Tuesday, June 10, 2014

The Biggest, Baddest Disease Facing Medicine Today? Human Behavior

Two college students walk into a bar.  It is about five o'clock in the afternoon and one says to the other, I bet I can drink more beer than you.

The second student smiles and says, Why dont we see who can drink the most before midnight, and the loser pays for both tabs?

The first student exclaims, Oh! Im definitely going to win! They each open their tabs and order a beer.  The first student eagerly gulps his drink and immediately orders another.  The second student slowly sips his drink, enjoying its taste and refreshing coolness.  Before long, two hours have passed and the first student slurs to his friend, “Mmm already drank five annnn I bet-ya din’t even finish yur seggond!"  The second student smiles and again sips his beer.

As the night approaches midnight, the second student decides to locate his friend whos been lost to the growing crowd at the bar.  He finds him alone, slumped in a booth near the back of the bar.  He tries to rouse him, but his friend is hopelessly unconscious and snoring. He throws his friends arm over his shoulder, makes his way to the bar, and discovers that, overall, he had more to drink than his slumbering friend.  In fact, the last beer on his friends tab was only at 8PM!  He generously pays both of their tabs before helping his friend home.

Despite being a somewhat silly anecdote, an analogy can be drawn between this series of events and societal perspectives on health.  We bite off more than we can chew, we misunderstand how our bodies operate, and we often limit our own foresight of consequence. The same attribute that limited the first student’s ability to win his prospective contest can be easily seen in modern medicine.  In fact, as a budding Emergency Medicine physician, I was once asked, “What is the most difficult disease to treat?”  After having finished only a few months in various Emergency Departments, I contemplated the immense array of disease and illness that plagues humanity before realizing an appropriate answer: human behavior.

We are complex beings, products of not only our personal environments and experiences, but also the experimental result of millions of years of evolutionary trial and error.  Our genetic constructs, though, being 99% similar to each other (and 50% similar to bananas), still create the enormous level of diversity we see in our species.  It is unfortunate that this same genetic construct can incur the wrath of nature: cancer, diabetes, nearsightedness, baldness, and so worth.  It is with this sentiment that individuals identifying genetics or molecular biologys role in human illness stand to carry a sense of truth.  However, it is with this same sentiment that these individuals begin to unknowingly accept certain defeat.Human behavior is as diverse as our individual genetic constructs, but, strangely enough, just as homogenous as well.  We often overlook the simple aspects of our behaviors that are strikingly similar in favor of identifying our unique traits, but I ask you this: When you are hungry, what is your first instinct?  When you are tired, what do you want to do?  Time and time again, “repeat business” presents to emergency rooms, doomed to a seemingly endless cycle of disease relapse and medical treatment, all the while ignoring the role of behavior in the cycle’s perpetuation.  These patients would gladly like to break the cycle, for, as it currently proceeds, they self-identify feelings of misery, pain, guilt, and hopelessness on a daily basis. Yet, after being discharged from the hospital, their illness having been “tuned-up”, they relapse right back into the same cycle!  It is not difficult to see that both themselves and the healthcare system have failed them, for while patients of certain disease types are often victims of themselves, they are victims nonetheless.

What makes breaking this cycle so difficult?  What prevents people from identifying perpetuators in their lives and striving to amend them?  In many cases, lack of knowledge may play a role.  Simply overhearing conversations at the supermarket underscores this hypothesis, No, dont buy those cookies, theyre unhealthy, but make sure you grab a box of Count Chocula because it has a ton of vitamins.  Some people simply do not know the difference between healthy and unhealthy.  How could they?  It is entirely unreasonable to assume that every person has a basic level of understanding of health, whether it be diet, exercise, or disease management.

Another commonly observed barrier is the amount of effort needed to enact change. Improvements do not come easy, nor do they occupy a single facet of lifestyle.  Changing only a single aspect of an afflicted patient’s life is much like changing only one tire on your car.  While an isolated improvement has been made, the overall function of the car has not been drastically improved.  Unfortunately, it is difficult to sustain prolonged improvements in patients suffering from a disease cycle, since, cumulatively, it may take more effort than that person has ever had to expend.  Four tires cost far more than just one, do they not?

Just as importantly, patients may not understand or identify potential improvements and abandon their efforts with feelings that the changes are simply not worth it.  Imagine if I asked you to walk into your basement every morning to ensure that a light bulb in a far-off corner was turned off.  I tell you that it would save you money on your electric bill while also giving you a tiny bit of exercise each morning.  After a few days, you may abandon the task, deeming the idea to be unworthy of the necessary effort.  However, if everyone with a basement were to do this, the energy demand of society as a whole could drastically decrease.  Patients often view the effort it would take to change their lifestyle from the perspective of the person walking up and down the stairs every morning: an unfamiliar and potentially irritating task that offers minimally observable rewards.  

A physician's view of a patient's efforts, on the other hand, reflects the comprehensive advantage that society would experience as a whole: a very simple and relatively easy task with enormous benefits.  The human body is that society, your own society, a gross aggregate of varying cells, tissues, and organs, each dedicated to a specific function while working together towards a common goal.  Through this lens, it is now much easier to see how comprehensive care can suffer from even the smallest infractions.  You see, sins of omission stand to cause just as much damage as the sins we actively commit.

There are an innumerable number of additional barriers that preserve the cycle of disease in patients lives.  Perhaps the person has already admitted defeat and is relegated to the bare minimum until (morbidly) they die.  Or maybe they are financially limited from enacting positive change.  In fact, resource availability could serve as its own dissertation for disease cycles.   Above all, though, the most pervasive attribute of all of these barriers is the role human behavior plays in perpetuating them.  We all have unique life experiences, environments, and perspectives, yet we are all governed by the same inescapable biological laws that mandate the best way we should live our lives so as to maximize life.  I certainly do not claim to know how to begin to improve this system, but I am compelled to recognize the importance of individual considerations in disease perpetuations.

My last analogy takes place in the kitchen sink. The only way a sink remains empty is if the drain can move water faster than the faucet can provide it.  It is your goal to keep the water flowing down the drain as quickly as possible.  All we need is for it to drain just 51% faster than the faucet can provide water, and the sink will never overflow. To bring this full circle, at patient's behavior is at least half of the battle against human disease.  If you do 51% of the work, you can get off of this endless disease cycle that I see so often in the ER.

Vedant Desai, MD, is a resident ER physician at Allegheny General Hospital in Pittsburgh, PA. You can reach him at

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