“
of menopause—not to mention a potentially increased risk of Alzheimer’s disease, as we’ll see in chapter 9. Medicine 2.0 would rather throw out this therapy entirely, on the basis of one clinical trial, than try to understand and address the nuances involved. Medicine 3.0 would take this study into account, while recognizing its inevitable limitations and built-in biases. The key question that Medicine 3.0 asks is whether this intervention, hormone replacement therapy, with its relatively small increase in average risk in a large group of women older than sixty-five, might still be net beneficial for our individual patient, with her own unique mix of symptoms and risk factors. How is she similar to or different from the population in the study? One huge difference: none of the women selected for the study were actually symptomatic, and most were many years out of menopause. So how applicable are the findings of this study to women who are in or just entering menopause (and are presumably younger)? Finally, is there some other possible explanation for the slight observed increase in risk with this specific HRT protocol?[*3] My broader point is that at the level of the individual patient, we should be willing to ask deeper questions of risk versus reward versus cost for this therapy—and for almost anything else we might do. The fourth and perhaps largest shift is that where Medicine 2.0 focuses largely on lifespan, and is almost entirely geared toward staving off death, Medicine 3.0 pays far more attention to maintaining healthspan, the quality of life. Healthspan was a concept that barely even existed when I went to medical school. My professors said little to nothing about how to help our patients maintain their physical and cognitive capacity as they aged. The word exercise was almost never uttered. Sleep was totally ignored, both in class and in residency, as we routinely worked twenty-four hours at a stretch. Our instruction in nutrition was also minimal to nonexistent. Today, Medicine 2.0 at least acknowledges the importance of healthspan, but the standard definition—the period of life free of disease or disability—is totally insufficient, in my view. We want more out of life than simply the absence of sickness or disability. We want to be thriving, in every way, throughout the latter half of our lives. Another, related issue is that longevity itself, and healthspan in particular, doesn’t really fit into the business model of our current
”
”