Regular readers of The Medical Beat (“medicalbeat.net”) know that I do not hesitate to criticize healthcare in the United States. But a recent opinion piece in the American Journal of Medicine made me reflect on genuine progress in many areas of medicine. The long term editor of this prominent journal, Dr. Joseph Alpert, reflected on advances in healthcare, listing “the ten most noteworthy developments in clinical medicine” over his fifty-plus year career as a practicing physician. Here are some highlights.
Myocardial Infarction (i.e., heart attacks)
Around 1970, the 30 day mortality for patients with a heart attack was about 30 percent. Today, it is six to seven percent. This is all the more remarkable as victims of heart attack are now much older. Reasons for the improvement include reperfusion therapy (i.e., mechanical and pharmaceutical opening of blocked arteries that cause the heart attack), statins, advances in treatment of heart failure, the creation of intensive care units, and many more. And these factors do not even speak to the decrease in the prevalence of heart disease that is preventable with lifestyle changes.
When I was a young doctor in the early 1980’s, I treated many young patients with a strange pneumonia that was impervious to conventional therapy. I witnessed many terrible deaths that introduced the HIV era of medicine. In the beginning of the scourge, the disease was uniformly fatal for hospitalized patients.Now HIV/AIDS is an entirely treatable disease. The remarkable, and fast, recognition of the cause and eventual development of safe and effective therapy is one of the great achievements of modern medicine. With effective pharmaceutical intervention, HIV/AIDS is now a chronic disease, much like diabetes.
Inflammatory Bowel Disease
In the beginning of Dr. Alpert’s clinical career, he was taught that ulcerative colitis (one form of inflammatory bowel disease, along with Crohn’s Disease) resulted from psychological distress, often related to adverse relationships with one’s mother (!). Advances in the genetic and molecular understanding of the disease has resulted in modern pharmacological therapy that has made this a highly manageable disease. Total colectomy (surgical removal of the colon), the treatment of choice back in the day, is now almost unheard of.
Personal Favorites in the Hit Parade
In addition to Dr. Alpert’s list of the top ten advances in medicine, I have many other personal favorites.
According to the Center for Disease Control, cancer mortality in the US decreased 27 percent from 2001 to 2020. The reasons are multifactorial and include tobacco cessation, vaccines such as one for hepatitis B (a cause of liver cancer), screening tests (for example colonoscopic screening for colon cancer), and other-worldly cancer treatments that attack mutations or use the immune system to find and kill cancer cells.
Prosthetic joints, especially for the elderly, are increasingly common and, though they have no demonstrable effect on life span, have resulted in vast improvement in the quality of life for millions. Studies on knee and hip replacement have consistently shown improvement in psychological well-being and functional capability. As a senior citizen, I can see the remarkable improvements from these procedures in many of my friends and relatives.*
Hospice care also deserves a place in the pantheon of notable advances in medicine. As a young doctor, I too often witnessed the inappropriate and futile aggressive treatment of the dying elderly. Hospice care, simply stated, is designed exclusively to give comfort care for terminal patients. This intervention has resulted in the provision of comprehensive at-home care, allowing for dignified, comfortable deaths that too often eluded terminal patients in the past. Patients, and families, now better understand that end-of-life treatment decisions are in their own hands. People increasingly opt for terminal care with hospice over the use of aggressive, painful, useless interventions.
Finally, of all the benefits modern healthcare has bestowed, public health is the crown jewel (see my blog on December 19, 2002). Vaccinations, education (for instance, the dangers of smoking), and maintenance of a safe food and water supply are but a few ways that public health programs have had an immensely positive effect on the population. Much of what public health accomplishes tends to fly under the radar, but it is nevertheless critical to the well-being of all Americans.
The future of healthcare in America is precarious. The cost is outlandish, care is impossibly fragmented, all providers are venal, and special interests will maintain the status quo for the foreseeable future. On the other hand, we have somehow made staggering progress in many areas. It seems that we should be able to create a coherent healthcare system, and make the types of advances I have detailed.
*Note: Decisions regarding joint replacement surgery should be undertaken with care. It is a rare replacement that results in restoration of perfect function, and complications, while unusual, increase with age.