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Op-Ed: On Medical Ideologies & How Our Thinking Has Changed

A Review of Poignant Ideological Shifts in Medicine

Most of you have lived long enough to see pilot sunglasses and wide ties come back. I am sure the hula-hoop is not far behind. More aware of the ebbs and flows of human thought we do well to take any belief or ideology with a grain of salt; it is sure to be replaced by some other “higher truth” until the next one comes along. Science would like to think its pronouncements are cast in stone. Sadly, this is not the case. Scientists are also influenced by the ebb and flow of public beliefs in their cultures.

Two recent articles caused me to reflect on these things. One, The Birth of Cooperation discusses our species’ urgent need to cooperate, a concept that has taken second banana status to survival-of-the-fittest capitalism. In many ways, Integrative Health is about cooperation. Contemplating opposing points of view requires not only a willingness to cooperate with other health providers for the good of the patient, but to respect those with different points of view.

These attitudes are not likely to develop when one is not able to quiet one’s mind in order to reflect, ponder and consider the possibility that our own beliefs may be wrong. Sadly, most people cannot quiet their minds for more than fifteen minutes! From the article “Just think: The challenges of the disengaged mind“:

“In 11 studies, we found that participants typically did not enjoy spending 6 to 15 minutes in a room by themselves with nothing to do but think, that they enjoyed doing mundane external activities much more, and that many preferred to administer electric shocks to themselves instead of being left alone with their thoughts. Most people seem to prefer to be doing something rather than nothing, even if that something is negative.”

Now, let’s look at some examples showing how science has changed its positions on poignant health issues in the past few decades.

 

On the environment

 

On obesity and diabetes

  • Diabetes was thought to be an all-or-nothing diagnosis. Now the concept of pre-diabetes is widely accepted. No disease happens overnight; problems start at the cellular level before they are picked up by a laboratory exam. Pre diabetes is now an epidemic in the USA.
  • Treatment for mild type two diabetes in the elderly may do more harm than good. The drugs of choice are now suspect and redolent with side effects. Even the cleanest of them, Metformin/Glucophage may interfere with our gut flora and cause kidney problems in the long run.
  • Growing up in the 50s I thought Coca-Cola was the nectar of the Gods. Now we know all it is not so good for us. Sodas have been shown to be addicting. They light up the brain in reward and executive function areas: translation = obesity. Remember the tobacco propaganda and cover-ups and their subsequent campaigns to tell us it was their idea to start warning us their products were harmful? Coca-Cola is now doing the same thing. I hope you read the article “Is Coca-Cola’s antiobesity scheme the real thing?
  • Drugs to lower cholesterol have been marketed quite aggressively even though their benefits have not been as clear as marketed. Then, there is the matter of their side effects. We have known for a while that cholesterol-lowering drugs may cause liver and muscle problems. Now, they carry a warning that they may increase the risk of diabetes.

 

On psychiatric treatment
A major breakthrough a few decades back was the advent of psychiatric drugs that allowed patients diagnosed with psychosis to leave institutions to live fairly normal lives in the community. Since then it has been a dogmatic fact that they cannot function without said medications. Could it be that this paradigm needs to be revisited? According to two recent articles, teenagers suffering from psychosis and schizophrenia may do quite well, to the point of not needing drugs, if cognitive therapy with their families is initiated early.

This is not a call for abandoning pharmaceutical therapy. But, we could all work harder to get teens to relate better to their families. Doctors and psychotherapists may be instrumental in getting this breakthrough therapy implemented. If nothing else, these articles at least are testimonies to the power of familial love.

 

On pharmaceuticals

  • Just about every patient that comes to my clinic is aware that the system is prescribing too much and that medications only treat symptoms. This is a dramatic shift from the time I started practice 3 decades ago. Patients and doctors are also now more mindful of side effects seen with practically all pharmaceutical products. Seniors are particularly vulnerable to adverse reactions from treatments. Since one of their greatest fears is that of falling, the report that ten of the twenty most prescribed medications increase their risk for falling should give us pause. Any medication that affects the central nervous system should be suspected: i.e. hypnotics, sedatives, analgesics and antidepressants.
  • Vitamin D, which is really a pro-hormone, used to be an afterthought in the consciousness of patients and doctors. Now, it is surprising to find a medical journal’s issue without some study on it. But, we still can get better: Vitamin D2, which is the prescribed replacement, does not reduce mortality like the D3 we can get over the counter. Also, we need to advise patients to aim for a blood level around 50 ng/ml, which is most often achieved by taking 2,000 IU a day. A level around 50 not only decreases mortality, but reduces the risk of Alzheimer’s Disease. This is a lot more than the 800 IU still recommended by some doctors. When in doubt, insist on a blood test.

 

On blood pressure issues
We have been taught that high blood pressure, like most diseases, is a matter of having it, or not; that there are no gray areas. Now we understand that just about every disease lives on a bell-shaped curve, or a “U” curve, meaning that there is an ideal range for blood pressure. To the left and right sides of the curve (or “U”) we now see less optimal function and health. A good study recently showed that the ideal number blood pressure number, the top of the curve or the bottom of the U, is 137/71. This is significantly different from the recommendation to get patients under 120/80. For diabetic patients the magical number is 131/69.

To achieve blood pressure control, patients have historically been asked to follow up in clinic each month to make adjustments to their medications. Now, with a more progressive generation of patients and less paternalistic doctors we have ample evidence, including my own practice, that most patients may be trusted to make adjustments to their medications on their own.

 

On testing
Wasting $750 billion a year in health care has sobered up a whole lot of people involved. Part of the problem has been excessive testing. We used to do an EKG and a chest X ray on every physical exam. Fortunately, we stopped doing that. Will we now stop doing pap smears? No, but good evidence shows that they could be done less frequently, like every 3-5 years depending on a woman’s lifestyle and sexual activity.