During this week’s The Rounds Table, Amol Verma (a senior medical resident) mentions that he thinks that the introduction of a new class of blood thinners – New Oral Anticoagulants (NOAC) – is the most important pharmaceutical advance that he has seen to date in his career.
I was a bit surprised by that, but that’s another story. Amol’s comment got me thinking about what I would rank as the top ten advances in health care during my career.
I started medical school at Queen’s University in 1976. So, I have a much longer history to reflect on than does Amol.
I’d be fascinated by the list that other readers would put together. Where do you think I am right, and where am I off base?
This list reflects my perspective as someone who has only practiced in a high income country. Thus oral rehydration therapy didn’t make the list.
Here is my Top Ten list, thinking back to 1976:
- The advent of CT scanners – I remember medical school lectures about doing cerebral angiograms in order to work up worrisome headaches; all of that disappeared with the advent of the CT scanner.
- The discovery of H2 antagonists like cimetidine and ranitidine – when I did my surgery rotation at the Hotel Dieu Hospital in Kingston in 1978, half the patients on the wards were having surgery to treat their stomach and upper intestinal ulcers. That is almost unheard of now.
- The discovery of antiviral drugs which are active against the human immunodeficiency virus – the emergence of AIDS in the 1980s is the disease that has had the most negative impact on humanity during my life time. However, the development of drugs that in combination can effectively treat the disease was a rapid and remarkable advance.
- Realizing that aspirin slows the progression of vascular disease – I remember reading the positive results of the Canadian randomized trial of aspirin in patients who had mini strokes in medical school. Aspirin is cheap, well tolerated, and has saved the lives of countless individuals.
- The development of angioplasty and stents – I remember being skeptical about how these would work when I read about the first coronary angioplasties. How wrong I was! This technology has allowed many patients to avoid more invasive surgery, and others who would not have been able to tolerate surgery have been successfully treated.
- The advent of laparoscopic surgery – I remember the first laparoscopic cholecystectomies being done while I was working in London Ontario in the 1980s, never dreaming of the number of surgeries such as bariatric surgery, that would eventually be conducted laparascopically.
- The advent of MRI – although not as big an incremental advance as CT scanning, the impact of MRI on the management of a number of diseases such as multiple sclerosis has been profound.
- The discovery in the 1980s that peptic ulcers are caused by an infectious agent (H pylori) is the most profound paradigm shift that I have seen in medicine – before that discovery we talked about the importance of “Type A personalities”, stress and stomach acid.
- The emergence of endoscopy – the ability to safely, effectively and reasonably painlessly insert a tube with a camera into any human orifice has been an enormous advance, gross as that sounds. Now, one can rapidly diagnose countless diseases, take biopsies and even treat some of them, thus avoiding more invasive surgery. The reassurance gained from a normal endoscopy should not be underestimated.
- The benefits of statins – during my first year of residency, a randomized trial of the cholesterol-lowering drug cholestyramine was published which showed a very modest benefit of a poorly tolerated medication. How times have changed! Statins are well tolerated, cheap, and are beneficial in most individuals at high risk of vascular disease, which includes a lot of us.
There are other advances that I thought of substituting for one of the above – erythropoietin has markedly decreased symptoms of fatigue for many people with advanced kidney disease, ACE inhibitors have extended the lives of many people with kidney and heart disease, new antipsychotic agents have improved the lives of many people with schizophrenia… I am sure there are many more.
I’d love to hear from clinicians and patients. I’d also like to hear from administrators and policy makers about the major advances in the last 30 years that have positively changed how we manage our health care systems.
The comments section is closed.
Vala Afshar, globally renowned health it thought leader listed these as his top 10 advances in the HuffPo http://m.huffpost.com/us/entry/5288574
Excellent commentaries just adding
I saw the introduction of ARVs empty wards and bring people back to life
Nicotine cessation therapy thanks to my dear colleague Michael Russell has saved millions
Neuro imaging and Molecular Genetics is laying the Future Foundations for a better understanding of disease process
S
Palliative care is our ongoing effort to humanise medicine in a technological era
DCCT: tight glycaemic control is very beneficial in DM Type 1
UKPDS/ADVANCE/ACCORD: glycaemic control doesn’t appear to be of susbtantial benefit in DM Type 2
Anticoagulation substantially reduces strokes in A Fib.
ACE inhibitors
Recognizing that guidelines and algorithms necessary but insufficient to improving care: the ascent of knowledge translation/implementation science
Efforts to reduce the undue influence of the pharmaceutical industry on prescribing behaviour
Dr Google: The internet, smartphones (previously PDAs), and the rapid access to knowledge
Palliative Care’s and Geriatrics’ ascendancies as disciplines
Molecular understanding of diseases, especially the immune system, resulting in molecular approaches to treating them
Recognition of the impact of infectious diseases as major safety threats to hospitalized patients (e.g. C. difficile, VAP, CLIs, SSIs, etc.)
PACS: saving physicians uncountable hours tracking down films
Physician acceptance (predominantly) that other professions can/should do some of the jobs we have traditionally done.
I could obviously go on, but these are front of mind as my eclectic list, moving from specific treatments to systems changes.
Once again the under awareness of the seriousness of auto immune diseases like inflammatory arthritis comes across loud and clear. Biologics for these diseases have transformed the lives of patients allowing them to remain in the workforce and for many women giving them the courage to have children of their own that they can now care for. These drugs are still relatively new and their full benefits not fully known but prior to the arrival of biologics most of us living with these diseases spent about a month per year in the hospital, a huge burden on the health care system. There are no longer any in-patient beds for rheumatology patients and that is as it should be. In 1984, the year after I was diagnosed with rheumatoid arthritis I met a woman with the same disease. My mother-in-law did her grocery shopping and took her to doctors appointments. Mary was around 60 years old but looked 80 and rarely left her apartment. Perhaps some of the reason for the low awareness of inflammatory arthritis is the fact that we used to disappear, becoming invisible to society when we were no longer mobile and independent. Mary died about 10 years after I met her, rheumatoid arthritis was the cause of her passing but I’m pretty sure it was not what was written on her death certificate.
Thanks for your compelling comments Linda.
Great comments. As a medical school grad of 1972 I was at 40th reunion in 2012 and there were lectures by various specialties on “Then and Now”. Just as this opinion piece and comments is, it was an incredible experience.
I think the biggest advances in ophthalmology have been advance in cataract surgery. Fortunately people today do not have to deal with aphakic glasses of the past. These had magnification and other distortions so that a normal life after cataract surgery was difficult even in the 1980’s. With this advance we no longer have to wait until patients are incapacitated by their cataracts as the cure with cataract glasses could be worse than the disease. Cataract patients of today cannot imagine that their lives are after surgery are so good compared to 35 years ago.
I would also like to mention the retinal imaging that we have today: HRT and OCT. When I was in school I could not wish for these as I could not even imagine them.
We are all lucky to be living in modern times.
The idea of overdiagnosis is not new, but is much more widely acknowledged by both professionals and the public. Sometimes all the great technologies are not what is needed, but rather a thoughtful decision about which ones to use (or not).
A great idea and excellent list.
I would add medication for benign prostatic hypertrophy (obviating the need for many TURPS) , much more enlightened use of opiates in terminal care and expansion of palliative care services ( when I started in health care morphine was doled out in a Grinch like fashion for dying people) introduction of advance directives and better pharmacotherapy for congestive heart failure
Very much agree with your list.
As far as great advances I think the ease of access to medical information/evidence via the Internet and the relative acceptance of the concepts of evidence-based healthcare, and critical appraisal and the Cochrane library should be way up on the list
The only thing I would change is what you said about statins – I think they should be on the list but, and maybe it just semantics and you may have meant something else, but to suggest they “are beneficial in most individuals at high risk of vascular disease” is not really correct in my mind.
Even in secondary prevention the NNT over 5 years for a cardiovascular event is roughly 20 – so 19 don’t benefit. One out of 20 getting a benefit is not most.
Even if roughly 60% of us develop cardiovascular disease over a lifetime and if statins reduced that risk by 25% – that means there will be a 15% absolute benefit – but that still means 85% get no clinical benefit over a lifetime of use. Again not most individuals.
Thanks for your comment James. You are right to point out that if 20 people need to be treated to prevent a cardiovascular event, then most people won’t benefit. However, that number needed to treat, for a relatively inexpensive (now that they are generic) and well tolerated class of drugs is pretty attractive. I’d sure take a statin. I guess what i meant to say is that a statin is indicated in most people at high risk of vascular disease. For “most” to benefit from any intervention, the NNT would need to be 2 or less, and that seems pretty unrealistic for almost any intervention.
My pleasure and I agree – however there are many who find a 5% absolute reduction of no value whatsoever. Weird but wonderful differences in people. Which reminds me – maybe shared decision making should be on the list!!
Hi James. I would happily put shared decision making on the list once we are doing it consistently well across the health care system
Great list. From a systems view I would add:
(1) the adoption of computers and telecommunications into all aspects of health care – medical devices, operations research, PACS, statistical modeling at all levels of health care from bedside to policy levels (still at very early stages of this transition along with broader society) …
(2) globalization of health care knowledge and research across cultures, systems and policy regimes
(3) international adoption of a determinants of health perspective … first adopted by Canada through the Lalonde Report and subsequently influencing how health and healthcare is viewed world wide …
(4) Principles articulated in the Canada Health Act … and subsequently refined by others
Thanks Andrew. Just two comments.
I was recently seen by my primary care practiitoner at Sunnybrook Health Sciences Centre, and she could not access my blood work that had been done at St. Michael’s Hospital. I’d consider adding EMRs to my list once they actually talk to each other.
Thanks for mentioning PACS (Picture Archiving and Communication Systems), which have been enormously helpful for radiologists and clinicians who want to quickly access the films of their patients.
I remember the days in London Ontario when I and my general medicine team would literally spend hours each day tracking down the films of our patients, which were often scattered across various offices in the hospital. That doesn’t happen any more, thank heaven.
However, at the risk of sounding like a dinosaur, there has been a downside in my view. Our team used to take the films that we were able to track down and meet face-to-face with radiologists like Dick Rankin and Linda Hutton to go over the films, talk about what other investigations might be needed, etc. These discussions were often extremely rich, and I don’t think they happen much any more.
I agree with your comments Andreas. In terms of computers I was thinking in broader terms that also include all areas – many are not given their due … for example facilities automation to control air handling systems in hospitals, most of the medical devices routinely used are essentially computers that process and display physiological and anatomical data collected from various processors, just in time purchasing and delivery systems that keep the very complex inventories and supplies available in OR’s, clinics ….
I also am concerned about the unintended consequence of isolating people (clinicians, staff, patients, families, government policy makers …) due to the expediency of computer processing these days … an area we need to emphasize more in future so technology becomes more of an enabler of meaningful and necessary interactions between people …
James M. is absolutely correct: One out of 20 is not “most”! 15 out of 100 is not “most”! What if I were to say 15 to 20 people out of 100 taking statins in the real world (outside the bounds of an RCT which uses a washout period) experience muscle weakening and joint pain? Would we then say “most” people on statins feel the adverse effects and don’t at all tolerate them? Instead we say they are ‘well tolerated’ even as we probably fool ourselves how poorly they are actually tolerated in the real world. I certainly wouldn’t put statins high on the list as a major advance; more likely on a list citing the most major scams of the century.
This is a great list Andreas. I would add the revolution in medical oncology that was started with Gleevec as has led and continues to lead to the “personalized medicine” transformation of oncology and many other disciplines.
Not so much a medical advance, but more of an increased focus in recent years on something as basic as hand-washing (to prevent the spread of diseases such as C. Diff, MRSA, etc., in hospital).
Andreas…Just saw this: http://www.qmed.com/mpmn/gallery/greatest-medical-devices-all-time?cid=nl.qmed02
Came here from twitter. Thanks for the medical “history” lesson. As a doctor of Amol’s vintage, I found the perspective very enlightening. While medicine isn’t perfect today, these are some great advances!
A, saw your teaser on twitter and taking this opportunity to reply, a bit differently than others.
I will add a brief comment to your points 1 & 7 which reflect a shortcoming of our manner of delivering publicly funded health care (I gave up using the term ‘health system’ for Lent…but that’s a story for another day). It’s not a medical advance but a failure to advance.
My M.Sc. thesis (1980, McMaster) presented a rationale for and design of an evaluation of the introduction of CT. Influenced by the late 1970s McMaster/CE&B thinking on the role of evidence in health policy (not to mention clinical) decisions, I thought that the public authority needed to know where CT could do a better job for the patient and which (invasive, costly, imprecise) procedures might be eliminated if CT were introduced. And, it should know these things before said scanners were installed. At the time I mused about taking this design to the level of PhD scholarship – and putting it to the test – but did not do so. A bit of a regret.
In answer to your question, I could not find a decent antonym for advance so I will put it this way: a failure to advance effective publicly funded health care is our reticence to require evaluation when new technology is introduced. I believe Ontario did just this when trying to manage (perhaps not the best verb) the introduction of PET scanning. Without belabouring the point: let’s start thinking of innovative technology (like imaging) as an investment and work out, in advance, how we will measure return on investment.
Interesting perspective. There was an intriguing comment from CADTH conference that the number of new drugs submitted was about 50 while the number of technologies was in the thousands. Huge cost implications!
Great List.
When I think of the advances in my field (Psychiatry) and limit it to pharmacologic advancements, I would list:
Antipsychotic medications for psychosis, bipolar disorder and delirium.
SSRIs for depression (fewer side effects than TCAs and others)
“Antiepileptics” for bipolar disorder
Stimulants for ADHD
The depressing part is that they don’t work for all, for those they do work for they don’t work that well, and they are bandaids not cures.
Hopefully the rest of my career will work on why there are more people with psychiatric disorders from autism to depression in the first place!
I will shift the discussion to the greatest regression during my medical career:
The abolition of the general rotating internship and general licensure.
This decision has done nothing but harm both the medical profession and patients, for multiple reasons:
1. It has marginalized family medicine academically, economically, and politically.
2. It has decreased family medicine access, since most students would rather go into specialties than into family medicine. Specialist physicians cannot practice primary care due to legislative barriers. New primary care physicians concentrate their practice in the ER or in other non-office-based paradigms.
3. It has forced medical students to make final career choices far too early in their careers. For instance, if a medical student wants to do something like ophthalmology, they’d better start greasing the wheels from day 1 of medical school. This reduces the value of general medical knowledge (since for most, such knowledge is not required in residency or to obtain a residency) and can lead to employment issues (like with orthopaedics) and burnout.
The move to relinquish the general license has been a huge step backward for Canadian medicine.
Thank you for including the H2 antagonists on your list. Three of my five uncles had surgical management for stomach/upper intestinal ulcers prior to the advent of these drugs. The class of drugs is now available without a prescription and, sadly, often regarded as being inadequate. How quickly we forget.
And seeing Joe’s comment, I can’t believe I overlooked pulse oximetry — possibly the greatest single factor in reducing operative morbidity/mortality (and anesthesia CMPA fees), not to mention ICU, NICU, and emergency care.
I also started med school in 1976, so I have a similar perspective, and agree with many of these points. I remember seeing my first CT scans as an intern. However, I’d put laparoscopy and endoscopy together — really just variations on a theme.
I’d add recognition of pain assessment and management (especially in children), as well as but not limited to palliative care, as a major advances in patient care.
I agree with the above.
I am so old that I recall when pulse oximetry was introduced. before that we used to guess about SaO2, and I was considered to be a good guesser. I was humbled to see howq often I was wrwrong.
Agree that pulse oximetry has been incrediubly important. This made me think of glucometers as well. Although over-used in some people not on insulin, it has made a big diffference in the management of diabetes
Thanks Andreas for putting a list out there. It would be interesting to take an “evidence-based” approach to come up with such a list but I will give you my perceptions based on what has caught my attention along the way in my career in healthcare management and policy development:
1. Laproscopic Surgery – The number of hospital beds used for surgery has plummeted (thank goodness or we would have no room for all the medical ptients). Earlier in my career patients were often admitted several days before their surgery for education and remained in hospital many days after.
2. Obstetrics – New mothers and their babies stayed in hospital for 5 to 7 days. My daughter-in-law after having her delivery took her baby home from the hospital after 5 hours.
3. Mental Health – Many thousands of people with mental illness were cared for in institutions. Very few mental health beds remain as people are now more likely to be served in the community (although not as well as we would like) with the help of better drug management, day programs and various community supports.
4. AIDS – I remember our strategic planning session at Sunnybrook in the early 1990s when we considered the scenario of our inpatient beds being overwhelmed by patients with AIDS. Fortunately, drug developments and public education have adressed this concern.
5. Heart Attacks and Strokes – Prevelance of heart attacks and strokes have dropped significantly due to better lifestyles and therapies. Also, thrombolytics have had a huge impact on outcomes with immediate treatment.
6. Laboratory Automation – Our ability to conduct multiple tests on samples simultaneously and quickly using technology with minimal human intervention has enabled low cost laboratory diagnostics and enabled their widespread use.
7. Hospitalists – Rather than having multiple physicians come to the hospital to manage their patients, using hospitalists to be the most responsible provider for many patients has enabled more consistent and evidence-based care. The downside of course has been the challenge of maintaining the linkage to community-based care.
8. Ehealth – Progress has been a lot slower than I expected it would be with Ehealth but most hospitals and community-based healthcare practices are now making very effective use of the functionality of internal computer systems and patient information exchange. Clinical decision support, electronic health records and productivity improvements are beginning to take hold.
9. Performance Reporting – It wasn’t until the 1990’s that any meaningful performance reports were available to providers, system managers, policy analysts and the public. The system is a lot more transparent and accountable today although this could still be done a lot better and address all parts of the system.
10. Structure – The number of organizations with their own CEOs and Boards has been in continuous decline. The purpose has primarily been to achieve economies of scale and enable integration of care across the continuum both horizontally and vertically. This has significant intuitive appeal but clarity regarding the best organizational design has proven to be somewhat illusive.
I will leave it there. Thanks Andreas for making me think about this.
Tom Closson
Pediatrician’s perspective:
1. Innovations in care for premature infants: surfactant, high frequency oscillation ventilators, body cooling to prevent hypoxic ischemic encephalopathy
2. Introduction of hemophilus influenza type B vaccine.
3. Discovery that most cases of acute otitis media do not require treatment with antibiotics. Perhaps the discovery that a disease may not require treatment with antibiotics is as innovative and health-promoting as discovering a new antibiotic to treat a disease.
Your comment about the treatment of otitis media made me wonder about a possible future “Top ten”: “Things we know we shouldn’t do, but still do.”
How about HPV discovery that led to a way to prevent cervical cancer?
Great list, Andreas! I’d add the oral oncology agents as a group, given their impact on not only patient outcomes but health system efficiencies.
Hi Judy. As I finalized the list (something i did over a couple of hours on a Sunday afternoon drinking a glass of red wine – so not a highly thorough process) I was aware that there was nothing specific about cancer on the list. I wondered about adding imatinib (Gleevec), which is very effective in the treatment of chronic myelogenous leukemia, and is also used for other cancers, but didn’t think it has had the impact of the others I mentioned.
For some cancers, like breast cancer, my sense is that a number of advances, all modest in and of themsleves (e.g. tamoxifen, earlier detection), have led to better outcomes when applied together. Of course, with the early detection, we need to be careful that we don’t confuse longer follow up with longer survival.