Implicit in all of the plans currently being debated in Washington is the concept of prevention. If you drop all the noise and clear the smoke away and remove the mirrors, the underlying philosophy for all of these grand visions is that eventually, after many steps and many new processes that are to be put in place, the real value of reform will be evident in the enormous cost savings that go along with halting the process by which people go from young, healthy, productive members of society to older, noticeably less healthy, and more resource intensive sick people with much less value. The enormous speed bump that is supposed to slow, or even abate this progression is preventative care. The reasoning is sound on the surface: inform people of the the things that are bad, that will cause them ill-health, that may add risk to their lives, and then, these people just stop those things and the process is halted. The smoker stops smoking, the obese person stops eating, the motorcycle rider gets in a car and presto a life saved here and one saved there and we are off to the races.
Its all pure gibberish. We are doctors and some things we just know. We might not be much better at remembering our spouses dress or pant size, we might be just the same as everyone else when it comes to social graces and even worse than others when it comes to business sense (as the folk legends go), but there is one thing we know and know it better than almost anyone (except ANY parent of a toddler) people simply have a mind and a vision and plan for their lives that may not be the same as the one we have in mind for them. People are often not very interested in doing what is best for them. They may intellectually understand what is best for them, recognize that abusing drugs, or eating badly or whatever may one day cause them great harm, but as a point of fact, they just might not want to do anything about it. Let this all sink in for a minute. Doctors are the only profession on Earth that have as the main goal of their efforts to eventually put themselves out of business. We want to heal people so that they do not need us any longer. This is the essence of our world trying to coax, explain, goad, draw, drag, pull, beg, plead convince people that we can help them they just need to listen to us and let us do our doctor thing. We have news for you its really not so easy. In medical school we learn of compliance issues with patients (doctor babble for people who do not take their medications or watch their diet or stop some behavior). In reality, we learn about human nature. People are complex and the combination of three basic, overarching, enormous factors play differently to different people for all sorts of reasons. What are these factors?
1. Biology. We are born, we age, we die. This is really the deal here. We can slow, but never halt this progression. Aging is not simply the passing of time in biology. It is the lessening of our physiology, the diminishing of our internal processes: our blood pressure gets harder to regulate, our cells do a worse job of repairing damage, our tissues are less resilient and less adaptable. Our skin wrinkles, it gets thinner, our cells accumulate errors that lead to their death or worse, to aberrant growth (skin tags, age spots, cancer), our hair follicles stop working and they fall out or the pigment changes from a lovely shade of auburn to a steely gray. Our bones lose minerals and get weaker, our vision gets worse, our heart muscle gets thinner and our organs struggle to do the work that they have done every second of every minute of every day for 50, 60, 70, 100 years. We age. Biology always wins. Here is the rub though, this win is so very different for each person. I age badly, you age well, your friend never ages, your mom aged so fast. At 40 I have a bad knee, you at 70 have perfect knees. Biology is all about variability. Question One for the interested reader: how does one apply a preventative recipe to this mixture of variability? Do I give a magic pill to everyone at 40 so as to prevent arthritis? Really? Why what if I may not get it, or worse, you already have it by the time I give it you the pill? Biology always wins. And she wins in an infinite variety of beautiful, morbid, sad, wondrous, tragic, slow ways. But she ALWAYS wins.
2. Behavior. You see a cliff and decide you have to climb it, or get to the top and parachute off of it. I see the same cliff and run for cover of the flat of my yard. I see a motorcycle and say never in a 1000 years while you hop an and go as fast as the throttle allows. I tell my patient to stop eating so much they look at me and tell me that they dont eat enough. I tell my patient to eat more vegetables and fruits and less candy and soda and they see a cliff that needs to be scaled or a motorcycle that needs to be ridden. There is a catch though (isnt there always?). These behaviors change as our biology marches us forward. My patient is going to become a father and sells the motorcycle and buys a Volvo. My patient loses a mother to cancer and starts to eat vegetables for the first time. What we value in life is not static, neither the things themselves nor the value we assign to them. So Question Two for the interested reader. How do I convince a group of 20 year olds to shun soda and pizza? One way is to wait until they are 50 much easier. Short of that, if you have an answer then you may likely win a Nobel Prize. Just as a few 20 year olds may value similar things similarly, no group of 20 year olds will value the same things equally as another group. Preventative advice to these people may just be their version of me ruining their day or raining on their parades (sounds alot like parenting, no?).
3. Risk. This is where all the marbles (or dollars) are. Assuming you actually agree that prevention is possible after getting through points 1 and 2 above, we get to risk. This one is simple to understand, but like something fundamental (like the mass of a proton) it really controls everything (if the proton mass were different in any way, matter as we know it could not exist amazing but true). Go with us on this one
-We all agree that preventative measures are a great idea so we sit down and come up with some.
-We all pick ones that look easy: over-eating, drug abuse, exercise.
-We get with the doctors and get them on the wagon and tell them to advise away make those things better prevent away!!
Okay, now what? Thats Question Three.
Well, there is more to prevent of course. We see that motorcycles cause lots of death and injury, so lets stop that. We see that eating highly refined sugar does the same, so lets stop that. We start to note that people who swim in the ocean seem to get sicker than others and surfers suffer more head injury that non-surfers and people who walk are healthier than people who drive and people who exercise once a day are healthier that those who do so once a week. Where do we stop? What is unacceptable behavior to us (our committee assigned to come up with this prevention manual) is perfectly acceptable to someone else (see #2 above). Why is it acceptable? Because even though the chances of throwing a 3 on a fair six-sided die is 1/6, I may choose to wager the house and kids on that bet and you may not so choose. If I am told that riding a motorcycle increases my chances of serious injury 10 fold I may sell that Harley the next day and you, may be the buyer. We are human and we balance risk with what we sense or wish the reward to be. That balance is so very personal and so unique that it is so very easy to encounter a person who finds nothing abnormal or wrong or dangerous (risky) with riding a motorcycle to and from a bar for happy hour and then smoking a half pack of cigarettes before engaging in unprotected sex with multiple partners before going home to his wife. Its also easy to find someone who would find that string of living absolutely unacceptable. Risk, like beauty, is in the eye of the beholder.
As an aside this risk issue lies at the center, the absolute center, of why any national plan for what to cover for sickness and at what cost is pure folly. I would not think it a good idea for the Plan to cover a $1,000,000 experimental treatment that has a 10% chance of extending a cancer-ridden life by 6 months. Unless, of course, that life was mine, or my sons or my dads. Funny, that. But we digress.
In the end, even if one could choose a slate of things that we would proffer as prevention (#3 above), actually getting someone to care (#2) or even necessarily have it be useful to them (#1) is hit or miss. Again, how do we KNOW this to be true? We are doctors and the above maze of complexities is the essence of our day. It is actually what we mean when we say we had an office full of patients, or an OR full of cases. We mean people who we are either seeing at the front end of this gauntlet, or the back end.
Case in point. Today, in my life, in my hospital, my patient.
A 62 year old man. He appeared to look 82. He has diabetes, high blood pressure and has suffered two heart attacks since 2000. We met him because he needed surgery to repair the damage these disease had wrought on him. He rarely took his medications. He never exercised. He drank. And smoked. He never bathed, and I dont mean sometimes, I mean never. He was sick. His feet were numb from the diabetes, he was weak from lying around the house and his heart was in sad shape. He is 62.
There are two related but discrete things to think about now: First my job was to help this man. Not judge him, punish him, lecture him. He needed surgery and intellectually I may think that all of this could have been prevented, but it wasnt and here he is. So, I did my job and gave him the benefit of 15 years of higher education and learning and caring and skill. Bravo for me not at all. This is actually my job. Second, and more troubling. When pondering the plans being bantered about for Health Care Reform, what is the ultimate incentive Mr. Obama would have us dangle in front of this man say, oh, 20 years ago when he was healthy and fit and happy. Should I advise him to live well and long and tell him how and then just cross my fingers he listens? If he rejects my words, 20 years later he still gets care and damn good care at that. Should I tell him that he wont get that care? Should I tell him I will penalize him somehow? How, HOW will I get him to listen to me? At the end of the day whatever people choose, doctors all over the country show up to work and care for people like this as I described. This is our job.
People know this. So, unless we are prepared to tell them that perhaps this care may be withheld from them if they choose their own path, we are powerless to do anything. Prevention, in the final equation, is a personal choice. Many people will choose to go along, some, perhaps many, will not. Either way, the woman who did it all the right way; who ate the right things and exercised and slept long hours, and avoided the bad stuff and did all the good stuff will find herself in a recovery room bed or hospital room right next to the man who did it all wrong. The man who ignored our advice, ate whatever they wanted, lived the life they wanted to live. And at that moment, two things will be true: the system that put those two people in such close proximity will be unchanged from what it is today, and those people will finally know the true value in having doctors that do one thing and one thing very, very well:aim to heal the person sitting right in front of them without judgment. Two parallel but opposite lives with two different slates of choices, but in the end, both succumb to biology and time and those choices. One did everything right and we feel sad for them. The other did it all wrong. Guess what, we still feel sad for that person too.
Prevention can, and will fail to prevent. We better recognize this before we invest our hopes into this black hole of a concept and then wake up one day and find that instead of feeling sad for that reckless person who ignored all our good advice, we instead punish him and tell him we told you so big man and send him back to his path and away from the help that we are so desperately trying to provide to everyone with this current debate.
Republished from Linked IN.