdiction, while shifting ever more to an emphasis on lifestyle as medicine in the prevention of cardiometabolic and other chronic, degenerative diseases.

There is a direct analogy between such efforts and their often-unrecognized utility, and the work of homeland security, with all of its reverberations into the current, noisome political campaigns.

Let's revisit immunization. You have surely heard the false contention that vaccines cause autism, and have likely been tempted to believe it. You have doubtless heard the true indictments of the 1976 swine flu vaccine, one tainted batch of which caused cases of Guillain-Barre syndrome. But can you say how many lives have been saved with the MMR vaccine, or the flu vaccine? Can you even hazard at a guess at the ratio of infections prevented, or lives saved, over a given recent decade, to unintended adverse effects?

I am guessing you can't, because I can't, and it's my purview. I could look up the figures, but I don't know them off hand. What I do know is that those ratios are enormously favorable. They are likely in the general domain of millions to one, and reliably well into the many tens-of-thousands to one.

And yet, it's the “one” that makes headlines, and grabs our attention. The number of cases of measles prevented by that vaccine does not make news. The discredited claim that the MMR vaccine causes autism makes news again, and again, and again.

Similarly, we are unlikely to have any idea about most threats of terrorism that never come to fruition. Every now and then we hear about such a threat, interdicted when near to full maturity. But given the nature of prevention, most such crises are surely averted at earlier stages, entirely unconducive to drama. There is no drama, there are no headlines, and we are none the wiser.

We are, of course, unlikely to live in a world where no acts of terrorism take place, now that there are sizable entities with considerable resources dedicated to the perpetration of just such acts. It might be possible to achieve perfect interdiction in a fully militarized state, but the loss of liberty would be far too high a price to pay.

Similarly, we are unlikely to live in a world where civil liberties and privacy are fully unfettered. There are real dangers to contend with here. Were we to renounce all security for the sake of unmitigated liberty for all, we would be taking our lives in our hands at every gathering we attend.

In health and security alike, we are seeking the sweet spot. We are aiming at a ratio of effective prevention to occasional lapse that rightly balances the advantages of interdiction with the costs, sacrifices, and inconveniences with which we are willing to purchase them.

But ratios and balance and realistic compromises are not the stuff of campaign bravado. Nor are they the stuff of headlines, and there are papers to sell and air time to fill every day. Failure of preventive efforts unfailingly gets the spotlight; success is consigned to the shadows.

Consequently, we will certainly know about every act of violence and terrorism that makes it through the existing filters, just as we will know about every screening test or vaccine gone awry. How easy, then, for anyone inclined to demagoguery to point an accusing finger at any evidence of current failure, blame it on those currently in charge, and promise us a world free of it- although invariably without any cogent explanation as to how.

In politics, this is how we tend to roll, and everyone seems to accept it. No doubt far too many are actually persuaded by the captivating combination of misdirected blame, and unsubstantiated promises.

But imagine for a moment if medicine worked this way. With every case of colon cancer, there would be an argument to abandon colon cancer screening altogether since, obviously, it had failed! The occurrence of breast cancer would propagate arguments to abandon mammography, rather than efforts to improve it. Opposing medical factions would blame bad outcomes on one another, and make vague promises about alternative approaches that would provide perfect results. We, the people, would favor first one group, then another, only to be disappointed by each in turn.

Whether in defense of the human body, or of our collective security, the best we can do is the best we can do. It involves tradeoffs between protection of life and limb, and protection of comfort, convenience, and civil liberties.

If inclined to think that someone else should be in charge because those who have been haven't prevented everything bad, ask yourself what you actually know about how much bad stuff has been prevented. The answer, inevitably for those of us without high-level security clearance, is: we don't know much. We might well be living in a world of six-sigma security, yet only know about the 1 failure in a million.

In my field, news not made by things that haven't happened tends to be what matters most of all. In a troubled, complicated world of terrorist organizations, much the same is apt to be true of our security.

Preventive medicine invites us to consider the importance of what does not happen, along with that of what does. In so doing, it might help us see past the distortions of political propaganda and false promises of perfect success, to a balanced perspective about balancing priorities, and the best we can do with that reality.

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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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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