(Thomas Eakins, The Gross Clinic, 1875)

Medical history is remarkable.  This quotation is excerpted from a NYU Medical Center publication I was reading while passing time as a lay person the waiting room of the labor and delivery ward while my sister-in-law was giving birth.  I find it interesting because it describes the obvious change in the presentation of the physician influenced by the understanding of the microscopic.  The past 125 years have bore witness to a truly remarkable shift in the paradigm of the cause/effect understanding of why we become sick and these two photos represent this change nicely.  

Suppose, however, that we could be coming to the end of the ride of reason advancing clinical outcome in high yield ways.  Were this true it would be even more profound in implication than the medical golden era as it would last for much longer than 125 years of human history.  After all the scientific advances may slow (breakthroughs vs. time vs. NNT graphed over the past century would certainly evidence this) and issues of lay-education and politics will likely become more prominent.  The “purity of intent of the physician”, though, will likely not change in spite of the shifts in daily practice that result.  It will hopefully be accompanied by greater education and data visualization on the part of our patients, allowing them the wisdom to understand their own essence and avoid us in the first place.  (Public, heal thyself?)  What will a post-microscopic society look like? (One that reaches a finite endpoint of microscopic discovery and intervention and thus realizes it is left with a constant set of conundrums that will not meaningfully change.  Fascinating to think about).  

“In 1875, when Thomas Eakins—who had considered a career in surgery before becoming one of the most important artists in America—painted The Gross Clinic, surgeons still wore black garb.  By the time he created The Agnew Clinic in 1889, the principles of infection prevention had become widely accepted, and white was the standard color of both surgical gowns and hospital coats.  

For over a century, the white coat has been an emblem of medicine at its best.  Medical students aren’t entitled to call themselves “doctor” until they graduate four years later, but the first time they feel like a physician is the moment they don their white coats during a ceremony that began in 1993 and is held each August at most of the nation’s 145 schools of medicine and osteopathy.  In the world of medicine, perhaps no symbol is more vivid and ubiquitous, no rite of passage more momentous.

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The standard kilogram.  It is kept in a vault outside of Paris.  A significant portion of the world’s commerce is based on this piece of metal, directly or indirectly, which was created in 1795.  Standards are a good thing.  Contemporary medicine needs more and better.  Picture data visualization standards which incorporate objective image as well as time.  Picture stop-action animation all grown up.  

I respectfully disagree.  There is no medical information explosion.  There isn’t. Certainly not in the way this junk mailing implies.  It arrived in my mailbox today and is typical, I I think, of how society perceives modern medicine. 

It is a wonder to me that physicians are encouraged by educational tradition to perform basic research and publish new “breakthroughs” that today, by all practical measurements, lie exceptionally far out on the cost/benefit curve.  It is astounding really, and even contrary to science itself, perhaps—this pursuit of decreasingly applicable medical information—yet it remains a rite of passage for medical students, residents, and doctors of supposed merit.  

Here are a few titles from the inner flap of the above pamphlet supporting the “explosion of medical information”:

• Magnesium infusion might improve outcomes after subarachnoid hemorrhage
• Comparing face mask ventilation techniques in edentulous patients
• Automated chest compressions increase blood pressure
• Emergency department use of Droperidol in adolescents in the ER

These are for the most part breakthrough studies that yield little practical knowledge yet the pamphlet implies that in order to stay “current and relevant” doctors should study these journal articles or risk being left behind by the wash of new information.  Is this true?   

In the first example—a study of a group of people who fell hitting their heads causing bleeding around their brains—it was found that during medical treatment, in addition to standard protocols, Magnesium, given intravenously, might help patients in such unfortunate circumstances.  Or, as an obvious corollary, it might not.

The study was inconclusive

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“A thin line separates the temperament of a promising entrepreneur from a person who could use, as they say in psychiatry, a little help.

Consider that the man displays many of the symptoms of a person having what psychologists call a hypomanic episode. According to the Diagnostic and Statistical Manual — the occupation’s bible of mental disorders — these symptoms include grandiosity, an elevated and expansive mood, racing thoughts and little need for sleep.

“It’s about degrees”, says John D. Gartner, a psychologist and author of “The Hypomanic Edge.” “If you’re manic, you think you’re Jesus. If you’re hypomanic, you think you are God’s gift to technology investing.”

Excerpt from an interesting article in the NY Times today.  

“During the Roman Empire, Romans had a approximate life expectancy of 22 to 25 years. In 1900, the world life expectancy was approximately 30 years and in 1985 it was about 62 years, just two years short of today’s life expectancy.”

Due to issues of scale and the limitations of our senses (and the technology they produce) people generations from now could very well look back on our hopeful sentiments about aging and feel nostalgic about our lack of foresight.  ”How passe”, they will chuckle as they tip back a drink with friends.

The upward slope of life expectancy we experienced during the medical revolution of the last century cannot possibly continue.  Diminishing returns will be the rule in spite of our hope otherwise.  Policy will adjust accordingly.  Markets will adjust accordingly.  Some [biologic] things will never change.

Early adopters will realize that there is a major historical discrepancy between the slope of the line in 2009 and the dollars being spent trying to increase it.