Cutting across clinical disciplines, non-communicable diseases have come to occupy centre stage in our day to day practice of medicine. This phenomenon has considerably changed our outlook towards patients and their families, although an epidemiological disaster the pandemic of COVID-19 has made us more sensitive to co-morbidities and has changed the way we deliver services. This article has cited these trends and has elaborated upon them and their possible causation. This review puts these trends in perspective in order that our peers might prepare themselves for the road ahead.
This is a vast topic which normally cannotbe encompassed. Save for our day-to-day practice which finds its resonance in the current medical literature and in media reports.
By this token, some trends now observed are:
1. A focus on wellness
2. Acceptability and mainstreaming of online practice
3. A cultural shift in the doctor patient interaction
4. A focus on cellular structure and genomics apart from merely tissues or body organs
5. A focus on the family and society instead of the individual patient alone
6. A greater understanding and acceptance of interventions related to mental health.
Let us now discuss them one by one.
Everybody intuitively relates to the aphorism ‘an ounce of prevention is better than a pound of cure’.
Nowhere has this been more extensively studied, than in coronary artery disease. Primary prevention here means modifying one’s lifestyle to address modifiable risk factors such as diabetes, smoking, hypertension, dyslipidemia (cholesterol) and obesity. Secondary prevention means managing risk factors, when an individual patient has one or more of them, so as to prevent effects on the heart and the circulation.
However, in practice, one had to consider the cost of these treatments against the benefit of the events prevented. Namely, the cost-to-benefit ratio.
Until the first decade of the millennium it was held that the costs for prevention and risk factor modification for coronary artery disease could not be justified vis-a vis the benefit of preventing hospitalisation or myocardial infarction (MI).
Subsequent experience and studies proved otherwise. For instance, an article published in Circulation in 2011 Updated under the auspices of the American College of Cardiology and the American Heart association made a strong case for secondary prevention.
It advised that intensive modification of conventional risk factors like diabetes, hypertension, smoking, cholesterol and obesity reduced risk improved outcomes and prevented recurrence in the context of heart disease, stroke and diseases of the blood vessels. It set down recommendations based on levels of evidence for each.
Further, the epidemic of COVID-19 proved to us decisively the hazard posed by co-morbidities.
The implication for cardiovascular care and for healthcare as a whole is that we would need to focus on preserving wellness and not merely managing illness.
That the profession should focus on keeping the patients away from hospitals rather than only treating them therein. One more benefit of this approach is the prevention of infections acquired by the patient in the hospital setting.
For instance, diabetes gives us a 10 year ‘heads up’ in the form of the pre-diabetic stage where damage to the small blood vessels which forms the basis of future complications starts. Diabetes is about 80 per cent preventable at this stage.
In the traditional practice of medicine, regardless of they were Indian, Chinese or Western, the physician used to visit the patient’s home. The chief merit of this practice was an ability to assess the patient, their lifestyle and their support systems as a whole.
For the patient and family, the advantages of such an approach, if it were followed at the present time are obvious —no need to take time off work, no need to make and keep appointments, no need to wait in the queue, expose oneself to crowds, noise, rudeness and infections. All this to obtain a 15 minute or half hour consultation with the doctor
The obvious demerits from the doctor’s perspective are traffic snarls, time, costs of fuel and the spread of infection.
The Covid-19 epidemic brought online consults to the fore. Now this has become an acceptable way to interact with the patient and their family from the comfort of their home!
Lyrically put: formerly Mahomet used to visit the mountain. Now the mountain moves to Mahomet!
In the past, the relationship between the doctor and the patient was paternalistic. The doctor acted as a father or a mother or even a god-like figure issuing prescriptions and proscriptions.
The internet served to bridge the traditional asymmetry in information between the doctor and the patient.
With regard to chronic disorders such as diabetes which is linked patient education becomes paramount doctors need to encourage their active participation at every turn. Put simply the patient’s role has become more proactive.
Furthermore, with a focus on the wellness of the mind-body patients have become ‘clients’ or ‘beneficiaries’. The designation ‘customer,’ which is often used in corporate practice is inappropriate because the system has to act to protect and enhance the person’s health. This clearly overrides the end points of ‘customer satisfaction’ or ‘customer delight’.
Strong therapeutic alliances between doctor and patient have become the order of the day.
The major scourges of modern times—diabetes, hypertension, cholesterol, cardiac diseases, stroke, deficiencies of Vitamin D and B12, disorders of the thyroid, depression and so forth are complex in nature. There is interplay of multiple genetic and environmental factors in their genesis.
For instance, in hypertension, we need to consider growth retardation in the fetal stage, complex genetic factors, hormonal issues, metabolism of salt and water and its complex regulation, output of nerve impulses which control the blood pressure, stress, salt intake, smoking and alcohol, the level of activity and soon…
This interplay becomes even more complex in psychiatric disorders.
Many of the above cited disorders are based on the demerits of modern lifestyles—erratic habits with respect to food and sleep, lack of family support in many instances, lack of physical activity and above all, stress. For instance diabetes evidently runs in families. This could be passed on from generation to generation. It could be genetic as in a tendency to have a certain gene or set of genes which make one more prone for diabetes. It could be because of shared diet and activities such as exercise in a given family. It could be combination of one or more of these factors.
It, therefore, becomes mandatory to understand the family, the professional and social background of patients and healthy clients.
The poetic phrase ‘No man is an Island’ (by John Donne) gains meaning!
Depression is quite clearly one of the epidemics of modern times. It is part of many chronic disorders. For instance, after a heart attack or in diabetes. It might mimic disorders such as muscular pains or the chronic fatigue syndrome.
Stress is causally linked to hypertension and diabetes. In high blood cholesterol. Stress induces a specific disorder of the heart muscle. The role of stress in our lives can never be overstated!
Further, as we have discussed, changes in lifestyle pose many challenges.
In the past, there was a stigma attached to mental health as reflected in many colloquialisms such a ‘screw loose’ and ‘mental’ used in our society.
With greater awareness, this stigma is gradually disappearing. Body and mind are being increasingly treated as one unit.
Within their professional span, physicians now have the opportunity to lead and to witness seismic shifts in their profession. Only time will tell if these trends would crystallise for the greater good.
References:
1. Circulation 2011 Nov 29; 124(22):2458-73. doi: 10.1161/CIR.0b013e318235eb4d. Epub 2011 Nov 3.AHA/ACCF Secondary Prevention and Risk Reduction Therapy for Patients with Coronary and other Atherosclerotic Vascular Disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation
2. Int J Prev Med. 2021; 12: 71.Published online 2021 Jun 25. doi: 10.4103/ijpvm.IJPVM_487_20 PMID: 34447513Challenges of the Health System in Preventing Non-Communicable Diseases; Systematized Review
3. J Med Internet Res. 2016 Oct; 18(10): e276. Published online 2016 Oct 28. doi: 10.2196/jmir.6423The Impact of the Internet on Health Consultation Market Concentration: An Econometric Analysis of Secondary Data
4. Indian J Public Health 2019 Jul-Sep;63(3):215-219. doi: 10.4103/ijph.IJPH_392_18. Internet and doctor-patient relationship: Cross-sectional study of patients' perceptions and practices
5. Indian J Community Med. 2020 Jan-Mar; 45(1): 100–103. doi: 10.4103/ijcm.IJCM_106_19Perception of Doctor–Patient Relationship in the Present Time from the Viewpoint of Doctors: A Qualitative Study at a Tertiary Health-Care Center in Eastern India
6. Hypertension Vol. 37, No. 4, HypothesisPulse Pressure and Human Longevity
7. Biological Origin of Schizophrenia By PAUL GOLDSMITH January 27, 2016 Harvard Medical School
8. INTEGRATING HEALTH CARE AND THE HEALTH OF THE COMMUNITY · by M Smith · 2013
9. The Lancet Psychiatry- Volume 7, Issue 2, p148-161, The burden of mental disorders across the states of India
10. J Family Med Prim Care. 2015 Jul-Sep; 4(3): 449–453. doi: 10.4103/2249-4863.16135 Perception of stigma toward mental illness in South India
