From a clinical standpoint, medicine today has evolved from the medicine of 50 years ago. While you might debate whether being a doctor in 1970 was better or worse than it is today. it’s undeniable that the quality of medical care has never been better. New vaccines, pharmaceuticals, surgical breakthroughs, and medical imaging, among myriad other developments, have improved patient outcomes and quality of life. To make some sense of this rapid advancement, we spoke to Dr. Scott Podolsky, professor of global health and social medicine at Harvard Medical School. Podolsky also happens to be a bit of a history buff, leading the Center for the History of Medicine at the Harvard Medical School library. In addition to maintaining a primary care practice, Podolsky studies the history of therapeutics, clinical trials, and notions of efficacy over time — particularly with antimicrobials. In short, if you’re looking for a crash course on a half-century of medical history, he’s the guy you call. The pace of medical change Perhaps as a byproduct of the information age, we tend to think that the advancements of the last 50 years have been the most impactful. But according to Podolsky, developments in the previous half-century were more radical. “Medicine in 2020 is much closer to medicine in 1970 than medicine in 1970 was to medicine in 1920,” he says. From 1920-1970, American physicians saw the advent of private insurance, as well as Medicare and Medicaid. Throw major pharmaceutical breakthroughs into the mix, such as antibiotics, antihypertensives, antidepressants, antipsychotics, and steroids, and you have radical transformation. “The whole pharmaceutical revolution really happens after World War II,” Podolsky says. “The advance of the randomized control trial as the arbiter of therapeutic efficacy happens between 1920 and 1970. I write a lot about medical history in 1970, and I can say that it looks similarly to how it looks today. But there are still important differences.” Those important differences, Podolsky says, include additional antimicrobials, the practice of medicine itself, diagnostics, treatment, the advent of professionalism and bioethics, and understanding the risk factors and burden of disease. We’ll get into each of these. Warding off common killers Speaking of risk factors and the burden of disease, physicians face a chicken-or-the-egg question: Should we thank advances in prevention, or improvements in diagnostics and treatment for declines among the common killers and overall increases in life expectancy? The answer, Podolsky says, is both. On the heart disease and cancer fronts, he credits the enormous reduction in smoking prevalence. But, let’s not give short shrift to new drugs. According to Podolsky, the impact of pharmaceuticals such as antihypertensives and statins has been undeniable for stemming loss of life from the leading killers. In diabetes management, for example, physicians now have access to more drugs, including options for managing A1C, as well as interventions for managing complications, such as the use of lasers for diabetic retinopathy. But it’s not just that preventive drugs have gotten better. Doctors and medical practice have also improved with respect to treating those who already have diseases like heart attacks and cancer. “There are certainly major innovations in the last 50 years with respect to the development of secondary care for when someone has actually had a heart attack,” Podolsky says. “People usually come out and say, we’ll give half the credit to prevention and half the credit to treatment. It’s really hard to say, but certainly both sides have been critical.” It also helps that physicians today are armed with numerous technological advances. Technology Seeing is believing. MRI, CT scan, and ultrasound have all been transformative, Podolsky says. “Some would say they have degraded physicians’ physical exam skills,” Podolsky says. “There are certainly unintended side effects such as this, or the radiation involved with CT, or a bunch of incidental findings that we never wanted to know about. But nobody wants to go back to a time when we didn’t have these three modalities.” Technological advances aren’t just confined to imaging. Surgical patients and surgeons themselves have benefited. “Laparoscopic appendectomy and laparoscopic cholecystectomy, for example, are truly revolutionary,” Podolsky says. “My patients who had these procedures more than 30 years ago have enormous scars, whereas now patients are sometimes in and out of the hospital in a day. That has been transformative.” A Journal of the Royal Society of Medicine analysis highlights the other advantages of laparoscopic surgery, including lower risk of complications, such as infections, blood loss, pain, and discomfort. All translate to a shortened recovery period and diminished risk of complications associated with inactivity.While these are some of the obvious technological standouts, it’s something a bit more ubiquitous that’s had the greatest effect. “If you were to ask, what’s the biggest transformation of practice in the last 50 years, it’s probably the desktop computer,” he says. “I now have the ability to go to PubMed and look up any article I want. I can look at the longitudinal medical record. We all bemoan it, but it is totally transformative.” That’s not to say that EHRs are perfect. “Most doctors would say it’s certainly a radically different experience than sitting in an office with a patient with no computer.” Ethics and efficacy Perhaps the starkest comparison between the two preceding half-centuries of medicine is on the subject of ethics. Two words: Informed consent. “As of 1970, we didn’t know about Tuskegee,” Podolsky says. “There was no Belmont Report, which comes out in ‘78. Historians often refer to the era of the ‘30s to the ‘60s as the golden age of medicine, prior to multiple critiques of medicine and its paternalism and insularity. From the ‘70s onward, medicine becomes more reflective. It comes out in the form of medical humanities and bioethics.” In addition to the ethics of medicine, clinical studies improve and transform radically from the 1970s and beyond. “Evidence-based medicine doesn’t come out as a term until 1995,” Podolsky says. “You have the advent of the Cochrane Collaboration. You have the whole notion of, how do we replace eminence-based medicine — I do it because my teacher told me to do this — with evidence-based medicine. You have this enormous proliferation of randomized-controlled trials, clinical trials — that expansion is a real post-’70s phenomenon.” Looking ahead The evolution of medicine is far from over. And according to Podolsky, much work remains to be done. The COVID-19 pandemic highlights the need for further change. “Among the many things that I’m hoping for as a result of this pandemic is an investment in public health infrastructure and vaccine development,” Podolsky says. “Perhaps most importantly, it’s further calling attention to existing racial inequalities and our need to address them, among other social determinants of health. “Now more than any fancy new ventilator, one would hope that attention to and correction of those inequities would be the transformative health initiative stemming from 2020 — even more so than a COVID-19 vaccine.” TL;DR This was an expansive interview covering a lot of history. There’s no way we could include all of the transformative developments, but here are a few more that should be mentioned, according to Podolsky: The entire range of antivirals, especially for hepatitis and HIV Increasing attention to global health, itself stimulated in part by HIV, which of course wasn’t a medical concern in 1970 and which could serve as the focus of its own separate interview Improvements in chemotherapy Rheumatological and autoimmune disease therapies Organ transplants Interventional cardiology Vaccines, including the combination of measles, mumps, and rubella; hepatitis B, and pneumonia Source
