Mesofacts and Megatrends

At the conclusion of a continuing medical education lecture, my ears perked up.  The speaker had been asked a question from a member of the audience:  what pathogen comes to mind when considering a diagnosis of conjunctivitis and otitis media in the pediatric patient?  His answer:  pneumococcus.  I was stunned.

Since my early days in training I had been taught that the clinical syndrome in question — conjunctivitis-otitis media — was nearly always associated with non-typeable Hemophilus influenzae.  Suddenly the pathogenic tables had been turned.  How could that be?

Any practitioner of medicine knows that nothing is ever set in stone in clinical practice.  From diagnostic criteria to clinical syndromes to etiologies to treatment:  everything, it seems, is in a constant state of flux.

Recently, I learned that what I had encountered here was a mesofact: a fact that changes slowly over the course of years or even over a lifetime.

Many facts that we learn in school and hold on to with dogmatic certainty morph into mesofacts.  One day we wake up to find out that things “have changed, changed utterly.”  The pathogen responsible for pediatric conjunctivitis-otitis media syndrome is just one example.  We recognize rapid change almost immediately; we are slow to pick up on those small subtle seemingly insignificant changes that occur over time.

In a Boston Globe article Samuel Arbesman, a postdoctoral fellow in the Department of Health Care Policy at Harvard Medical School, quotes a few interesting mesofacts:

  • Since the 1970s twelve new elements have been added to the Periodic Table.
  • The percentage of the world population that uses mobile phones has jumped from 4% in 1997 to nearly 50% in 2007.
  • Since 1995 the number of planets newly discovered outside our solar system has risen to over 400.

Mesofacts have always been part and parcel of medicine.  Yet I can’t help but ponder the difference between mesofacts and megatrends in medical practice, for not all of our latest technological and pharmacological armamentaria are brought to bear on mesofacts.  Megatrends can masquerade as solutions to medical dilemmas as well.

A few examples:

Mesofact: the incidence of asthma in the general population has increased exponentially over the past two decades.

Megatrend: inhaled corticosteroids have become the standard maintenance medication for asthma treatment during the same time period.

Mesofact: the diagnosis of pediatric ADHD has mushroomed over the past three decades.

Megatrend: the number of psychoactive drugs for ADHD routinely prescribed by general pediatricians has skyrocketed over the previous twenty years.

Mesofact:  20% of the general population suffers from clinical depression at some point in life.

Megatrend:  the SSRI class of antidepressants has risen to the rank of most prescribed psychoactive medication in the USA.

Astute readers will note that in each of the above examples mesofacts and megatrends can be interchanged with little difficulty.  This brings up the question:  which drives what?  Do mesofacts drive megatrends, or do megatrends influence mesofacts?

Is the use of inhaled corticosteroids as standard treatment of asthma based upon the mesofact of the increased incidence of asthma in the general population or upon treatment trends underwritten by the pharmaceutical industry?

Is the widespread prescribing of psychoactive drugs for the treatment of ADHD and childhood bipolar disorder based upon a true increase in the incidence of those disorders or upon treatment trends?

Is the increased incidence of autism in the pediatric population a mesofact or the direct result of trends in diagnosis?

In medicine which comes first — the mesofact or the megatrend?

Are mesofacts in fact facts?  Or in some instances are they merely created by megatrends?