What Matters II

What really matters? Why are we doing what we do? What are the ultimate goals of medicine? Are we in the business of saving a guy from a heart attack just for him to get a stroke a few months later? Are we striving to make people immortal? How much are we willing to pay to make people healthy? Does anyone deserve more or better health care than anyone else?

These are somewhat fundamental questions to the practice of medicine but ones that are rarely addressed. I get the sense that most of my peers believe in universal health care; they believe with respect to health, we all deserve the same attention and treatment. But what does this mean on a population scale?

With limited resources, how do we distribute health care? If, for example, I give someone a treatment that costs society $30,000 for him to live a year longer, is that worth it? What about $100,000? Or a million dollars? At some point, we should abandon these costly interventions and focus on more cost-effective treatments for our patients. Dialysis may cost $30,000 to extend someone's life expectancy a year. But what about counseling a person on diet and exercise? How much does that cost? And how strong are its benefits?

A Mediterranean diet and 30 minutes of exercise each day exert a huge health benefit. But I guarantee that if doctors suddenly became nutritionists and coaches, we'd become a much less palatable field. Yet shouldn't our focus be here? If we want people not only to live longer, but enjoy better quality lives, shouldn't we spend the bulk of primary care visits counseling about fruits and vegetables and swimming and smoking cessation? If successful, this beats all the colonoscopies and stents and antibiotics in the world.

But this still is thinking on too small a scale. To really get people to live longer and better lives, we need large scale system wide changes. We need to ban smoking. Get rid of trans-fats in food. Increase the educational level of the general population. Get people to exercise.

For a long time, I thought I would end up in critical care or anesthesia. It now disappoints me a little that these fields really aren't the ones that will make hugely influential changes in lives of the general public. Probably no traditional medical fields will. We focus on individual people and specific diseases not large populations. What matters? Helping out one person or helping many? Doing expensive cool technically challenging things or mundane obvious and obstinately difficult things?