Many people believe that neurologists are particularly attracted to detail. I prefer to think of the issue as one of precision rather than pointless obsessiveness. Some years ago, I was asked to discuss a case for the New England Journal of Medicine’s series of CPCs called the Cabot Cases.
In preparing the case for publication, I found myself in an argument with the editor about the placement of an apostrophe. There were two diagnoses in this case: aphasia from a cardiac source embolism to the left cerebral hemisphere and hypercoagulability as a paraneoplastic syndrome. In my view, aphasia is a Trousseau syndrome (i.e., the word “aphasia” was suggested by Trousseau), whereas hypercoagulability as a paraneoplastic syndrome was Trousseau’s syndrome, because Trousseau both described and suffered from the disease. I am very much opposed to the trend to remove eponyms from the names of diseases and syndromes as to do so strips medicine of some of its most illustrious history. But, only a handful of eponymic disorders deserve the apostrophe. Antonie van Leeuwenhoek’s disease (diaphragmatic myoclonus) is another example.
History in medicine is not a mere avocation. In addition to the old saw of helping to prevent the same errors from being repeatedly made, it provides us with the perspective needed to approach diagnostic and scientific challenges in our own era. It also combats hubris. In carefully researching my eleven New England Journal CPCs I have never encountered an idea that had not evolved from those before it.
In grand rounds, in medical journals, and particularly in the lay press, we are regaled with “revolutionary” ideas, but that they are completely new is an illusion. Throughout history, people have always been on the “cutting edge” and have repeatedly believed that they had some sort of huge advantage over prior generations.
I wish I could assign Lisa Rosenbaum’s characteristically wonderful essay in the latest New England Journal of Medicine to every twentysomething programmer in Silicon Valley planning to disrupt healthcare based on his uninformed interpretation of the problem to be solved.
Consider – as Rosenbaum does – the problem of medication adherence. As many as half the Americans prescribed medications don’t take them as recommended, even after a heart attack – despite very strong evidence of benefit in this context (namely, the prevention of a second heart attack).
At first blush, this seems like a perfect opportunity for a smart app, or a clever pill case that monitors usage and reminds forgetful patients to take their next dose. In fairness, for many patients, such technological innovation might prove impactful. Yet what Rosenbaum (a cardiologist) captures in her piece are the many reasons why patients, in the real world, deliberately choose not to take their medicines – even after a heart attack.
Some patients begin with an intrinsically negative view of medicines, and consequently tend to exaggerate potential side effects, and underestimate the likely benefits. Other patients choose not to take medicines because they don’t like to be reminded that they are sick – each pill taken to stay healthy paradoxically reinforces the concept that they are ill. Of course, many patients avoid medications because of the view that drugs are chemicals and therefore “unnatural” — in contrast to vitamins, or herbal remedies, which presumably are made only of organic goodness.
Still other patients subscribe to the view that “if it ain’t broke- don’t fix it,” and prefer to avoid medications when (as in the case of preventive care) the benefit is often imperceptible. (There seems to be less discussion of non-adherence in the context of oxycontin, for example.)