This is by no means a new problem. A couple of thousand years ago, Virgil wrote “aegrescit medendo,” which means, roughly, “healing (medendo) makes it worse (aegrescit).” (Aeneid XII) About four hundred years ago, Francis Bacon wrote “The remedy is worse than the disease.” Back in those days, the remedies were indeed pretty severe. Blood-letting, leeches, surgery without anaesthetics, enemas, ineffective but loathsome potions and lotions. And even more recently, the remedy or treatment for some health problems might consist of spending a couple of weeks at a resort of some kind – dieting and “taking the waters.”

We might suppose that the situation would have changed hugely in the present era, when medical treatment is much more closely focused on the illness/disease. Infections are treated (presumably) by identifying and killing the pathogens. Surgeons zero in on the particular area that requires cutting, using instruments that allow them to focus on the tiniest details. Drugs are painstakingly tested to make sure that they are a close match for the medical/clinical condition that needs addressing. Medical science is not perfect, but it has advanced vastly from the era of blood-letting and leeches. So in what circumstances might the inclinations of the healthcare system and the best interests of patients not totally align?

The impetus for this Doc Gumshoe missive came from an excellent book, Being Mortal: Medicine and What Matters in the End, by Atul Gawande, which I just recently read despite it having been published about ten years ago. Gawande is a surgeon at Brigham and Women’s Hospital in Boston and a professor of health policy and management at the Harvard T. H. Chan School of Public Health. He was born in Brooklyn of Indian parents, both of whom are physicians, and grew up in Athens, Ohio.

I became aware of Gawande several years ago when I read a few articles by him in The New Yorker. One in particular resonated with me. It was about the huge importance of checklists in the medical system. If you wonder why you are asked for your name and date of birth innumerable times when you are in any kind of healthcare setting, it’s to prevent the kind of goof-ups that can cause severe and sometimes critical problems.

For example, when a medical assistant puts up the X-rays on a screen in the operating theater, there are repeated checks to make sure the X-rays are displayed correctly. It has happened more frequently that we would like to believe that X-rays are displayed in reversed positions. (Perhaps these days, when X-rays are more frequently shown in computer screens, this is less of a problem.) Consequently, surgeries are screwed up. The patient who was supposed to have surgery on his right lung might have his left lung sliced up, due to a simple, easily avoidable mix-up.

And as far as repeatedly asking patients for their names and d.o.b.’s, here’s a little story.

More than thirty years ago, I was doing a documentary film about emergency trauma medicine, on location at Parkland Hospital in Dallas, which you may remember as the hospital JFK was taken to after he was shot. We had spent most of the day and all night in the emergency department there, filming the trauma cases as they came in. We were exhausted. While the rest of us were sitting around waiting for the next trauma victim to be brought in, my assistant cameraman decided to have a quick nap on a gurney.

A couple of guys came over to the gurney and started to wheel it in to an operating room. My guy was out like a light and didn’t stir. I stood up and asked, “Whoa, where are you taking him?” The answer was “To surgery.” I said, “But he’s not your patient. He’s one of our crew.”

The guys were clearly horrified. “Good thing you caught us in time!”

Would they have discovered their error before they cut him open? I would guess that the a.c. would have woken up and straightened them out.

However, asking for names and d.o.b.’s is a guardrail. It’s one of many checks that are now part of standard practice in healthcare settings. This was not always the case, and Gawande had a good deal to do with making checklists part of standard practice.

Gawande led the “Safe surgery saves lives checklist” initiative of the World Health Organization, which was published in 2008 for use in operating theaters. About 200 medical societies and health ministries collaborated to produce a checklist, which was published in 2008. His book, The Checklist Manifesto, was also published in 2008.

Gawande retraces his own evolution in the matter which is the subject of this meandering Doc Gumshoe communication. As one would expect of a practicing physician, no doubts had entered his mind as to whether medical practice was in the best interests of patients. Doctors did what was best for patients, and that was all there was to it. Why should there be any doubt?

The doubts appeared gradually, in connection with the treatment of specific patients. Gawande describes these cases in detail in his book, and points out the specific areas in which there were divergences between proposed treatment plans and patients’ life circumstances.

One of the first cases Gawande tells about illustrates the kind of treatment that indeed closely matches the patient’s life circumstances. The patient in this case narrative – we’ll call her Agnes – is being treated by a geriatrician, a physician who specializes in the care of the aging. She is 85 years old and has no urgently-threatening health conditions, but her internist recommended that she consult a geriatrician. She comes in walking normally with nothing unusual except her bulky orthopedic shoes.

Agnes tells the geriatrician, Dr Bludau, that she has lower back pain which sometimes made it difficult for her to get up out of bed. She also has bad arthritis. Her fingers are swollen at the knuckles and bent out to the sides in what’s called a “swan’s neck deformity.” She has had both knees replaced about ten years earlier. She has high blood pressure and has had glaucoma. She never had “bathroom problems” until recently, but now has to wear a pad. She skimps on her meals and has lost some weight, and she regularly experiences “dry mouth.” She has had surgery for colon cancer and a recent radiology report has indicated that she has a lung nodule which could be a metastasis – a biopsy was recommended, but not urgently.

To Gawande’s surprise, what Dr Bludau focuses on is Agnes’ feet. He helps her take her shoes off and examines her feet and toes, carefully looking at the web spaces between her toes.

Dr Bludau’s assessment is that the most serious threat to the patient’s life and health was not the lung nodule nor the back pain. The greatest threat was falling. He pointed out to Gawande that every year about 350,000 Americans fall and break a hip. Of these, about 40% wind up in a nursing home, and 20% are never again able to walk. The three greatest risk factors for falling are poor balance, taking more than four prescription medications, and muscle weakness. Elderly people without those risks have about a 12% chance of falling within a year. Those with all three of those risk factors have an almost 100% chance of falling within the next year.

Agnes had two of those risk factors. At present, she was not experiencing muscle weakness, but she was on five medications whose combined side effects would include dizziness affecting her sense of balance. In addition, her feet were swollen, her toenails were unclipped and there were sores between her toes. The balls of her feet had thick, rounded calluses.

Dr Bludau said to Gawande that the job of any doctor should be to support the patient’s quality of life, by which he meant two things: as much freedom from the ravages of disease as possible, and the retention of enough function for active engagement in the world. Most doctors treat disease and figure that the rest will take care of itself. And if it doesn’t – if a patient is becoming infirm and heading towards a nursing home – well, that isn’t really a medical problem, is it?

To a geriatrician, it is indeed a medical problem. Geriatricians recognize that aging cannot be prevented. Medical practice can alleviate some of the problems and conditions that come with aging. Dr Bludau’s patient had had two knee replacements, and as a person who has had two knee replacements myself, I can attest to the huge improvement that those pieces of titanium have made in my ambulation and, indeed, in my daily life. I have had numerous other medical procedures that have not only resolved temporary acute problems, but helped with conditions that would have affected many aspects of my life had they not been addressed. Dealing with those conditions is central to healthcare, but these are not always the primary focus of the physicians that we consult at any given time.

Dr Bludau’s aim was to make Agnes’s aging more manageable. He referred her to a podiatrist, whom he wanted his patient to see every four weeks or so, to improve the quality of her walking and, to whatever degree possible, reduce the likelihood that she would have a fall. He didn’t see any medications that he could eliminate, but her switched her blood pressure medication from a diuretic to another medication that would not cause dehydration, which was a condition that he had detected in the patient.

About a year later, Gawande checked in with Agnes and her daughter. She had made some minor changes in her eating habits. She has gained a couple of pounds, is more hydrated and no longer has “dry mouth.” She lives comfortably and independently in her own house, and she has not experienced a fall. She is now 86 years old and living comfortably.

The case of Agnes and her geriatrician represents a kind of desirable norm that healthcare should stay close to. A large part of Gawande’s book focuses on the range of instances where healthcare does not follow this norm. The particular instances that Gawande describes fall roughly into two large categories. One category focuses on the benefits of the medical treatment plans. The other category concerns patients’ living arrangements, in particular when there are perceived problems in having patients continue living independently in their own homes.

Gawande gives several examples of medical treatment plans that may not be right for a particular patient at a particular time. A typical scenario goes like this:

The patient has an illness or condition that physicians have been trying to manage for a considerable period, perhaps for years. The condition gradually worsens, despite the efforts of the physicians, who have tried several interventions. These interventions worked for a time, sometimes resulting in improvement for a time, and sometimes only preventing marked worsening of the patient’s condition. The key phrase is “for a time.” At a certain point, each of these interventions stops working. The patient gets worse.

As long as there is another intervention whose benefits are understood, and whose benefits are clearly known to outweigh the risks, the physicians have a fairly straightforward course of action, namely to progress to the next intervention.

But what if the next intervention is ineffectual, or if the effects are unacceptably short-term? At that point, physicians will search for further option.

As it happens, current medical research being what it is, there usually are some further options. However, the benefit of these options is far from clear. We see news about these options all the time. An example that has garnered a great deal of public attention is that some drugs for Alzheimer’s disease (which we have discussed in these posts) – in some patients at least – slow the advance of dementia and may even reverse the advance of dementia to some degree. But these drugs are also linked with an increased incidence of brain bleeds. How serious are these specific side effects, and to what degree should consideration of the side effects weigh on the decision whether to use the drugs in a particular patient? Those are matters for careful evaluation and discussion.

And then there are situations where no intervention, no drug, no surgery, no intervention of any kind has been demonstrated to be effective. However, there may be clinical trials in progress that have suggested that at least in a certain fraction of the patients with that particular condition for which – up to now – no treatment has been shown to work, for that certain fraction, a particular new experimental treatment provides some benefit, at least some of the time.

When is it accepted medical practice to give it a try, for example, on a patient for which all other available treatments have failed? Note that in some cases the most that the new experimental treatment does is give patients, who would otherwise have perished in a couple of months, an additional year or so of life.

The accepted medical wisdom is that of course an additional year of life is better than two months. Common sense strongly seconds that view – come on, when is a year of life not better than a couple of months?

What that question is missing is the phrase “everything else being equal.”

The problem that Gawande points us to is that everything else is not equal. Sometimes after these new treatment options that offer patients an additional year of life, that additional year of life is spent in a hospital bed or nursing home. The patient does not go home fit as a fiddle and ready to spend that additional gift year sipping gin-and-tonics and playing badminton in the back yard.

As the title of Gawande’s book suggests, his particular focus is on an older population. It is that older populace that is mostly affected by those decisions. Yes, younger folks get laid low by devastating diseases, and sometimes these devastating diseases can be successfully treated, giving their victims not years, but decades of additional life.

This is not possible for the elderly. The question which Gawande is facing head on is whether for that population many of those treatments are worth it.

The patients themselves are not necessarily informed as to how to decide whether to go ahead with some of these treatment options. Physicians don’t outright lie to their patients, but they project expertise and confidence. The patients feel that they are in the care of experts who know more about their health and their prospects than they can possibly know themselves.

And the physicians are members of the present-day healthcare system and strongly influenced by the current thinking in the present-day healthcare system. It is a fact that there have been monumental achievements in the healthcare system, and physicians are justifiably proud of those achievements. In many cases, those achievements have to do with treating and ameliorating, if not outright curing, many, many diseases and conditions which in even the recent past would have been considered hopeless.

Faced with a patient with a difficult-to-treat disease/condition, even one in the nearly “hopeless” category, the inclination of the current physician is to try something, even an experimental treatment with slim hopes for success. Better something than nothing.

Gawande doesn’t come out and say so in so many words, but the suggestion is that for many elderly and truly “old” patients, nothing might be better than something. Especially if that “nothing” consists of a more or less comfortable and relaxed period of remaining life – a period of “letting go.”

Being comfortable and relaxed is what most people want, but often the options for older folks are not very easy. Gawande discusses those options at length and in depth. He states that “most older folks consider modern old age homes frightening, desolate, even odious places to spend the last phases of one’s life. We need and desire something more.”

He mentions a woman named Alice, in a home which seemed to have everything going for it – up-to-date facilities, with top ratings for safety and care. “Alice’s quarters enabled her to have the comforts of her old home in a safer, more manageable situation. The arrangements were tremendously reassuring for her children and extended family. But they weren’t for Alice. She never got used to being there or accepted it. No matter what the staff or her family did for her, she grew only more miserable.”

Gawande asked her what it was that made her unhappy, but she couldn’t put her finger on it. “The most common complaint she made is one I’ve heard from nursing home residents I’ve met: it just isn’t home.”

The difference is more than obvious. At home, we do what we want to do. We have meals when we want, plan our lives to suit ourselves or our needs. In the nursing homes or senior care residences or assisted living facilities, we have all our meals on their schedule, eat (or don’t eat) whatever they serve us, get our rooms or apartments cleaned when it’s on their schedule, report for games or physical therapy or meetings, and live under the watchful eyes of the care authorities.

Sometimes it’s easier and quicker for the staff in these places to bathe and dress the residents and escort them to the toilet than to let them do these tasks by themselves, to the extent that they are able. Without doubt, there comes a point in the lives of many people when they can no longer accomplish those tasks, but many of those facilities accelerate that point because it is more convenient for them. Is that a way for older folks to have a comfortable and relaxed period of their lives?

There are bits of positive news regarding senior care residences and their like. A young physician named Bill Thomas took over as the medical director of a facility called Chase Memorial Nursing Home. It looked to be about ideal. Beautiful buildings and grounds, highly rated for safety and other measurable standards. But Thomas thought that the daily lives of the residents were far from what he thought life at that stage of life should be. It was limited and boring. He was able to institute a number of changes. He introduced plants and animals into the facility – cats and dogs and more than a hundred parakeets. He had some of the perfect lawns dug up and converted into vegetable and flower gardens. The residents were encouraged to look after the animals and work in the gardens. The residents provided child care for the children of staff members and participated in an after-school program. Overall, he greatly relaxed the daily schedules and gave the residents a good deal more say in how they spent their time.

The residents were highly appreciative of Thomas’s relaxation of the strictures on their lives. But there were measureable changes as well. Researchers studied the effects of this program over two years, comparing a variety of measures for Chase residents with those of residents of another nursing home nearby. The specific differences were considerable. The study discovered that the number of drug prescriptions required per residence fell to half that of the control nursing home. Psychotropic drugs for agitation such as haloperidol (Haldol) particularly decreased at Chase. Total drug costs fell to 38% of the drug costs in the control nursing home, and deaths fell by 15%.

Obviously, the changes Thomas instituted at Chase Memorial brought considerable benefits. The study could provide no reason for these positive changes. But Thomas believed that he could. “I believe that the inference in death rates can be traced to the fundamental human need for a reason to live.”

The activities and the human contacts that took place at Chase gave the residents a reason to live. Perhaps the basic underlying change in their lives was the restoration of the sense that they were again in control of their own lives.

The changes at Chase Memorial are not unique. Gawande describes a number of other residential facilities for seniors that have instituted changes that gave residents a reason to live, and the results in these facilities have been similarly positive. The overall picture is beginning to brighten.

* * * * * *

A small addendum to the above.

Looking at the total picture from my personal point of view, I need to add that as far as my own health and my own future prospects, I am committed to remaining as healthy as possible, enjoying my daily life, and looking forward to the future – at least, my own future, and the futures of my wife and my loved ones.

What will Doc Gumshoe be looking into in future dispatches? A question that deserves some thought and discussion – perhaps not in the next piece, but fairly soon – is a deep and fundamental difference between the two basic parts of medical practice, those being diagnosis and treatment. These have evolved separately and are frequently based on different data and evolve through different thought processes. I will look at data and apply my own thought processes and inform you of the outcome.

Stay well, best to all! Michael Jorrin (aka Doc Gumshoe)

[ed note: Michael Jorrin, who I dubbed “Doc Gumshoe” many years ago, is a longtime medical writer (not a doctor) and shares his commentary with Gumshoe readers once or twice a month. He does not generally write about the investment prospects of topics he covers, but has agreed to our trading restrictions.  Past Doc Gumshoe columns are available here.]