This column has pointed out that health care, which saves millions of lives every year, is also America's No. 2 killer, due to side effects and complications of treatment. In order to get better results from health care, it may help you to know how this unlikely situation arose.

Health care is organized to solve the problems of prior eras. In the first era, it didn't have to focus on people individually to save lives. In the second era, it didn't have to consider its long-term effects on patients. Today, in the third era, it needs to do both of these things in order to get good results - but the healthcare system hasn't caught on to this fact yet.

In the first era, more than a hundred years ago, people usually died of infectious diseases such as the flu or pneumonia. Big improvements in health came from cleaning up the water supply, improving sewage treatment, and taking other steps to prevent the spread of infectious diseases. The people who drove those actions were trained professionals working in public health agencies.

It is easy to understand why professionals who were focused on sewer systems or water treatment facilities did not repeatedly consult individually with each resident. Despite the fact that the average person was not involved in these improvements, life expectancy increased by 21 years in half a century - from 47 years for people born in 1900 to 68 years for people born in 1950.

In the second era, many people still died of infectious diseases and other sudden-onset problems such as injuries from accidents. They were just much older when they succumbed, compared to people in the previous era.

Improvements in health came by treating those acute conditions with acute interventions. Penicillin, vaccinations and surgery are examples of such treatments, which are delivered once or over a short period of time.

In the second era, wise doctors like those in Norman Rockwell paintings took the actions needed to improve health. They were trained professionals. They had studied medicine for years. Taking these actions was their job, 10 or 12 hours a day.

Individuals in this era did have to be more involved than people were in the prior era: they had to show up to be treated. But patients still might not have been told what their diagnoses or treatments actually were. It wasn't critically important that they have that information. As an example, the doctor gave a shot of the miracle drug penicillin and the patient didn't die of pneumonia. Patients didn't need to know the details to get good results.

Life expectancy continued to rise - not as much as in the previous 50 years, but it still went up nine years between 1950 and the year 2000.

The third era is today.

With the great and continuing successes of the prior two eras, one could say that we now have the "luxury" of dying of chronic diseases. A chronic disease is something that usually develops slowly and can last a long time, such as diabetes or heart disease. Chronic diseases typically aren't cured. Instead, the idea is either to prevent them or to manage them to reduce their harm.

Today, 70 percent of all deaths in this country are due to chronic conditions, according to the Centers for Disease Control and Prevention. Research from multiple sources suggests that effective ways to prevent or manage common chronic conditions involve the actions people take every day in areas such as diet, exercise, alcohol use, tobacco use and stress management.

In the case of common chronic diseases, doctors cannot make good health happen. They can't snatch the potato chips off your lunch tray. They can't drag you up off the couch after dinner so that you go for a walk instead of watching old "Law & Order" reruns. They're not there.

People go to the doctor on average four times a year. Where common chronic diseases are concerned, what drives their health is largely what they do the other 361 days a year, in a dozen decisions every day.

For example, do they go for a bicycle ride or sit in front of a computer playing video games? Do they order the small ice cream cone or the triple-decker? Do they fume endlessly about their boss or find a constructive way to manage their stress?

Unlike the case in the previous two eras, the people who have to take the actions necessary to improve health in this era are not trained health care professionals. They're the entire population of the U.S. To get good results, people need to become CEOs of their own health and health care.

But both doctors and patients have been trained over many generations to expect doctors - trained professionals - to take charge of improving people's health. Often, both doctors and patients expect patients to put their lives in the hands of Marcus Welby, M.D. - the kindly general practitioner who solved every problem and healed every ill, the key figure in the second era of healthcare.

Patients have been trained not to ask questions. Doctors have been trained to believe that the grand finale to an illness or injury is their delivery of an acute intervention. Then the credits roll, so to speak.

But in this third era of health care, the doctor's delivery of an acute intervention is often only one short scene in a multi-year drama. Patients may end up getting dozens of acute interventions in the course of dealing with their chronic conditions, increasing the chances that something will go wrong.

Doctors may be so focused on their heroic role in the spotlight delivering treatments that they are ill-prepared to think about and prevent complications that surface after they have left the stage. These include infections, blood clots, side effects of medicines, and other short-term and long-term complications of the care that they deliver.

They may also be unprepared to share information, to consider the patient's views, or to involve the patient in decision-making. Historically, they had no reason to do so. (Asking "Do you want me to give you this shot and save your life or would you rather die?" would have seemed simply like a waste of time.)

Today, in preventing and managing common chronic diseases, two big changes from prior eras are: 

  1. You are the main actor.  
  2. The story doesn't end once a treatment is delivered. Both short-term and long-term complications can cause serious problems.

It may be a challenge for both you and your doctors to absorb these two changes. As a result, a large gap can arise between your doctors' good intentions and what actually happens to your health when you are treated.