Two hundred and fifty years, if you happened to live in the “colonies,” now the United States, you had a life expectancy of around 43 years.. Interestingly though, if you managed to make it through childhood, childbirth and avoid infectious diseases and accidents, your life expectancy could be considerable. The life style of the day (whole foods, strong community, and built in daily activity) is one that promotes longevity. Health care was provided by the midwife, local herbalist, mothers and wives, as there were few doctors (probably a good thing given that blood letting was the norm) and almost no hospitals. Paying for health care was nominal in most families and often times, bartering was the norm. This was very much a patient/family driven approach, where health practices were quite diverse depending on who was delivering the care.
The 19th
century laid the foundation for the incredible strides made in life expectancy
in the 20th century. Organized medicine starts to take center stage,
with the establishment of medical schools, and hospitals. It’s the dawn of the
scientific age, and public health becomes more established. However, average
life expectancy is only increased by about four years.
At the beginning
of the 20th century, the majority of people are continuing to die
from acute illnesses, and so medicine is practiced with the idea of the patient
getting better or dying. However, by the end of this century, it has
significantly changed. There has
been no century like this as life expectancy jumps 62%, from 47.3 years of age
in 1900 to 76.8 in 2000. MMWR 5/20/11
These gains came
about largely through the following:
• Public health
(immunizations, motor vehicle and work place safety, control of infectious
diseases, tobacco control etc/)
• Social
programs, such as Social Security helped to meet basic human needs of food,
clothing and shelter
• Government
sponsored health programs such as Medicare, Medicaid
• A more
scientific approach to health care resulting in better treatments for
conditions that were once untreatable.
In addition to
advanced life expectancy, the 20th century achievements came with a
very high price tag. In addition, the old acute “medical care model” no longer
works as the majority of people will die with a chronic condition-therefore
requiring care for many years.. Lots of things are being tried to reduce costs
and extend life expectancy.
In September,
the Institute of Medicine of the National Academies issued a report “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.” This report starts off by saying America's health care system has become far
too complex and costly to continue business as usual. Pervasive inefficiencies,
an inability to manage a rapidly deepening clinical knowledge base, and a
reward system poorly focused on key patient needs, all hinder improvements in the
safety and quality of care and threaten the nation's economic stability and
global competitiveness. Achieving higher quality care at lower cost will
require fundamental commitments to the incentives, culture, and leadership that
foster continuous "learning”, as the lessons from research and each care
experience are systematically captured, assessed, and translated into reliable
care.
Among the
“sacred cows” of 21st century medicine are yearly physicals and
preventive testing, such as PSAs for prostate cancer and mammograms for breast
cancer. “Well child” visits have been very important in reducing childhood
death and disease, as they involve immunizations schedules, testing for things
like lead poisoning and TB, normal growth patterns etc. Prenatal care has
significantly improved outcomes for pregnant women, resulting in healthier
babies, so it would seem logical that yearly physicals for adults would yield
similar results.
Earlier this
month, the Cochrane Library published a new study “General Health Checks in Adults for Reducing Morbidity and Mortality for Adults.” Sixteen randomized studies from primary care or community settings were
reviewed in the aggregate and the bottom line was that having a yearly exam did
not reduce the risk of dying from serious illnesses like cancer and heart
disease, and in fact caused unnecessary harm. One of the studies reviewed found a 20% increase
in diagnoses among those being regularly screened but it ultimately did not
translate into better health outcomes. Long story short, there is no convincing
evidence that general health checks are beneficial. How long do you think it’s
going to take for that message to filter down?
It seems almost
weekly there is new information about how things thought to be bad for us (like
chocolate) actually have value-I have one friend that keeps saying, “come on
red meat”-and things we believed to be important- like routine yearly
mammograms and yearly physicals- may not be as helpful as originally believed.
Screening for
disease to prevent it makes sense, but the latest evidence, from government
health groups such as the United States Preventive Services Task Force
(USPSTF), shows that the data don't always support the idea that screening
leads to better health.
As my good
friend and mentor Dr. Seymour Leven always says, “We are each unique so
therefore medicine must be tailored to the individual.” So here in lines the
important points of this post:
• The 20th
century was able to eliminate many of the diseases that shortened the lives of
people 250 years ago. However, the lifestyles of the early settlers were
probably a lot healthier than today. The best example of how lifestyle promotes
longevity can be found in the Blue zones project. The “Power 9” to
increase longevity include: Natural movement; sense of purpose; stress
reduction; plant based diet and not eating until full; wine (not to excess);
social belonging; and faith of some sort.
• A large
percentage of the life expectancy that came about in the 20th
century occurred because of public health and social programs. The 21st century needs to build on what we’ve learned, continuing to apply good public health and social programs, but recognize the needs to develop new strategies to deal with chronic conditions and the need for medicine that makes sense for the individual. "...When
contemplating screening, practitioners should focus on tests that are targeted
to the patient's age, sex, and specific risk factors, and that are supported by
high-quality evidence. All screening tests (general health checks or focused
screenings based on age, sex, or specific risk factors) have potential for
benefits and harms, so consideration of patient preferences is critical,
especially for those tests where such preferences vary between individuals or
where the overall benefit:harm ratio is less favorable."
• To obtain
the individual care that you need, establish a good working relationship with
your primary care provider and the person you see for your chronic condition,
if different than your primary care provider. Discuss with them what really
makes sense for you to be tested and treated for and how often you need to be
seen. Be clear about what you realistically can afford to do and are willing to do.
• Be an e-patient, so you can learn from others with similar health issues and share your data
with them. This is the new wave of
health care.
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