Asking Patients the Wrong Questions

A survival analogy from WWII with medical implications

My daughter once read that every Boomer generation father is perpetually studying for a test on WWII; he just doesn’t know when it will happen. I also read that once a man hits 40-years-old, he has to pick either grilling or WWII.

I’m on the edge of the boomers, as I was born in 1964. Some say I am among the last, some say those born my year are part of Generation X.

Nevertheless, I picked WWII. Or it was thrust upon me.

So when I saw this article some time ago, it struck me as interesting.

https://www.wearethemighty.com/popular/how-the-allies-saved-bombers/

Many of you may have read it, but it concerns how unconventional thinking about ‘survivorship bias’ allowed B-29 bombers to be armored in the right areas rather than the wrong areas.

See, B-29 bombers would return from bombing missions riddled with holes from machine guns or anti-aircraft fire.

Experts started asking ‘what can we do to prevent this.’ But ultimately Abraham Wald, an Austrian PhD in mathematics who was working for the government, realized that was the wrong question. The fact was that certain patterns of damage still left the aircraft flying. These, it turned out, didn’t matter because they made it back. Thus the Army began more effectively protecting vulnerable areas, like the engines, so that more bombers could return safely and stay in the fight.

What does this have to do with medicine? Well, sometimes our patients look like this. That is, beaten up. Wounded. Sick. And we sometimes ask the wrong questions.

When we have men or women in their 80s or 90s who still smoke daily, who still drink alcohol daily, who have survived multiple heart attacks, strokes or injuries, we tend to simply ‘tsk tsk’ and berate them.

We also attribute their long survival, not incorrectly, to our medical interventions in their times of distress. Coronary stents, antibiotics, chemotherapy, ventilators, all of these things help snatch men and women from imminent death.

Probably.

We have these conversations: ‘Now Mr. Maynard, you know you should stop smoking and drinking!’ Yes, I suppose he should. But what if we’re missing something else here? What if some of our patients, the ones who seem to live the hardest lives and live the longest, just have something going on that we’re ignoring?

Back in the ‘dark ages,’ when the old-school, hard-corp drunks still walked the earth, free of methamphetamine and unexposed to almost immediate death from fentanyl, I met some amazing individuals. While some were women, most were older men.

One of them lived across the street from my house when I was growing up. His name was Jake. I don’t imagine he was ever sober for more than a couple of hours. When I was a boy he was probably in his late 60s or 70s. (Although he might have been a ‘rode hard, hung up wet’ 50s.)

He still ambled up and down the road at all hours. At night he and his woman would scream at each other; we heard their fights in the wee hours through their thinly shingled shack of a house. It was chilling, like bobcats in the dark.

Both of them looked perpetually sick. And yet an ambulance wasn’t there every week. These were the days before aggressive cardiac or stroke intervention. These were the days before the wildly successful chemotherapy agents we have now. But on they lived.

My grandfather, a clean-living, perpetually anxious teetotalar, died in his bed in his 60s.

Jake and is wife were much like the old alcoholics I saw early in my medical career; men who would wreck their cars, get ejected through windshields, and who would then sign out of the ER because they had things to do. And we wouldn’t (mostly) let them smoke on the campus. Except when the nurses would smoke with them; or the surgeons.

How did they do it? How did they live so long?

Look, tobacco, alcohol and drugs are devastating things. The end game of these substances is often tragic.

Likewise, cancer and heart disease, diabetes and COPD, all shorten lives.

It seems on first pass that perhaps our modern lives, our sedentary lives, our horrible diets all lead us to early sickness and too early debility, too early graves.

Still, some of our patients navigate substances and/or afflictions, the assorted car crashes, falls from roof-tops, stabbings and shootings and just live on into ripe old age.

Mind you, I’m not saying they live well but goodness, they live!

Maybe we need to take a page from Abraham Wald. In addition to asking our older, sicker patients to stop their bad habits, we might need to see what it is about their habits or their physicality, or their sheer orneriness that keeps them going into old age when far more healthy individuals die running marathons or from unexpected and devastating malignancies or even minor injuries that turn bad.

The secret may lie in genetics or epigenetics. We’re only scratching the bare surface of these sciences. Some people just survive better than others; they’re gifted in the DNA area.

Of course, if you think about it, we all have some echo of survival genetics. If you are reading this, you are descended from the line of homo sapiens which seems to have first appeared from other hominids about 200,000 to 300,000 years ago. You are heirs of survivors. Some may simply have inherited more of our ancestor’s abilities.

The secret of my tough patients, unstopped by the usual suspects, may lie in purpose, or in struggle; even if their purposes and struggles don’t make sense to the rest of us. Maybe hard lives set off metabolic pathways that keep us going so that we can defeat what our bodies see as existential threats to survival…and of course, to reproduction.

Maybe ‘blessed are the poor’ is more than a comment on matters spiritual.

As I stop at the gas station to get my caffeine for work, and see the vast amount of stimulants and tobacco products, I wonder if the secret may lie in some unforeseen salutary benefits of the things we try to get some patients to stop using. (Goodness knows fats were once the enemy but less so now than carbs, and coffee seems to have remarkable health benefits even as we used to tell people to cut their usage.)

I often wonder about the amount of nicotine people use; is it to increase alertness among those with stressful, dangerous lives? Is alcohol a helpful social lubricant that bonds as well as causing disease? (Some researchers have asserted this.)

I don’t know. I just know that there are some people who defy the odds. And as I’ve watched them down the years, I can’t help but admire their tenacity, their persistence. Or maybe the simple joy they take from proving physicians wrong, year after year.

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