Wednesday, May 13, 2015

Just Along for the Ride

Admit it: when it comes to our health, most of us want something done to/for us.  Give us a pill, a procedure, a test.  We don't expect to leave a doctor's office with something we're supposed to do (like eat better or get more exercise), or, if we do, all-too-often we end up ignoring it.

If managing our health was like driving a car, most of us would be in the passenger's seat, maybe even the back seat.

I was reminded of this analogy when I read Atul Gawande's latest provocative piece -- Overkill -- in The New Yorker.  In it, he describes the "avalanche" of unnecessary care that our health system generates.  Nothing he talks about should come as a surprise to anyone who only even mildly follows health care, but yet the problem remains.

At least we're talking about it (including, I'm pleased to remind readers, a post I did last month).  

Dr. Gawande recaps some of the recent research on how much unnecessary care there is, which always tend to end up in the ballpark of about a third.  He did a sample of eight of his own patients' histories, and found that seven of them had, at some point, received what he believed was clearly unnecessary and/or inappropriate care.  It might have been a small, non-random study, but the point is that eventually we're all likely to be subject to such care.  Most times no real harm comes of it, but it only takes one bad outcome to severely impact our health.

He cites the examples of the hundreds of millions of scans and billions of lab tests, noting that: "Often these are fishing expeditions, and since no one is perfectly normal you tend to find a lot of fish."  That can lead to more testing and possibly procedures, and sometimes to damage from them (e.g., radiation exposure from excess CT scans).

I also liked Dr. Gawande's discussion of our we treat cancer.  He refers to H. Gilbert Welsh's Less Medicine, More Health,  Welsh believes that we treat cancers as rabbits, which we want to catch quickly, when in fact many are more like turtles.  They're not going anywhere, at least not in any hurry.  With our vastly increased testing we're finding more cancers at an early stage, and both patients and providers tend to want to take action.

Early detection is not always better.  Dr. Gawande points out the example of thyroid cancers.  We've tripled the detection and removal of them in the past two decades, but haven't impacted the death rate at all.  Maybe those patients' quality of life has improved, but many of them faced anxiety and procedures that weren't necessary -- and that may have caused harm.

The reasons for the over-treatment is no surprise.  As Dr. Gawande says, as a physician, he's more worried about doing too little than too much, since it is the things he should have done that come back to haunt him.  Plus, of course, most of our providers still get paid for doing more, not less.

And we just allow this overkill to happen to us.

I was further reminded of the passenger metaphor when I recently read Missing Microbes, by Martin Blaser, M.D.   Dr, Blaser makes the case that many of our "modern plagues" -- obesity, diabetes, allergies, asthma, and many others -- may be attributable to the disruption in our microbiomes caused by overuse of antibiotics.

For anyone in need of a quick refresher, scientists have found that our bodies are thoroughly colonized by hosts of bacteria.  Indeed, it is estimated that 99% of the unique genes in our bodies actually belong to "them," and only 1% to "us."   Our guts are a particularly rich area of concentration for bacteria, but virtually every part of our bodies has some.

Since we began using antibiotics in the middle of the 20th century, we've increasingly become exposed to them, allowing us to beat back infections that once would have killed millions.  They've been a blessing, but may also be a curse in disguise.

The problem of antibiotic resistance, in which continued exposure to antibiotics creates strains of bacteria resistant to them (e.g., most recently typhoid) is now well known, but Dr. Blaser believes an even more important but less obvious problem is how we're disrupting the ecological balance bacteria and our bodies had achieved throughout our mutual evolution.

The book documents some of the evidence for the association between changes in the microbiome and the various "lifestyle" epidemics that we are experiencing.

If it sounds crazy, remember that until a generation or so ago it was "known" that ulcers were caused by stress, and were treated by trying to reduce stress, change to bland diets and sometimes surgery.  In the 1980's evidence began to accumulate that a bacteria called H. Pylori was actually the culprit most of the time, so we started treating ulcers by attacking it.

Just to show how complicated the balance is, though, it appears that reducing H. Pylori may help mitigate ulcers but that may then impact stomach cancer or esophageal diseases like GERD.

Dr. Blaser was a pioneer in stressing the importance of our microbiome, and his views are not yet conventional wisdom by any means, but others are joining the band wagon.  Just this week researchers at the University of Minnesota confirmed a link between antibiotic use in infants, changes in gut bacteria, and disease later in life.  They aren't the first researchers to support Dr Blaser's views, and I suspect they won't be the last.

So when I describe us as passengers in our health, it's not even clear who "us" is.  Much of what we think of as our health may rely on the health of millions of bacteria in our microbiome, which modern medicine has long been treating as dangerous interlopers.

Dr. Blaser's work suggests that we may need a new paradigm about what produces good health and how to best achieve it.  Last fall I speculated on a health care system without doctors, or at least with less reliance on them, and treatments centered around the microbiome was a prime example.

Dr. Gawande sees a health system much like our current one, but with a more judicious use of care.  If Dr. Blaser is right, the health care system of the future might look and act very differently.   In either event, when it comes to our health, we need to be more than along for the ride.

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