Dr. Van Helsing Does Not Practice Primary Prevention

As recommendations for treatment of hyperlipidemia become broader and more generic, drifting toward the poly-pill conclusion, I can’t help but think of Dr. Van Helsing’s predicament in Dracula. In the story, though he has information which suggests the possibility of primary prevention, he practices secondary prevention. It is only after the symptoms appear – Lucy’s mysterious anemia and the rash of similar cases following her death – that the doctor suggests putting garlic around the windows. He has to wait. He’s in a story, so he knows the horrible truth all along, but he can’t reveal it without his patients sending him packing. Every doctor understands Van Helsing’s predicament. Few can see his patients’ logic however. It is one thing to indulge a crazy old man’s belief in vampires. It is quite another to indulge a crazy old man’s belief that a vampire has moved into the old mansion down the street and has begun to prey upon the household.
When doctors tell patients to treat public health problems, like cardiovascular disease prevention, on an individual basis, the patients take it as if they were being asked to put garlic around their windows because there have been vampire sightings in their neighborhood. They are slightly incredulous. And, the patients are right.
If we medical professionals are to treat asymptomatic individuals based on a 10 year risk calculated from epidemiologic data, for a disease which they have may or may not have started to develop, we must be honest with them. We have to admit that medication is the best that we can do, ask for their help, as a group, and then make it easy for them to help. Doctors don’t like to treat populations, though. Individualized care and patient centered care are the current watch words. But the greatest successes of medical science have been the opposite sort of effort. Nobody thinks that we should stop immunizing people for pertussis and move to an individualized prevention program with regular swabs for the pertussis bacteria and antibiotics for every runny nose. The approach is ostensibly patient centered, and it really is in a way, just like Dracula’s interest in Lucy and Mina is patient centered. Looking down from the established high ground, it’s easy to recognize the shift to an individualized strategy for preventing whooping cough as impractical and myopic. Medical professionals are clever enough to avoid bad moves from the general to the specific. However, decisions to move from a dysfunctional individualized program to a population based program can trip up anyone, even though the determining factors are the same.
The problem is Van Helsing’s problem. At the level of the vampire hunter’s interest, garlic around the windows is garlic around the windows. He’s like Dracula that way, for whom young ladies full of blood are young ladies full of blood. Dracula and Van Helsing are at risk of availability bias, cognitively and practically, as are all the physicians with lipid profiles, risk calculators and statistical correlations at their fingertips. There is a insidious, vampiric class of maneuver from population-based conclusions to individualized care. But the patients’ motivations lie outside of the action’s focus, and that focus is therefore myopic. It does matter to patients whether the doctor is asking them to deck the sills in order to cut down on the incidence of vampire attacks or because they should fear the vampire staring at them through the window. The latter request involves adopting an astringent manner of thought and behavior, the stuff of anxiety disorders. The former is an appeal to solidarity and public safety. We shouldn’t be surprised when the same people we’ve been instructing to fear the vampire outside their window come in demanding that we do something about the pale figure lurking behind their cough, in their prostate, or under their nipple. Having ceded the high ground, we’ve no credible response.

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2 thoughts on “Dr. Van Helsing Does Not Practice Primary Prevention

  1. The difference between vaccines, and medication for a possible heart attack later on, is whose risk it is. If enough of my community are vaccinated, I am not going to meet a carrier, so it is against my interest to be vaccinated as vaccination carries a small risk. If I have a small but significant risk of a heart attack, and medication is shown to reduce that risk, then I can decide to take it, for my own good and not for the good of the general population. The doctor is not giving a particular medication which will have a definite effect on a particular certain thing, but then, do they ever?

    • keithnoback says:

      When I give someone epinephrine for anaphylaxis or a thrombolytic for a heart attack, I’m giving a medication which will have an effect on a particular thing. Sure, it’s still playing the odds – you may still vapor lock from airway edema, or the clot in your coronary artery may not dissolve enough to let blood flow again – but the odds are no longer even either. You have a disease so, not only have you singled yourself out statistically, but you have a lot less to lose.
      Primary prevention is a different story. To individualize it, you need some pretty powerful tools to single out the right people for preventative treatment. Safe tools. Cheap tools (we all pay for them).
      The alternative is just to treat everybody, if you have a treatment that turns out to be cheaper and safer than your screening tools (and remember, you have to include the cost of missed prevention opportunities). The question about which course to follow is a very important one, and one which has largely been avoided in the case of cardiovascular disease, mostly because the flip from individualized to population treatment is something the profession likes about as much as Dracula likes garlic toast. If you are interested in the gory details, the journal Circulation published an article in 2010 called “Polypill in the Prevention of Cardiovascular Disease”. It is pretty well-written with a minimum of jargon. Thanks for your interest and the comment.

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