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Behavior Vs. Disease: A New Way To Look At Health

What is the leading cause of death in the United States? Heart disease? Cancer? No, it’s smoking. Smoking? Yes, depending on how you ask the question.

In the early 90s, McGinnis and Foege turned the age-old question of what people die of on its head by asking not what diseases people die of but rather what the causes of these are. Instead of chalking up the death of an older man to say lung cancer, they sought to understand the proximate cause of death, which in the case of lung cancer is largely smoking. Using published data, the researchers performed a simple but profound calculation — they multiplied the mortality rates of leading diseases by the cause-attributable fraction, that proportion of a disease that can be attributed to a particular cause (for example, in lung cancer 90 percent of deaths in men and 80 percent of deaths in women are attributable to smoking). Published in JAMA in 1993, their landmark study became a call to action for the public health community.

When looked at the conventional way, using data from the 2004 update of the original study, heart disease, cancer, and stroke are the leading causes of death, respectively. This accounting may help us understand the nation’s burden of illness, but does little to tell us how to prevent these diseases and improve health. Through the lens of McGinnis and Foege we get the actual causes of death (e.g., the major external modifiable factors that contribute to death). This analysis shows that the number one cause of death in America is tobacco use, followed closely by poor diet and lack of physical activity, and then alcohol consumption. Read more »

*This blog post was originally published at BeyondApples.Org*

A Taste Of Canadian Healthcare On Chicago’s South Side

This past September, a group of medical residents at my institution began seeing primary care patients at a free clinic down the street from our tertiary academic medical center (“hospital clinic”). Far from my expectations, the care we are able to provide at our free clinic is in many ways better than our hospital clinic. Somewhat paradoxically, the experience has given me a taste of what the practice of medicine is like in single-payer healthcare systems like Canada’s.

When I volunteered to start seeing patients at a nearby free clinic, I had little idea what I was signing up for. The term “free clinic” conjured up memories as a medical student in East Baltimore tending to patients at a local homeless shelter with severe frostbite or at a student-run clinic rummaging through the storage room for anti-hypertensive medications. I expected our patients to be terribly poor, the clinic to be little more than a warehouse, for supplies and medications to be few and far between, and for the care we provided to be more about putting out fires than delivering high-quality primary care.

But the place I have come to cherish working at is none of these things. A surprising number of our patients have stable lives and regular jobs — it’s just that their jobs don’t offer health insurance (including some who work in healthcare!) Patients call for appointments. When they arrive they are triaged by a nurse who takes their vitals and asks about their chief complaint before putting them in an exam room. We provide comprehensive primary care complete with routine lab tests for cholesterol and diabetes, age appropriate vaccinations, and referrals for mammograms and colon cancer screening. Read more »

*This blog post was originally published at BeyondApples.Org*

Preventive Health/Medicine/Care: Let’s Give It A Name

It’s a scene that plays out thousands of times every day in doctors’ offices across the country — the moment the doctor shifts from addressing the concerns that brought the patient into clinic to when he or she attempts to make sure everything else is going okay.

Often this happens at the end of a sick visit, after working up an upper respiratory infection or back pain. Sometimes it happens after following up a chronic medical problem such as high blood pressure or arthritis, and occasionally it happens under ideal circumstances, during an annual physical or routine wellness visit. It doesn’t necessarily happen at the end of the visit. Often it sneaks it’s way into various points in the encounter — as when the doctor places his or her stethoscope over a patient’s chest while evaluating for knee pain.

What I’m referring to is so indistinct that it doesn’t even have an universal name, but rather goes by many titles — “preventive health,” “preventative health,” “preventive medicine,” “preventive care,” “healthcare maintenance,” “routine healthcare,” “routine checkup,” “annual physical,” and “health and wellness” — to name a few.

But whatever you call it nearly everyone agrees how important it is. The healthcare reform debate was ripe with calls for more “health”-care not just “sick”-care, and one of the most welcome measures in the new healthcare legislation across both sides of the aisle are provisions to support it. Outside of Capitol Hill, from cereal boxes to magazine racks and celebrity doctors, messages about staying healthy are everywhere, as is the general belief that “an ounce of prevention is worth a pound of cure.” Read more »

*This blog post was originally published at BeyondApples.Org*

Basic Health Education: Not So Basic

The past two weeks I’ve been the “dayfloat” resident on the cardiology inpatient service. With the 30-hour-shift work “restrictions” placed on medical residents, there has been a need for new systems of care to ensure the safety of newly admitted patients and cardiology dayfloat is one of them. My job is to round with the post-call team, help them get out of the hospital on time, and then take care of their patients through the end of the work day. It’s a fairly easy rotation, as they go, though because I “float” from one team to another without patients of my own, it’s also not the most satisfying.

Towards the end of my two week rotation, I was paged by a nurse because a patient’s husband wanted an update on his wife’s condition. Glancing at my “signout” — a one-page synopsis of the patient’s presenting illness and hospital course — I learned that Mrs. FN (as I will call her) was admitted to the hospital for heart failure secondary to “medical noncompliance.” It appeared that she had not had any of her medications for well over a week, which likely precipitated the shortness of breath and fluid overload that led to her admission. On top of this, the patient had a number of “dietary indiscretions” including eating Chinese food, which likely only exacerbated her condition. Read more »

*This blog post was originally published at BeyondApples.Org*

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

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How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

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Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

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The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

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Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

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