IV. A Half Century Of Change

(and sometimes progess)

Next in our rankings are the Blockbusters, those happenings which got much of our attention and made our jaws drop slightly.

SCANNING TECHNOLOGY INVENTED

Young readers may have a hard time getting a handle on this, but scanners (CT, MR, PET, etc) have not always been available to help diagnose tough problems. In truth, the scanning revolution would not have happened without the development of desk-top computers. Xray equipment had already been developed which could focus on tissues at different levels within a body, but interpretation of the information gained was not easy. The combination of computers and the ability to take xray images in layers was a natural, but the timing wasn’t right until 1970. Scanning has taken physicians’ diagnostic burdens and lightened them to an amazing degree. Our only problem now is that we tend to overuse scanners and underuse our other diagnostic abilities, to the detriment of the medical expense bottom line. Scanners play a huge role in defensive medicine, a topic to be discussed later.

EFFECTIVE BP MEDICATION DEVELOPED

The health toll due to elevated blood pressure has always been very high. Early death or disability due to heart disease, kidney failure, and strokes was until the middle 1960s the expected and unalterable outcome. Drugs to control high pressure were led onto the stage by diuretics, which made patients unable to pass a rest-room, but lowered the BP well, if not perfectly well. Although we don’t to this day know exactly why diuretics work, studies have shown that their use is associated with more disease-free years than allowed to patients not similarly treated. In succession following diuretics, we were presented with beta blockers, alpha blockers, calcium channel blockers, ACE inhibitors, and AR blockers. All members of each group possess similar mechanisms of action and side effects, but may have different characteristics such as long or short duration of action. As each new drug comes on line, it bumps the cost of care up, even though older agents may do an excellent job as well and cheaper. Controlling hypertension presents a huge opportunity for pharmagiants who are not dummies when it comes to marketing.

MAMMOGRAPHY DEVELOPED

The accepted method of evaluation and treatment of breast lumps found in all mature women prior to 1970 was the following: Biopsy performed under general anesthesia, an immediate tissue examination by freezing and staining the tissue, and then, for those positive for cancer, and without awakening the patients, a radical surgical mastectomy. Talk about Dark Ages! Not to mention the horror of this sequence of events, there were other problems of major magnitude, including erroneous diagnoses, postoperative disabilities both physical and mental, and then the crowning blow– studies which showed that in most situations, radical mastectomy was only a little better than doing a generous biopsy. Mammography put an end to parts one and two of the above sequence, and led to better biopsy methods which helped us get where we are now. In 2007, a woman with a suspicious finding on mammography can be evaluated fully and diagnosed accurately prior to making therapy choices with the aid of her physicians.

SMOKING'S LINK TO MANY DISEASES ESTABLISHED

A favorite teaching doctor in my medical school training years smoked everywhere except patients’ rooms. He was a young, active, dedicated man, who died before he reached 60 years of age. The association between smoking and emphysema was made in the late 1950s, but had been suspected for a long time. Definite links between cigarettes and lung cancer came later, and, still later, their ability to damage coronary arteries. The bladder cancer link was demonstrated about 1975, but smoking and strokes (particularly those caused by carotid artery disease) weren’t associated until the 1980’s. At about the same time, we all became aware that, in regard to smoking and vascular disease, any place in the body was fair game, from the largest arteries in the legs to the smallest arteries in the eyes, kidneys, and heart. Technology has permitted us since 1990 to rescue many smokers from their destined fate at huge expense and with a large amount of persistent disability. If cigarette smoking were to disappear magically tomorrow, twenty years later it would be possible to close many ICUs around the country, and put a lot of oncologists and cardiologists out of work.

PATIENTS AS ADVERSARIES, THEN AS EQUALS

In 1960, a new physician could expect a pleasant relationship with his (not very many physicians at that time were female) patients. The paradigm of benevolent and all-knowing doctor with grateful patient had existed for centuries and was destined to do so until the great medical awakening which occurred in the 70’s. It happened coincident with women’s fight for equal rights, for good reason. Women were always treated with a pat on the head and a comment, “Don’t you worry your pretty little head –etc”, and Gloria Steinem taught them how to revolt. Formerly acquiescent patients now arrived in exam rooms armed with lists and jutting jaws, plus the ready comment, “I know my body better than anybody, including you!” Men, often slow to catch on, never made such a comment in my hearing, although some may have secretly wanted to. The end result for most of us is a more collegial doctor / patient relationship rather than a Socratic one dominated by lectures and nodding heads. One might conclude rightly that this paradigm shift was partly caused by the entry into medical care of more and more women, who have always been better listeners.

MONITORING AND ICUs

Fifty years ago getting an electrocardiogram was a major event and interpreting it a labor intensive process. ECG readers were often swathed in yards-long strips from the machine which they studied using calipers and intuition. For a heart attack patient in a general hospital, an ECG might be done daily at first, then less frequently as the situation seemed to dictate. Thus doctors and patients held their breaths hoping that tomorrow’s recording would not show anything bad, or worse, that some unusual event with dreadful portent or outcome had taken place during the night. After President Kennedy suggested we take a trip to the moon, the die of change was cast. NASA, or whatever it was called at the time, got scientists working on methods to monitor the vital signs of young men hurtling through space in small capsules. Their success led to the now routine practice of constant electronic monitoring of all potentially precarious patients. For years, the monitors have had loud beepers to awaken distracted caregivers to possible life threatening changes in a person’s condition. Doing this in a special care section offering close patient scrutiny, the Intensive Care Unit in all decent hospitals, improves the odds for good outcomes. Combined with CPR, monitoring even before an ambulance gets to a hospital, has decreased millions of unnecessary and unexpected deaths.

MALPRACTICE CRISES AND DEFENSIVE MEDICINE

Gone forever are the days when an exam room was just an exam room, not a figurative courtroom with a nervous physician facing an aggressive plaintiff’s attorney. Malpractice “crises” occur regularly, with the first coming about 1970. Multiple causes are: true malpractice by physicians and hospitals with sharp tools, not all of them surgical; physician arrogance / paternalism; provider carelessness often related to overwork and fatigue; unrealistic patient expectations; patient avarice; too damn many attorneys looking to make a killing; and no reliable method for admitting then correcting mistakes which are bound to occur in the real world. Defensive medical practice, in which every test or consultation imaginable is ordered for the sake of the doctor and not the benefit of her / his patient, is the monstrously expensive accompaniment to out of control malpractice torts played to a tune performed by trial lawyers. Beyond the cost of this activity is the magnitude of the loss of trust and the development of healthcare adversary-ism which has taken place. It is difficult to wage a battle against our common enemy, disease, when we are circling each other like rival wolf packs.

REPRODUCTIVE TECHNOLOGY

Despite proof that humans figured out how to maintain the species about the time Lucy was trying to stroll on two legs, some would-be parents have been left barren. It’s “barren” no more, thanks to two major developments - drugs to induce ovulation and instruments to remove the eggs thus produced by the subject female (not necessarily the titular mother-to-be). From there on the steps are relatively simple. Mix in some spermatozoa, incubate the mixture a few days until fertilization occurs, and put the result(s) into a handy uterus. Initial attempts to cover all possibilities of failure by implanting more than just a couple of eggs thus fertilized resulted in mega-pregnancies. The offspring were not always in the best of shape, and some families are having to cope with children who, quite simply, never got a proper chance to develop in utero. Current recommendations call for implantation of no more than two fertilized ova, and the days of circus-like presentations of huge mamas giving birth to multitudes, like ant queens, are probably over. The techniques for creating designer babies are tested and could be used now. Whether this is a good thing remains to be seen.

A PILL FOR EVERY SYMPTOM

Symptoms are feelings, held by an individual, that something somewhere in the body or mind is not quite right. Often there is pain, but the perturbation could be anything from crawling skin to dancing visual arrays to sensations of unworthiness. Physicians practicing during the first half of the last century had it easy. When Jack or Jill arrived in the office with a symptom for which there was no available treatment, they could be sent off with a pat on the back plus the sincere hope that the symptom not prove to herald a fatal condition. There’s a bit if a shift in that position now, caused by all the parties involved; providers of healthcare, consumers of healthcare, and those who invent, produce, and sell treatments for previously untreatable conditions. Providers would like for their customers to get off their backs and get well; consumers would like the same thing, only they want it faster than the providers; and, finally, those who make and sell the pills involved would like to enjoy a tidy profit. Thus, we are now an egregiously over-medicated population, because all of us are led to believe there is indeed a pill to take away every undesirable symptom. To determine who is at fault, each one of the big three need only look in the mirror.

CARDIAC CATHETERIZATION

It has been said that the first person to catheterize a heart did it on himself. Whether this is true is immaterial to this discussion except as an, “Ugh!” item. The procedure extended diagnostic capability leading to better preoperative evaluation of patients with congenital or valvular heart defects, and it paved the way for angiography (and subsequent angioplasty) of the coronary arteries. Any hospital which offers acute care for cardiac problems now has a catheterization suite which is likely to be well used.