Wednesday, May 16, 2012

Medicine Is Getting Squishy

I recently went to preop a patient who had one of the longest lists of medications I'd ever seen. But if you think this was another ASA IV disaster with a positive review of symptoms, think again. There was not a single antihypertensive, anti-arrhythmic, anti-diabetic drug on the list. Instead it was populated by anxiolytics, antidepressants, and antipsychotics. You see, this patient had a litany of diagnoses that made her medical problems difficult to define. She had generalized anxiety, chronic fatigue, panic attacks, and a host of other anxiety disorders that made it hard to understand the nature of her medical issues. Goodness, they didn't teach most of this stuff when I went to medical school.

A long time ago, when doctors first started treating patients, most of the medical problems were pretty obvious, clearly visible to the naked eye. There were the broken bones, the wound infections. Though the treatments were crude and frequently misplaced, at least the doctor could see what the problems were, or at least their symptoms.

Much later, when medicine started becoming more sophisticated and scientific, we doctors were able to diagnose patients down to the cellular level. With the invention of the microscope, we could recognize diseases like cancer, coronary artery disease, and acute tubular necrosis.

Once laboratory equipment was cheap enough and widely available, doctors could measure chemical and hormonal imbalances in the body. Diagnosing diabetes, metabolic acidosis, and sepsis became routine. Medicine has now taken its analytical capabilities down to the genetic level, analyzing strands of DNA that were not even known to exist until half a century ago. The miraculous evolution of medical testing is all but taken for granted now.

But now we have this new category of medical problems, the unmeasurable anxiety disorders. They affect a large portion of the population and appear to be growing every year. Chronic Fatigue Syndrome affects at least one million people per year in the United States and millions more with similar symptoms but who haven't been labeled yet with the disorder.  Panic Attack or Disorder will affect 20% of Americans, or 60 million people at some point in their lives. Generalized Anxiety Disorder has been linked to nearly 7 million people in the U.S.

None of these problems can be determined with a microscope, CT, or MRI. There are no blood tests to definitively diagnose an anxiety disorder. Headache, listlessness, and jitteriness? These are pretty amorphous symptoms for an internist to work with. Now, the new heroes of medicine are the neurologists, psychiatrists, and psychologists. Once the patients are recognized to have these issues, they are thrilled that they have finally been found with a "disease," rather than being told it's all in their heads.

When the "disease" has been made, it is easier to start a treatment. Unfortunately most of the treatments are also pretty ambiguous. So now a patient comes to the hospital with a long list of drugs like Celexa, Zoloft, Paxil, Effexor, Xanax, and on and on. The only thing that rivals the length of their medications is their list of drug allergies, which are also usually quite extensive.

I feel sorry for all the primary care doctors out there. As an anesthesiologist, the diagnosis has already been made by the time I see them. I just have to work with all the medications that the patient presents to me and avoid any adverse drug interactions that might occur with all these different medications floating around in the blood stream. We're rapidly gaining the upper hand on traditional illnesses like coronary artery disease, diabetes, and hypertension. These new medical issues are going to require future doctors to have the patience of Jobs and the cunning of Sherlock Holmes. Psychiatry might become the most important field in medicine.

1 comment:

  1. My allegiances are divided between psych and anesthesia (ok, and EM) as I get closer to applying for the match. It is really hard to decide what to do with the rest of my professional life! Good points here, doc.