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.