1 Boring Old Man

He was a portly New Englander with a gravelly voice [from many allergies] and a sarcastic wit. He was a Corpsman in the Air Force for four years [to avoid serving two years as an Army private in Viet Nam]. There may have been a war going on, but it didn’t have much to do with our day to day life on a base in the UK. He had married a knock-dead gorgeous British girl [we wondered why she’d married a jolly fat guy]. In the Ward chatter in the mornings, he entertained us with a running dialog about his family back home, all Morticians for generations.

One morning, he showed up in an agitated state. Some relative had died, and that meant a prime Mortuary was up for grabs if he could get out of the Air Force. He thought about claiming homosexuality [this was pre-Don’t Ask, Don’t tell, but he’d heard that didn’t work anymore [correct, particularly with that wife]. Then one day, he was jolly again. He had a plan. The Air Force had weight standards, and like many he was way over his limit. That meant a monthly visit to the weight control officer. He’d been the day before, and he’d asked what would happen if he didn’t make the weight loss goal. "Out you go!" was the answer. So he set about eating his way out of the Air Force with a vengeance. He was rarely seen without ice cream [quarts], a mega-bag of potato chips, and Kandy Korn [sugar with coloring]. His progress seemed visible almost daily, and within a couple of months, he was being mustered out of the service.

A few months after he left, we got a letter about his exciting new job at the family Mortuary [and about his trouble losing all that extra weight]. Soon after they got to the US, his wife smiled, said goodbye, and took off never to be seen again. But he was a good sport about it "I always figured something like that was coming. It was good while it lasted" [I told you he was Jolly]…

While it’s an absurd example, it was a time [early 70s] when guidelines were really beginning to flower – weight, blood pressure, cholesterol, exercise, blood glucose, etc. The yearly physical was in vogue. Traditionally, doctors had treated diseases, but things were changing and the new version of the preventive medicine meme was on the ascendancy – nothing like now, but heading our way. I remember thinking that the "risk factor" talk that was emerging sounded sort of like a good idea, but I hadn’t signed on to be a health counselor, and it looked like that’s where we were headed. It didn’t seem like what doctors were for, at least not this doctor. And I actually recall fantacizing about something like a health counselor as  an allied health profession. I particularly balked at treating minimal blood pressure and lipid elevations because the medications of the day made people ill [and I wasn’t really convinced that I was doing something of worth for the patients].

I was thinking a lot about how I was going to spend my life back then. The thought of being a health  cop  counselor just didn’t appeal to me, but I felt guilty for having the thought. How much that had to do with changing specialties is lost in the mists of time – but I know it was, at least, part of the story. After running a few services and programs along the way, I changed my tune about feeling guilty about taking my own interests into account. The key to a successful program is to protect the staff from burning out, almost inevitable when dealing with chronic conditions [and bureaucracies]. Now, when I think about spending my time doing what’s proposed as a role for me in Collaborative Care, I shudder. Even if I thought it was a good idea, I’d pass [but it isn’t a good idea].

Benefits of Early Detection and Intervention and Treatment
The USPSTF found no studies that directly evaluated whether screening for MDD in adolescents in primary care [or comparable] settings leads to improved health and other outcomes. However, the USPSTF found adequate evidence that treatment of MDD detected through screening in adolescents is associated with moderate benefit [for example, improved depression severity, depression symptoms, or global functioning scores]…

Harms of Early Detection and Intervention and Treatment
The USPSTF found no direct evidence on the harms of screening for MDD in adolescents. Medications for the treatment of depression, such as selective serotonin reuptake inhibitors [SSRIs], have known harms. However, the magnitude of the harms of pharmacotherapy is small if patients are closely monitored, as recommended by the U.S. Food and Drug Administration [FDA]. The USPSTF found adequate evidence on the harms of psychotherapy and psychosocial support in adolescents and estimates that the magnitude of these harms is small to none…

I’ve read all the studies reviewed in 2009 and this current version. There’s not even a hint of a rational reason to recommend a preventive intervention in adolescent depression, and what these USPSTF papers conclude is as much bull-shit as some of the papers themselves. I’ve read a lot of the papers in the adult  articles too. Same deal. So when I think back on my soldier days in the early 1970s, I wish I’d had my present mind and spoke it. Our Base Commander wasn’t thinking about his troops’ health. He was thinking about how they looked on inspections, or about being strong on the "regs," or about getting that star he wanted on his epaulets. And the reason he wasn’t going to get the star was widely known by all – his affinity for bourbon – which made his subsequent campaign even sillier.

I don’t know what drives the current mania about prevention [that has a spot now on most evening news broadcasts] other than the timeless fear of death, but it’s not about a sensible and effective adherence to public health and preventive medicine principles – nor is it about making the health care professions, particularly front line specialties, something people want to do with their lives.