Plus ça change, plus c'est la même chose: What’s changed (and what’s unchanged) in Medicine since 1966

| 3 October 2016

NBC’s Dr. Kildare show-doctors in the 1960s

The good physician treats the disease; the great physician treats the patient who has the disease

~William Osler

Dr. Paul Armstrong (Med 1966) recently asked me to summarize the changes that have occurred in in the practice of Medicine over the past 50-years in a lecture to their class for Homecoming. This assignment caused me to reflect on what has changed in Medicine (at first blush everything), and then to reflect on what has remained unchanged. As I considered the numerous inventions, miraculous drugs and devices, it became clear that our cleverness and inventiveness, while beneficial when applied judiciously, is at the root of the twin dilemmas of modern health care: cost and congestion. Initially I thought of the 50 year time frame only as a convenient mid century marker; however as I read more I realized that Dr. Armstrong and his class mates entered the profession just as private payment for health care gave way to an elaborate public insurance system. The significance of this is clear-what one individual can pay for is limited; however, we the people, can pay for elaborate therapies. In addition, a rewind to 1966 takes us back to a time when the Canadian population was young and rate of reproduction high; fast forward to 2016 and we are aging and families are smaller. Acute illnesses and deaths from infection and childbirth have given way to chronic illnesses like cancer, cardiovascular disease and neurodegenerative syndromes.

1966 was a critical year in Canada. The Pearson government introduced the Medical Care Act which was passed into law by a vote of 177 to two. The Medical Care Act built upon the 1957 Hospital Insurance and Diagnostic Services Act, which assisted Canadians in covering the costs of hospital services. In 1983, Trudeau the Elder’s government incorporated the contents of both earlier pieces of legislation creating the modern Canada Health Act. The Canada Health Act (CHA)was designed "to protect, promote and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers." The CHA specified that our Universal Health Care system should be: Publically administered, Comprehensive, Universal, Portable, and Accessible. Health Care is a provincial mandate and so to ensure compliance the Feds wielded a stick. Namely, unless the plans fulfilled the Canada Health Act’s criteria they would not receive their federal transfer payments, which account for 33-50% of the health care budget.

However, the CHA was forged in an era when medical care was, by modern standards, cheap. The Medicine of 1966 was marked by conservative care, observation and for the enlightened physician, a sense of our profession’s limitations in the face of a panoply of incurable diseases. However, 1966 was an inflection point, both in how we paid for health care and in our competency to cure. From 1966 onward each year saw an increasing array of modern miracles. First we noted their awesome impact on people (usually optimal candidates for the therapy or device). Then we became cognizant of their equally awesome cost. Of late we have struggled with ethical and societal issues of how to apply these interventions to ever-older patients with complex multisystem disease and frailty. As Medicine has become more effective (better drugs, less invasive interventions) spoken (and implicit) rules of triage that once simplified the practice of medicine have been discarded. In 1966 patients were routinely denied access to new procedures (like dialysis and bypass surgery) based simply on their age being >65 years. Now most inpatients are in the 70-90 year old age range. To the challenge of paying for their care we now must think carefully about their goals of care. Do our medicines, surgeries and procedures enhance quality (not just quantity) of life?

One consequence of the revolution in Medicine is an escalation of cost of health care that has suddenly become unsustainable. In this milieu, doctors and the Ministry of Health and Long-term Care (MOHLTC) are not getting along well, perhaps because each sees the system challenges from their own perspective. In 2013 Canada spent 11.2% of its GDP on health care ($211 billion). The distribution of these funds was: hospitals (30%), drugs (16%) physicians (15%) (CIHI, 2013). Physician compensation is the fastest-growing category expected to reach $31.4 billion (3.6% growth) (CIHI, 2013).

To illustrate the problem facing the doctor of 2016 and the MOHLTC let’s consider a patient case. Although hypothetical this patient is not unlike many I see in my own clinic.

Case: A 66-year old female with aortic stenosis, sick sinus syndrome is referred for management of exertional dyspnea, palpitations and syncope. She also notes an enlarging mass on the side of her nose

PMH:
- Type 2 DM with nocturnal hypoglycemia
- Transfused in 1980s for GI bleed-acquired Hep C
- Poorly controlled hypertension
- Stage 3 renal disease
Social: She lives at home with her husband and is employed as an office worker. Her husband is 72-years old and has recently been diagnosed to have Stage 4 NSCLC
Risk Factors: active smoker (1-ppd cigarettes X 30 years), LDL cholesterol 3.5
Medications: Triazide daily, Metformin bid , Insulin bid, Atorvastatin daily
P/E: BP 155/95 mmHg, Hr 45 bpm, RR 14/min; BMI 29, Looks stated age 
Derm: 1 cm, pearly, scaling growth on the left side of her nose
CV: III/VI murmur of aortic stenosis, A2 absent, pulsus parvus and tardus
Labs: Creatinine 210, Hb 100, Platelets 220, AST 42, Hep C (+), HbAIC 9, fasting blood sugar 5, albumin 30, urine dip-positive for trace protein
Echocardiogram: Normal LVEF, critical AS, MG 45mmHg AVA 0.75 cm2
EKG: sinus rhythm 1^st degree A-V block, RBBB, LAFB
Holter: sinus bradycardia 40 bpm with multiple 2s pauses and paroxysmal rapid AF (130 bpm)

The patients first concern was the mass on her nose-which proved to be a basal cell carcinoma.

bcc-nose

Based on its location conventional resection was not possible because it would have cause deformity. She was referred to Dermatology and underwent Moh’s micrographic surgery. The resection, guided by real-time histopathologic surveillance of the margins allowing the minimal safe resection margin (see Figure below), worked well!

mohs-surgery-graphic

In 1966 she would have had application of a topical chemical, fractionated dose of radiation or perhaps an attempt at local resection, each of which would likely have disfigured her face.

One month later she is at home and suddenly develops right-sided weakness and aphasia 

She was diagnosed to be having stroke and underwent thrombolysis with relief of hemiplegia and aphasia. In retrospect it was discovered that despite having documented paroxysmal atrial fibrillation she was not on anticoagulation therapy. After an urgent CT scan she received thrombolytics and then underwent catheterization. This revealed thrombotic inclusion of her middle cerebral artery. A stent retriever catheter was used to remove a large amount of thrombus (example below). While on the table her aphasia and hemiparesis began to resolve. She left hospital 4 days later with no functional impairment.

thrombolysis

In 1966 she would have completed her MCA stroke and likely died or been let permanently disabled.

3 months later she returns to stroke clinic noting she is have more runs of atrial fibrillation at a rate that is usually ~120 bpm. She detects this on her AliveCor® device and iPhone® and has emailed you a trace (below). Episodes last for 2-3 hours and make her fatigued and short of breath. She also notes episodes of near-syncope, often after AF runs terminate.

alivecor

She undergoes atrial fibrillation ablation and placement of a pacemaker for her sick sinus syndrome.

pacemaker

Pulmonary vein ablation-a contact sensor tells the electrophysiologist when the contact between the left atrium and ablating catheter are optimal. At this point a burn is administered and the connection between the arrhythmic source in the cardiac muscle of the pulmonary vein and the left atrium is severed.

In 1966 she would have received propranolol and digoxin and likely would have struggled with bradycardia and exacerbation of her symptomatic pauses. She might have received a Holter monitor to detect the arrhythmia. This device, invented by the American physicist Norman J. Holter, was in clinical service in the early 1960s.

She continues to have syncope despite the pacemaker and you determine it is due to her critical aortic stenosis. You refer her for transcatheter aortic valve implantation (TAVI). She undergoes successful placement of a #26 Medtronic CorValve

tavi The patient had degenerative, calcific aortic stenosis

TAVI has proven to be the equal of conventional aortic surgery.

tavi-graph

In 1966 most centres did not offer aortic valve surgery, and those that did usually restricted its application to patients under 65 years of age. Our patient would likely have died within 1-2 years due to critical aortic stenosis with little cost to the system.

Post TAVI creatinine >500 and she develops uremia, needs dialysis.   Her renal function does not recover. She begins home hemodialysis and does well. This technique provides better outcomes than in-centre dialysis, likely because it offers the possibility of longer more frequent episodes of dialysis.

hemodialysis

In 1966 she would not have had the TAVI but might still have developed renal failure (due to diabetes and hypertension). Had she developed renal failure she likely would have died from uremia in weeks-months. Most centres did not offer dialysis until the late 1960s, and again only to those under age 65 years. Dialysis at Queen's University began in 1967 at Dr. Peter Morin's initiative.

She does well for a month then develops watery diarrhea, abdominal pain and bloating. Her stool positive for C. difficile (culture and toxin). She was treated medically for 1 month with oral vancomycin without resolution. The patient loses weight and diarrhea persists and so she receives a fecal transplant. Stool from unrelated donors (frozen or fresh) is mixed into a slurry, filtered and administered by enema. Her colitis is cured.

stool-transplant

Dr. Elaine Petrof and team have developed a defined bacterial cocktail to replace the microbiome. This next generation of therapy for C. difficile is called Re-POOPulation!

In 1966 C. difficile colitis had not been described and she would not likely have been exposed to the medical stresses and hospital environment which predispose to C. difficile colitis.

She now has had a TAVI and her SSS is treated with pacemaker + ablation. She is stable on dialysis and her C. diff is cured.

She asks you whether her Hep C should be treated?

After determining her Hepatitis C serotype and quantifying cirrhosis with a Fibroscan (below) you prescribe Epclusa ® (sofosbuvir+velpatasvir).

hep-c

After 12-weeks of oral therapy (at a cost of $90,000) she returns cured.

In 1966 the Hepatitis C virus had not been discovered!

The patient returns feeling entirely healthy for the first time in years. You note her home BPs are consistently > 140/80 mmHg (measured using her home BP device). She is on a thiazide diuretic monotherapy.  

Based on the Sprint Trial (N Engl J Med 2015;373:2103-2116) you add an ACE inhibitor and a calcium channel blocker to achieve a target BP of 120/80mmHg. This intensive treatment reduces all cause mortality compared with treatment to conventional treatment (target BP of 140/90 mmHg) (below).

bp-graph In 1966 there was no evidence basis for hypertension treatment. The first RCT proving the benefit of antihypertensive therapy for severe hypertension was performed in 1967! (VA-1).

va1

She returns after 6 months and feels well with resolution of her many symptoms. She is tearful and distressed because her husband has requested medical assistance in dying (MAID) having determined that his quality of life is unacceptable because of his cancer, despite excellent palliative care. He is eligible because he is >18 years old, has a grievous illness and is competent to make the request. MAID became legal in Canada in 2016 (see Supreme Court Decision in the Carter case below) and is currently being performed in Kingston.

maid In 1966 our patient would likely have been dead within 2 years from critical aortic stenosis. The cost of her care to the MOHLTC (had it existed at the time) would have been negligible.

In 2016 she will likely survive ~5 years, her survival determined by the mortality of dialysis. In 2013 US Renal Data System reported that the adjusted, 5-year, survival probability was 36% for dialysis patients.

We can question the quality of life the patient experienced. It may have been substantial; but perhaps not.

A rough estimate of the bill for all this year of care?

screen-shot-2016-10-03-at-1-00-26-pm

Needless to say, a lot has changed since 1966-our Universal Health Care System, miraculous drugs and devices, the cost of care and the aging population with its high expectations from Medicine and high burden of chronic illness.

What has not changed since 1966?

In 1966 the physician often had to sit beside the patient and acknowledge there was a limited amount that could be done to cure many diseases. They offered comfort care and supported the patient through their ordeal. Of course there were brilliant diagnosis and valuable surgeries and cures for many illnesses, particularly infectious diseases. Still Medicine remained an art. The cost of our care was modest and was largely paid by the patient out of pocket in cash.

In 2016 despite many more tools in our kit; Medicine remains an art. We are challenged to be wise and to counsel patients, who are increasingly well-informed, when it is better to engage in aggressive versus conservative therapies. We are also faced with the patients’ increasing age and many co-morbidities. Finally, our therapies are hugely expensive and the public pays, so personal resources are rarely the limiting factor in choosing a therapy. While physicians work for the patient we must also be responsible custodians of the health care system and Choose Wisely®.

Nonetheless, much is unchanged over the past 50 years. The need for compassionate, curious and collegial physicians remains undiminished. The desired attributes of a Physician in 2016 are still the “3 A's” , unchanged from 1966: Available, Affable and Able. 50 years hence this will not change.

Also unchanged over the past half century of the truth of Osler’s adage:

The good physician treats the disease; the great physician treats the patient who has the disease ~William Osler