Texas Tech University Health Sciences Center
Cause and Effect: How the immediacy of preventive measures determines their implementation

Cause and Effect: How the immediacy of preventive measures determines their implementation

I had the good fortune to hear Atul Gawande, M.D., MPH, speak at a conference recently. I am a big fan of his and try to read all of his writings. At one point during the speech, he talked about the rate of adoption of innovations in health care.

His first example was Henry J. Bigelow, M.D., (1818-1890) and his work on the advancement of modern anesthesiology. Dr. Bigelow was born into a family with many advantages and attended not only Harvard Medical School but also several of the leading medical schools of the day in Europe. He pioneered the use of ether as an anesthetizing agent. Great scientific discoveries are rarely the work of one individual, and the history of anesthesiology is no exception to that rule—this challenge (putting people to sleep for surgery) had been worked on by the ancient Babylonians, Assyrians, Egyptians, Greeks, Romans, and Chinese. Many people over the years had contributed to the process. But, the introduction of ether as an anesthetizing agent (far from perfect as it was) ushered in the modern era of anesthesiology and its adoption was rapid and widespread.

Contrast that innovation, as Dr. Gawande did, with the one that came from Joseph Lister, M.D. (1827–1912). He is well known for his advocacy for the use of carbolic acid as an antiseptic to sterilize surgical instruments and to clean wounds, which led to a reduction in post-operative infections and made surgery safer for patients. But, many of Dr. Lister’s very excellent recommendations were enacted quite slowly.

Dr. Gawande asked why the difference in the adoption rate. Why were Dr. Bigelow’s recommendations quickly and almost universally utilized, while Dr. Lister’s were implemented extremely slowly or not at all for a long period of time?

The answer, he said, lies in the “obvious” advantages of one over the other to patient and physician. Consider effective anesthesiology. Patients loved it in consideration of the alternative, and surgeons welcomed it. Imagine trying to perform surgery on someone screaming and who required several strong men to restrain. In other words, the benefits were immediate and beneficial to both surgeon and patient.

But, with the infection-control ideas of Dr. Lister, the benefits were not obvious and while infection was (and continues to be) a big problem, not all surgical patients of that era became infected. It takes several days for an infection to manifest itself, and some of the infection control practices were probably viewed as a hassle to the surgeons, nurses and others in the operating arena. You might say this observation is rather intuitive; but, consider the practical implications of it.

Let’s talk about preventing heart disease, for example. I was listening to Janet Wright, M.D., on Doctor Radio talk about the Million Hearts campaign, a national initiative launched by the Department of Health and Human Services to prevent 1 million heart attacks and strokes by 2017. They are promoting what they call the ABCS of clinical prevention: Aspirin when appropriate, Blood pressure control, Cholesterol management and Smoking cessation.” A person can do these things and not see any dramatic change. So, the temptation is to procrastinate and not get blood pressure or other conditions under control. The damage is subtle and may take decades to develop, so why the big rush one might ask? Of course, that is the wrong question.

We see innovations that give rapid reward and we want to do them. What about long-term things that are very good for us? Well, those can wait for another day, if we do them at all. This procrastination is the challenge of preventive medicine. This week, I think it worthwhile to ponder what we could do to change this way of thinking.