I’m ready to confess that I’ve been basking in a particular drug-induced fantasy for a number of years. It’s a different type than we usual read about, and I suspect it’s shared by a fair number of other folks who work in biopharma. We dream of the day when a medicine we created begins to help patients. All those years of training and hard work (both yours and your colleagues), coupled with a little bit of luck and backed by a whole lot of money, have finally paid off. Maybe a family member has their life saved. Perhaps it helps your favorite athlete or musician, and they send you a nice note expressing their gratitude. Maybe no one you know personally takes the new drug, but sales figures tell you its helping thousands, if not millions, of people. Kudos rain down on you like an Oklahoma summer downpour, and one day it all culminates in an early morning phone call from Sweden.
That’s the dream, anyway. Reality, however, has a way of forcing itself into your reverie whenever you start to feel like you have a good understanding of how it all works. I love the awesome technical capabilities that the latest breakthroughs in biotechnology confer upon us. We can identify a whole genome’s worth of individual cancer mutations at the molecular level in just a few days. It’s possible to visualize the growth of a bacterial infection in living animals using bioluminescent imaging. The capability now exists to create entirely new organisms using pre-assembled genetic building blocks in a synthetic biology approach. A list of recent biomedical advances would easily fill a number of pages.
Living in this futuristic world is highly seductive, but what I’ve been reflecting on lately is how science has yet to catch up with either society or medicine in being able to actually solve a number of healthcare problems. A recent article revealed how doctors identified previously unknown gene mutations that were the underlying cause affecting sick newborns in a neonatal intensive care unit. The analysis took only two days, and it eliminated the need to run a large number of other tests. This knowledge, however, wasn’t actionable. It didn’t enable the doctors to treat the children, and they died.
While the technology is dazzling, it’s pretty humbling to recognize just how much more important low-tech solutions can be in the real world. Equally impressive is how well these solutions acquit themselves on an expense: benefit calculation. Many healthcare solutions cost virtually nothing, but contribute immensely to patient outcomes. While we toil to discover new, life saving medications, it’s become clear that a number of simple, inexpensive solutions can be more effective in helping a much wider spectrum of patients than any drug we can come up with.
Let me share a few examples:
Hand Washing By Hospital Staff Prevents Infections
Doctors, not surprisingly, hang out in an environment that is rife with viruses and bacteria. Touching and being coughed and sneezed on by countless patients every day makes them ideal disease transmitters. Virtually every hospital insists that their doctors (and nurses) wash their hands in between seeing patients, but, unfortunately, not every medical professional heeds this advice. Hand washing is an incredibly effective, low-tech method for preventing the spread of infections, but getting our health care professionals to consistently practice this technique has been challenging. We’ve read about the rise of dangerous drug-resistant bacteria (e.g. MRSA), yet studies have shown that only about 30 percent of the interactions between patients and hospital workers are preceded by hand washing. Every year some 48,000 Americans die from hospital acquired infections, and many others have their stays prolonged. Ironically, numerous high-tech approaches have been rolled out in an effort to combat the rise of hospital-acquired infections. One group has installed video cameras that send images of doctors seeing intensive care patients to India, where workers have been trained to check that hand washing gets done in every case. Another approach uses smart wristbands that use lights and vibrations to remind doctors to wash their hands when meeting new patients. Positive and negative reward programs have also been tried in an attempt to increase the practice of washing hands. It’s gotten to be so bad that at least one hospital has resorted to the same system your third grade teacher used when she wanted to motivate you: they pass out gold stars that workers can wear on their lapels.
Prescriptions Go Unfilled
I started off this article by reflecting on the dream of creating a very useful new drug. A bigger problem may be that people are not taking the existing medicines that were prescribed for them. A recent article estimates that 130,000 people die each year in the U.S. because of this. Exactly why they don’t do this is unclear, and a number of potential explanations have been put forward. These include not being able to afford the medicine, a lack of time to fill the prescription, difficulties in opening the container, and a fear of possible side effects. A recent poll by Consumer Reports indicated that 45 percent of U.S. consumers who don’t have prescription drug benefits fail to fill their prescriptions because of cost. Some 62 percent of these people declined a medical test for the same reason, and they also skipped recommended medical procedures and put off doctor visits. Since almost half of adults take prescription medicines, this indicates that millions of people are not getting the medicines they need to stay healthy. The Centers for Disease Control reported that some 36 million Americans have uncontrolled high blood pressure, putting them at an increased risk for stroke and heart disease. As a result, nearly 1,000 people a day die, and the direct cost of this is estimated at $131 billion per year. Finally, a recent Kaiser Permanente study found that nearly 30 percent of women failed to pick up new prescriptions for osteoporosis. One approach taken to combat this problem (and which appears to be successful) is actually paying patients to take their medicines. Compliance by patients taking medicines for HIV and tuberculosis was increased for a surprisingly low amount of money.
Simple Checklists Improve Surgical Outcomes
Adding something as simple as a checklist into the surgical suite environment was widely met with resistance when it was first introduced. As doctor and author Eric Topol once described it, “Of all the professions represented on the planet, perhaps none is more resistant to change than physicians.” Despite the fact that the checklist concept is already firmly entrenched in other complex fields (e.g. flying airplanes), many doctors wanted no part of this process and didn’t understand the need for it. This resistance is difficult to understand in light of the many well-publicized stories about what happens when things go wrong in the O.R. Surgery performed on the wrong limb or patient actually made up some 0.5 percent of all medical mistakes according to a study done several years ago. This means surgery is done on the wrong body part about 40 times per week across the U.S. The eventual acceptance of checklists at a number of medical centers and hospitals showed that these lists really do help reduce patient morbidity and mortality. I felt very reassured during a recent medical procedure when I was asked by person after person for my name, my birthdate, and what treatment was I there for.
The examples go on and on. We know that many people can’t afford to see a doctor, and the number one cause of bankruptcy in the United States is unpaid medical bills. By using the phrase “can’t afford,” I’m not just referring to not having the money to pay a bill. Sometimes these patients can’t afford to get the time off from work (they’d get fired), or they can’t squeeze the time into their rigid work schedules to receive a lengthy and debilitating series of radiation treatments. The special problems that poor people encounter in trying to meet their health care needs are well described in How We Do Harm: A Doctor Breaks Ranks About Being Sick in America by Otis Brawley (with Paul Goldberg). The book is filled with heartbreaking anecdotes that illustrate how the availability of new medicines and treatments (as well as older ones) do not trickle down to many poor Americans. The first story in the book sets the tone, about a woman who arrives in the ER carrying one of her breasts in a plastic bag. It’s literally fallen off due to advanced cancer, and her primary request is to find a doctor who is capable of reattaching it. The story, sadly, did not have a happy ending.
The data seem pretty clear: we need to adopt a more comprehensive, cost-effective approach to providing health care solutions that benefit the most patients. In many cases this means turning to low-tech approaches. I’m not arguing that it’s time to radically scale back on trying to develop viable treatments for amyotrophic lateral sclerosis (ALS), pancreatic cancer, or any number of rare diseases. It’s simply time to acknowledge that as a society we may get the most bang for our healthcare bucks by investing more in trying to help our citizens use approaches that don’t cry out for a science/technology/engineering/math (STEM) education. Let’s focus on making sure that prescriptions get filled and people can afford to see their doctors in a timely way. For all of the money and resources we devote to developing new treatments and medicines, it seems pretty clear that compassion and common sense need to be a part of the equation as well.
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