Caring for patients doesn't end in the office

I received some supportive email responses, but many people were not happy and stated firmly that I and other doctors have no right telling people how to live.

One respondent said, "If you nag me about smoking, I'll punch you in the face."

A third reader objected "to the unwelcome and unwarranted intrusion on privacy."

"BO" said that the writer (me) "had no obligation to invade my personal space, intrude on my life, and insert himself into issues that are none of his concern."

"Lorenzo" simply told me: "Shut up, Doc."

Wow.

I do not agree. I believe it is my obligation to my patients and to all members of society to use the knowledge and experience I have to give people the opportunity to live more healthful and safer lives.

I know more about the overwhelmingly proven dangers and complications of smoking than the man at the airport does, and I believe he might be more willing to consider cessation if he knew what I know. I chose to remind him of the risk he was taking by smoking and make him aware of the opportunities we have now to help him become tobacco-free.

NO LONGER REACTIVE

When I did my medical training, I was in a university-affiliated hospital, and we waited there until people came in with what was usually illness in an advanced stage. As did my colleagues, I trained in a world where understanding pathology-what was wrong-was stressed, not etiology-what had caused it. The focus was on aggressive intervention, necessary because everyone was so ill. Some people did get better, many did not, but the message we received was that such serious illness could not often be cured.

We learned to accept blindness and extremity amputation as normal results of diabetes, strokes and heart attacks as the anticipated result of hypertension, and cirrhosis and severe gastrointestinal bleeding the frequent complication of extensive alcohol use. People had workplace accidents, people got mugged, women were abused. People with arthritis stopped walking, people with osteoporosis broke bones, and people with glaucoma lost their vision.

It was a reactive approach to medicine: wait until something bad happens, and then respond. And that is the way that medicine had always been. Reactive. It never felt right to me.

FOCUS ON PREVENTION

Although epidemiologic work, such as the famous Framingham Heart Study, had been completed previously, it was only in the mid-1980s that a new approach developed: Let's look at the causes of illness and determine whether we can prevent or modify those causes-and do so before people get so ill.

I'm not certain when I first heard about that proactive approach, but I was immediately more comfortable with it. And so, it seemed, was everyone else.

No longer do we wait for patients to show up with life-threatening illness. We want to prevent them from becoming ill or help reduce the disabilities associated with their current illness. That is a huge change-and a very good one, in my opinion.

Over the past 30 years, we have reduced the complications of metabolic and vascular disease, and we have made great progress in identifying illness at early and treatable phases. Cancer no longer is a death sentence, and patients with diabetes no longer must anticipate amputation, blindness, and dialysis. People are living longer and better, and physicians deserve some of the credit.

That approach may not sound very revolutionary to a 30-year-old physician, but it is a concept a 60-year-old doctor has had to learn in practice, and it is something a retired 80-year-old colleague never will fully understand.