Four Ways to Decrease Overall Mortality

Good medicine is all about careful observation. You’ve probably heard the legend of the medical school professor who teaches his students about the importance of using the five senses as diagnostic tools. In front of the class, he dips a finger into a beaker of urine from a patient with diabetes mellitus and then puts a finger in his mouth, remarking on the sweetness. He passes the beaker around the class so each student can sample the urine. Once the entire class has tasted the sample, the professor reveals that he dipped his index finger into the beaker but then put his middle finger into his mouth. He goes on to stress the importance of observation.¹

Over my now long career, I have observed behaviors among my patients that are not associated with better blood sugar levels or blood pressure, or even with weight loss or quality of life; they are associated with changes in overall mortality — the only endpoint Drs. Prasad and Mandrola think is important. Changing these behaviors would therefore save lives.

I know the traditional approach would be to test my so-called hypotheses in an observational trial, using statistical analyses to control for confounding. Then, if the associations were supported, I would design a robust, multicenter, double-blind, placebo-controlled RCT to demonstrate the effectiveness of the proposals I outline below. But, come on, I am a doctor, a professor of medicine, with two Ivy League schools on my CV.² How could I possibly be wrong?

Here are four simple interventions that will reduce mortality among our patients. These need to be instituted immediately. They include changes to our practice, our medical centers, and our medical record system.

1. Disconnect all landlines

Patients who have landlines listed in their contact information have higher mortality rates than those who do not. This association even has a dose-response curve; those whose landline is their preferred line, or their only number, have the highest mortality. Disconnecting all of Ma Bell’s phones will save lives.

2. Make valet parking at medical centers free for all

Some of my patients walk to visits with me, some ride public transportation, some ride Pace Paratransit. Others drive themselves; they park on the street, in the medical center garage, or they use the valet parking service. When you exclude people who walk to their visits, those who use the valet service have a statistically and clinically significant lower mortality rate than street and garage parkers.

If we enable everyone to use valet parking, the mortality benefits will be immediate.

3. Add preferred pharmacies to patients’ medical records

Most of my patients have one or two pharmacies listed in the electronic health system. They usually list the medical center pharmacy and one close to home. Depending on their insurance, some list a local pharmacy and a mail-order one. A few patients have long lists of pharmacies, with locations such as Martha’s Vineyard, Lake Tahoe, Santa Fe, and Scottsdale. Patients with this diverse array of pharmacies live decades longer than those who only use Chicago pharmacies. Add a smattering of pharmacies located in American Blue Zones, and we will bend the mortality curve.³

4. Never remove “general healthcare maintenance” from the problem list

When I precept the residents, I am a stickler for cleaning up medication lists and problem lists. “Make them clean and accurate so they help you care for your patients better and more efficiently,” I say again and again. I have the residents remove duplicate diagnoses and ones that are out of date.

One thing that I caution them never to remove is the “Screening” or “General Healthcare Maintenance” problems under which people track due dates for things like colonoscopies, mammograms, and bone density studies. My experience has been that whenever this problem is deleted, patient demise soon follows.

I also oppose deprescribing statins or any drug on the Beers’ list. These actions always lead to patients exiting this mortal coil.

Rest assured, I will continue to observe associations between my patients' behaviors and their outcomes, and I expect to routinely update this list of recommendations. Recently, I have noticed that patients who pay for the Galleri® Multi-Cancer Test or full-body MRIs have decreased mortality. I might start recommending these, but because these people usually have multiple pharmacies listed in their medical record (see #3), I am not sure if these are independent, causative factors. Yet!

1. Maybe he makes the point that sight is more important than taste in medical diagnostics. I actually don’t remember the point of the story.

2. Many more if you include my CV of failures and all the ones I was rejected from.

3. If this intervention seems excessive, we might just add pharmacies in different Chicago neighborhoods.