Preventive Medicine

In the past, I have mentioned that one of the keys to fixing our healthcare system, and more importantly improve people's quality of life, is preventive medicine. I thought it might be good to share what preventive medicine means to me.

As an exercise science major I have studied extensively physical activity's profound impact on our overall health. In fact, increasing physical activity has a greater impact on overall health than any other lifestyle change. All-cause mortality is decreased by increasing physical fitness alone. This is a part of preventive medicine, but it doesn't stop there. Allow me to illustrate using a hypothetical example.

Let's say somebody has numerous gallstones which block the gallbladder and cause immense pain. This pain would lead that person to the doctor's office. The doctor assesses the situation and decides it would be best to surgically remove the gallbladder. This treatment alleviates the pain and the patient goes home happy right? Wrong. This type of medicine neglects the underlying lifestyle which caused the problem in the first place. Let's say that a major reason the gallstones formed was due to obesity. Obesity reduces the amount of bile salts in bile, thereby increasing the cholesterol content. Obesity also decreases gallbladder emptying. Now, the cause of the obesity is the person's high levels of stress, caused by their huge workload, lack of time to exercise, etc. Taking out the gallbladder still leaves the root cause untreated.

Another example is the man who comes into the emergency room with a broken arm. The doctor sets the arm in a cast and the arm heals perfectly. The patient is healed right? Well it turns out that the man has a drinking problem, he broke his arm because he was drunk and fell from his buddy's balcony. He comes into the ER a few months later with another drinking related injury.

Dr. Dan Schmidt shared another great story in one of my previous posts.

Essentially, a specialty doctor quick fixes many people's injuries, but too often the root causes go untreated. I don't really think a universal health care plan will fix this problem. How will free quick fixes give any more incentive for people to make lifestyle choices that will keep them out of the doctor's office to begin with? Preventive medicine helps people make these choices, choices such as controlling their diabetes, their weight, or their nutritional habits.

General practitioners are essential to providing this type of care. GPs see people over long periods of time. They are familiar with a patient's lifestyle and are able to better provide holistic care.

One of the things we need is more incentive for GPs to enter the medical field. Unfortunately, in the U. S., GPs make up only 13% of physicians available to help people. The U. S. is in dire need of this trend to change.

GPs make far less money than specialists and their work environment is far from ideal. Why would I choose primary care when I'll spend twenty years paying off student loans which are pretty much irrelevant to a specialist?

Obama has mentioned that he will help with primary care physicians' student loans. That would be great. Only with more primary care physicians can we really start treating the whole person, practice preventive medicine, and come up with a realistic health care system that is sustainable.

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Altruism

Altruism is self-sacrifice which individuals perform for a cause greater than themselves. These actions often are done despite great personal risk. As such, altruism is a characteristic of much intrigue in science, since at face value it seems to be inconsistent with natural selection. From an evolutionary stand point, one could predict that such altruistic traits would be selected against. Oddly, this doesn’t seem to be the case. Something must reinforce this type of behavior. I believe the driving force behind altruism is to better the world around you. A prime example of altruism is seen in the life of George Frideric Handel. The work defining Handel’s life was Messiah, his most famous piece, yet, Handel didn’t accept a cent of payment for his masterpiece. He donated everything to an orphanage. Interestingly, altruistic acts are not seen to be inconvenient, but a responsibility one shares with the world around them. Perhaps evolution’s hand is at play then, since helpful service would increase the fitness of a species overall.

In my own life I have found great satisfaction in giving of myself to others in need. I did so in a dramatic fashion serving a full-time two year mission for my church. That instilled within me a spirit of charitable service. Later I discovered what that meant in real life. As an undergraduate preparing for medical school, it is easy to fill you time with self-serving activities. These selfish acts can be draining. It is important to have an avenue with which you can escape your own interests and focus on helping others. For the past eight months I have tutored Gerardo, a Mexican gentleman in his late thirties. Meeting twice a week for a couple hours, Gerardo and I study English reading and writing. I have been impressed with Gerardo’s desire to succeed and provide a better living for his wife and children. He recognizes the need to read and write proficiently in English as a tool to better succeed in America. His drive to learn has pushed me to teach him the best that I can. Since the time that we started meeting he has progressed immensely. Being part of this man’s life has been rewarding to me and I enjoy our visits each week. By helping Gerardo realize his own dreams, I find myself more motivated to work towards my own. As one so often finds, my attempt to serve selflessly has ironically given my own life more joy and meaning.

While my desire to serve others comes from my Christian upbringing, I am quite confident that altruism is a consistent personality trait seen across the board. The English poet John Donne observed that “no man is an island. entire of itself; every man is a piece of the continent, a part of the main.” Mankind is connected. One person's actions has an influence on others. This profound insight is telling of man’s desire to help one another. Within each of us is contained an acknowledgment that life is bigger than just one person. In order for society to function properly we must fulfill our responsibilities one to another.

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The Save

Dan J. Schmidt

I started medical school thinking I wanted to be a family doctor--someone who could work in a small town and deal with whatever walked through the door. But in our third year, when we received our first taste of clinical medicine, I found my surgery and ER rotations exciting. I was at our state's major trauma center, and I loved it. Fixing things gives me a thrill--and the power to save a life is even more alluring.

Each "save" felt like a miraculous triumph. Take the nineteen-year-old visiting Australian, stabbed in a random street altercation, his blood pressure dropping as fluid accumulated around his heart. Right there in the ER, he had his chest split open and his right ventricle patched by the very cool chief surgery resident.

But after several weeks of 5 a.m. surgery rounds and every-third-night call, I started to feel a nagging sense of unmet need, both my own and the patients'. To me, it seemed that the specialized care we were giving was excellent but fractured: No one was responsible for the whole person.

It was 8 a.m. during my third week of the rotation. The third-year resident had led us medical students through our rounds, and there'd been time for some drug-rep doughnuts before we headed down to the ER. At the nursing station, we joined those who'd been on call the previous night and were sharing their war stories.

"You shoulda seen what we just got!" said one of the students.

A twenty-something guy had come in with a near-amputation. "He cut off his arm with a Skilsaw!" (the powerful circular saw used by professional carpenters and builders). "He's down in the OR now. Orthopedic surgery thinks they can reattach it."

After the descriptions of the bones, the x-rays, the blood loss, I asked one student, "Which arm?"

She frowned. She didn't know. I looked at the x-rays. It was the right.

I caught the gaze of a third-year surgery resident and asked, "Do you know how hard it is to run a Skilsaw left-handed?" (It's a lot harder than scissors. I knew: I'd spent a year building condos before I'd entered medical school.)

The resident nodded. This injury was no accident.

That evening I heard the orthopedic surgery team talking about how happy they were with their neurovascular and bone-plating work. It looked like the patient's hand would be saved. But they were aware of his psychiatric risks: He was being kept in restraints until they could get a "full psych eval."

The guy was in the post-operative ward; when I'd gone around to check on my patients, I'd seen him. Straight black hair. Intense gaze. Cold affect. Girlfriend sitting at the bedside, then leaving in tears.

The next morning, the psych team came by to evaluate him. They started him on an antidepressant, but thought that he was no risk to himself.

Coming back from lunch that afternoon, I heard stat pages overhead, calling the chief ortho resident to a "thrash" on the post-op ward. Hurrying down the hall, I saw a bed barreling towards me, pushed by three residents. A nurse knelt on top of the patient and his bloody sheets, pressing her hands hard against his arm as they steered the bed into the elevator.

"What happened?" I asked the senior resident.

"He pulled it off! All that work, and he just pulled it off!" he raged.

Before the elevator doors closed, I heard him say, "Damn if we're putting this back on again! He'll get what he wants!"

And off they went, back down to the OR.

I went to his room. There were fine blood spatters everywhere, and a big, dripping arc across the far wall. The Filipina housekeeper quietly mopped the burgundy-stained floor, shaking her head.

A technological success. A medical catastrophe.

We had treated this man's injury, reattached his limb, evaluated his psyche--but not one of us had tried to care for the whole human being. It seemed that our academic and specialized-care system had accomplished a wondrous feat of technological prowess, but didn't foster a focus that could actually heal the patient.

Standing amid the gory mess left by a man I didn't know--a man who seemingly wanted not to be whole--I realized that I wanted to treat the whole person.

So I decided to stick with family medicine and left trauma and surgery behind.

A save still thrills me, although in family medicine they are thankfully rare. I get to keep my eye on the big picture. And I'm rewarded by a constant stream of quieter saves--the type 2 diabetic patient who loses fifty pounds, the alcoholic who's been dry for a couple of years now, the young single mother who's learning to raise her infant well.

These triumphs, bloodless but still lifesaving, keep me going.


About the author:

After seventeen years of practicing full-spectrum family medicine, Dan Schmidt now covers small-town practices on the weekends. Married, and with four grown daughters, he also fixes old cars and remodels houses--yes, sometimes using a Skilsaw. "I find that writing eases my need for reflection." This is the first of Dan's stories to appear outside of his Web site.

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Obama's Health Care (my optimistic skepticism)

I haven't blogged in quite a while. The time I usually spend blogging has been displaced recently by some really great books (see my updated book list to the right).

An issue on my mind these past few weeks, which I feel affects everyone (especially people in the health care professions), is health care.

Now, I don't claim to be an expert on public health, so keep in mind my thoughts are still being developed (in other words correct me on things you don't agree with). That is the main reason I blog, to develop my thoughts and build stronger opinions.

Obama says his new plan will cost one trillion dollars over the next ten years. He presents a plan as to how he will pay for it. I think this is all well thought out, and I was impressed by many of the ideas he presented. My first point of skepticism is that Obama seems to avoid explicitly stating that doctors will personally pay for a great deal of the new plan. How will this affect our health care system? Many know that to become a doctor takes way more work than it is worth (money wise), should we reduce this already meager motivating factor for quality people to pursue a career in medicine? I don't know.

Second, I think the unspoken truth behind Obama's plan is that having a public plan will create a monopoly, effectively getting rid of private insurers. How can a private insurance company, which complies to the rules and regulations the government puts on it, compete with a government option which makes its own rules? Again, I don't know.

That all said, I love that Obama recognizes the need for more primary care physicians. These are the physicians that get deep into debt in medical school and have trouble getting out. These are also the most important doctors when it comes to preventive medicine, in my opinion one of the most important keys to solving many of our health care problems.

I am glad Obama is aware of Gawande's article on health care. If you haven't read that yet, take some time to read it. I think the observations he made are crucial to understanding health care reform. Indeed his piece has changed the way I approach a solution.

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