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"First, let me make it very clear, poor people aren't necessarily killers. Just because you happen to be not rich doesn't mean you're willing to kill."
Washington DC, 19 May, 2003

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By all indicators, if modern medicine were a manufacturing industry, its doors would now be starting to close for what is termed a "reorganization". It has lost the battle on several fronts: cancer, viral infections, bacterial infections, degenerative arthritis, osteoporosis, and vascular disease, to name a few. Glossing over it all is "media medicine": Siamese twin separations, coronary artery surgery on media figures, organ transplants on forgotten heroes, macabre pictures of trauma services, T.V. shows on emergency rooms, etc. This all amounts to a glorification of trauma, for example, by making its management into television entertainment.

Does anyone remember "Medic", starring Richard Boone, "Dr. Kildare", with Raymond Massey, and some years later, Richard Chamberlain, or "Dr. Ben Casey", starring my friend Vince Edwards? These were fifties and early sixties entertainment considered too intense for most children by parents of that time. Then came "Marcus Welby, M.D.", and Dr. Richard Kiley. All along there have been soap operas, like "General Hospital". Compared to these shows what we are seeing now is a mixture of drama with sexual overtones (the doctors and the nurses, again!), intense horror (severely injured trauma victims), and science fiction (the technical arena of modern medicine); and all on prime time television. Also, it is impossible to view television without endless commercials on every type of over the counter medication imaginable. Actors very competently present "scientific" data on the effectiveness of one headache medicine or the other. The message is so clever that one feels a little stupid not having this stuff around! Personally, I'd rather figure out how to avoid the headache in the first place.

A logical regression analysis from utilization of medical services by patients, back to the level of raw materials, illustrates an interesting point. Fine detail will not be used in this analysis, but the reader is invited to explore the fine detail in his own mind.

My example will be a 63 year old male who has received a total knee prosthesis for degenerative arthritis from which he has suffered for eight to ten years. The average patient of this description is overweight, chronically sedentary, on medications for at least two other "medical problems" (hypertension and hyperacidity, for instance), and profoundly deconditioned. Nevertheless, he has seen a doctor regularly all this time for follow-up tests, medication adjustments, and periodic examinations. A complete battery of preoperative tests would have been ordered.

Here is an example of an abbreviated regression analysis on a few of the parameters of surgery. Each and every separate item used in surgery is manufactured, marketed, sold, operated by qualified personnel, and serviced by technicians. A fleet of vehicles is used in the physical delivery of each and every item. This fleet has its own maintenance requirements, insurance requirements, etc. The prosthesis is made of virgin stainless steel and nylon, and is the result of years of research and development. The manufacture is high tech. It starts with raw materials; and a similar regression applies; and so on, and so on, and so on. There is really no end to it all! The employment of a large segment of population depends directly or indirectly upon the insertion of this total knee prosthesis. I will not touch on the regression analysis of the rehabilitation process, but it is similar.

The message is that high-tech pharmaco-industrial medicine is as good as it gets. But the results, however, are just not there. I view what we are doing as the equivalent of putting a new valve stem in the wheel of a twenty year old vehicle that has had only five oil changes in its life. Yes, the tire will now hold air and we can "limp" the vehicle into the garage for expensive tests and follow-up. But is this sensible or cost-effective? Impeccable, inexpensive maintenance by the owner of the vehicle over the twenty years would have prevented all of the expensive problems (and eliminated the mechanic). And so it is now with "health care", a misnomer; it is "sick care". What if tomorrow no one was sick? This is the logical progression to an ideal endpoint of a well-designed national prevention program. Sounds great! Imagine though, the effects of not needing any more total knee prostheses because people took care of their joints (yes, joints can be preserved in near-original condition with a good lifestyle program!). Unemployment would obviously increase. Illness as a major employer in America is a fact of life.

The whole system, then, boils down to a way to keep a lot of folks employed, paying taxes, buying insurance, but getting slowly sicker, so they will then recycle all of their money into the system through costly, interventional medicine. Well, costs have long outstripped the contributions, and now we have "managed care", another medical neologism, which really means absolutely nothing except that governmental bureaucracy is now managing the purse strings of the easiest targets: doctors and hospitals. It is now obvious that the system is a failure that is bankrupting the entire government.

A parallel industry, which I will call "Wellness and Prevention through Lifestyle Counseling" is rising along with "alternative medicine". Central to prevention are effective lifestyle changes, including the design and administration of effective exercise programs. A whole industry is on the rise to develop and administer these programs. Scientific data abounds on the effectiveness of exercise on the prevention or resolution of the "diseases" of sedentary living. These diseases comprise nearly all of what modern medicine treats.

Modern medicine is feebly trying to get in the act by laying claim to such revelations as "eating fruits and vegetables is good for you" or "exercise is good for your heart". A whole aerobics industry grew from the last statement. Aerobics as prevention is a thin tentacle of modern pharmaco-industrial medicine that is firmly entrenched. Although the philosophy that exercise is wonderful for you was and is correct, the "aerobics answer" is turning out to be only a list of questions. Highly technical fitness assessments and cumbersome "formula aerobics" training have spawned many industries: shoes and apparel, heart-rate monitors and high-tech testing equipment. But once again, the results are just not there. A new role of resistance exercise and its correct application is emerging. This is a phenomenally important movement, but now we are back to "What if tomorrow no one was sick?"

Modern medicine is valiantly trying to "discover" resistance exercise. Has anyone ever seen "Before starting any resistance-training program, please consult your doctor"? Every exercise program on television begins with this statement. To a physician with expertise in the whole spectrum of the fitness field, this statement makes about as much sense as "before buying a new stereo system, please consult your plumber".

With the amount of friction about to be generated by the scenario depicted above, added to the fact that nearly all professional, certified, fitness practitioners now carry liability insurance, questions involving the following problem areas will be posed to the judicial system, and competent accurate expert testimony will be needed: Validity of certification, all aspects of program design and administration, and/or the trainer-client relationship, validity of claimed results of programs, equipment design and utilization, facility design, operation and utilization, doctor-trainer relationships or interactions, such as the need to see a physician prior to starting an exercise program, the validity of physician-recommended programs, personal injury or wrongful death involving all of the above and rights infringements or contractual problems.

An experienced physician with high expertise in the fitness-wellness-prevention industry will be of inestimable value in resolving the many questions about to be asked.

  * Dr. Breehl is a board certified practicing anesthesiologist who has developed an interest in physical fitness and has become a Certified Strength and Conditioning Specialist under the Nat'l Strength and Conditioning Assn.