Ethics in Medicine

Prevention: Making the Invisible Visible

Kristen Sparrow • February 02, 2019

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A previous blog post that discussed prevention touched on something I’ve grappled with ever since I was in classes learning acupuncture.  And maybe this isn’t a super deep insight, and I’m sure that others much smarter than me have thought about this more.  The issue with medicine (and one could argue other aspects of modern life such as climate change) is that no one is really interested in prevention.  It’s not really monetizable, it’s not exciting, it doesn’t trigger dopamine.  Just as no one wants to fund prevention for floods inevitable with rising seas as the Netherlands has done, they would rather pay for the clean up once it happens.
In the previous blog post, an expert on plastic pollution preventions says “ “We always love the idea of cleanups more than we love the idea of prevention, or mitigation,” she said. “We love treating illnesses more than we do preventing them. But our affinity for simplistic solutions isn’t innate; they’re narratives we’ve been sold.”
And I think that’s the crucial and urgent challenge.  To change the ways that we tell the story.  When I was an anesthesiologist in my previous life, you would get a tremendous sense of satisfaction after a difficult case, or a difficult code blue, or emergency intubation, or dicey C section.  And, of course, that kind of high level expertise is extremely valuable.  But to somehow see the value in preventing things from getting to that point.  For example, I was in Miami recently and horrified to realize they have no helmet laws for motorcycles or scooters.  Seriously???
So part of the challenge is to tell different stories.  Lots of efforts are going into gamifying different aspects of life which lends the dopamine rush to routine tasks of learning or fitness goals.
So the issue is how to make prevention something that you can see and measure in real time, rather than over years in massive studies (which never get funded by the way). Though there is always money for a cool sounding treatment or pill, even if they have not been proven to work, it’s exponentially more difficult to get funding for cheap, safe solutions.
As readers of the blog know, I’m intensely interested in using HRV (heart rate variability analysis), a type of noninvasive stress monitoring to evaluate patients’ response to acupuncture and also transcutaneous auricular vagal stimulation.
The primary reason I’ve worked on this, lo these many years, is pragmatic.  I would love to have a marker for effective treatment. In effect, making the invisible visible.  So I vary the treatment that patients receive in the clinic and then compare their HRV response.  But I also would like to be able to show a shift of improvement in patients reaction/stress levels over time so that we could show a metric that correlates with clinical improvement.  This would be particularly helpful in patients who have chronic autoimmune conditions, Multiple Sclerosis for example, where optimizing stress levels and immunity can be key to keeping flares to a minimum.
In this recent paper by friend of blog, Vitaly Napadow, they explore using fMRI results in conjunction with HRV to predict pain severity.  So, in essence, establishing a biomarker for pain intensity.  It may be a reach, but I do think that combining data can be useful.  In my data, I multiply HF HRV data which represents parasympathetic activity, and Sample Entropy which is a nonlinear measure of HRV with the idea that by combining and amplifying the two measures, you might be able to pick up more nuance in the data. In the data below, higher is healthier, and is a combination of parasympathetic activity (rest and digest) and complexity data (Sample Entropy). Combining the data makes it easier to detect subtle differences in treatment outcomes.
What I have also found is that it does depend on the overall stress level of the patient which data is the most relevant.