Doc Gumshoe’s Perspectives on the Current State of Healthcare: The Long View

By Michael Jorrin, "Doc Gumshoe", March 27, 2015

[Ed Note: Michael Jorrin, who I like to call “Doc Gumshoe”, is a longtime medical writer (not a doctor) who shares his thoughts with us from time to time, generally on non-financial topics in health and medicine (as today, though, he sometimes mentions a couple publicly traded companies). His words and opinions are his own. You can see his past articles here.]

The word “perspectives” can be a bit contradictory. The reader, an astute denizen of Gumshoeland, can already tell that what this post will feature is my own point of view on a large and diverse bundle of complex issues. But perspective also means that the subject matter that’s closest to the viewer looms largest in the picture. I have a small 17th century steel engraving with a religious subject taking up most of the foreground, but way in the background there is also a miniscule depiction – and I mean miniscule, less than an inch across – of a hunting party, including a couple of hunters, dogs, and deer. The hunters are not aware of what’s going on in the foreground; they’re busy with their own pursuits, which are important to them.

The same effect of perspective affects the time dimension – often the most recent events loom largest, but that doesn’t mean that they are the most significant.   When that happens, we have to “put things in perspective” – meaning, trying to understand the likely long-term importance of the issues of the day.

So, first, here are some current issues and trends that loom large. Then, I’ll try to make adjustments, to account for the distortions of the perspective of the moment.

The primacy of technology, and what this implies for diagnosis and treatment

In my days as a film-maker, before I became a medical writer, I made a short documentary about the Mayo Clinic, and one of the things that they proudly demonstrated to me, and which amazed me utterly, was a blood analyzer that could produce upward of 40 test results from a single small blood sample in just a few minutes. I had taken organic chemistry in college, and I had a pretty good idea of what it took to carry out an analysis for even one single substance. What this machine could do, accurately and quickly, was many, many orders of magnitude greater than anything I had imagined.

But that kind of thing is now routine. Consider this: a person with diabetes can now have an implanted device that releases either insulin or glucagon as needed, depending on the levels of these two agents, which are monitored in real time. Insulin is needed for the metabolism of glucose in the bloodstream, and glucagon is the agent that tells the liver to convert stored glycogen into glucose, so this device keeps the diabetic individual’s glucose level in balance, avoiding both hyperglycemic (too much glucose) and hypoglycemic (insufficient glucose) episodes. The whole thing is monitored by a smart phone, which does the calculations and sends instructions back to the device. (Note, this device is not yet in wide use – diabetics are still monitoring their blood glucose with needle sticks.)

To put that device in perspective, my father was a type 2 diabetic, diagnosed in his 40s, and totally adherent to treatment. He relied on injected insulin, that being before the oral agents had been developed. The only way he could monitor his disease state was by means of urine tests – a little test strip, like litmus paper, dipped into a test-tube of urine. He then compared the color of the test strip with a reference, which told him whether he was “clear” – good news! – or whether there was sugar in his urine, the levels being one through four-plus, four-plus being decidedly bad news. But he also had to be on the alert for hypoglycemic spells, which could lead to dizziness, or even to severe reactions. To ward these off, he carried sugar-cubes with him at all times. He only had actual blood glucose tests when he saw his doctor (who was our excellent, caring, family doctor and good friend) once every few months. That was the norm. Just consider the change!

Therapeutic drug monitoring

The implanted device that I described, which at the same time monitors blood glucose and delivers the quantities of either insulin or glucagon needed to maintain blood glucose at optimum levels, is a form of therapeutic drug monitoring.