Monday, September 10, 2012

My Ideas for Fixing Our Healthcare System, 1

     In my perfect world, every American would be required to visit a physician's office twice a year.  It would be looked upon as a duty to oneself and one's country.  After all, if a person doesn't look after his or her own health, someone will have to pay.  Very often, that someone is the state.  It would be best, therefore, for the state to acknowledge this statistical fact at the outset of a program for redesigning the healthcare system, for the good of all, and to make it as necessary as jury duty and taxes that each one of us sees a physician twice a year, as follows.
     Visit 1:  The physician would meet with the patient, perform an exam, and obtain on-the-spot tests based on that patient's history, physical exam and genetic and age-related risks.  The purpose of any testing would be to ascertain that patient's  disease/illness/death risk, following which this information would be used to offer counseling and make specific recommendations for reducing risk and prolonging life.
     Visit 2:  The patient would return to the office six months later to meet with either a physician or a mid-level provider to follow up on the advice given, and measure how well the patient is meeting medical and risk-reduction goals.
     Other Visits:  Group counseling for chronic diseases like obesity, diabetes, hypertension, coronary disease, alcoholism, drug abuse, chronic pain, STD's, speeding tickets, accident reduction, depression, child-rearing, teen challenges, and insomnia could be useful, cost-effective ways for people to get help, share ideas, lessen feelings of isolation, make friends, and learn more about how to reduce the adverse health effects associated with these conditions and states.
     Physicians who preside over these visits would have to be well-versed in the risks that are associated with each age group, gender, race, and socioeconomic group.  Most such risks are well-established.  It is unfortunate that they rarely find their way into exam room encounters between doctors and patients because patients are the ones who, in the current scheme, dictate the frequency and reason for visits with healthcare providers.  Funding for medical studies could focus more heavily on analyzing health risks, and comparing interventions for reducing them.
     In my revamped system, physicians and other trained providers would have clear knowledge of an individual's particular risks for illness, accidents and death--and would take direct steps to attenuate or completely undermine those risks.  In every year and every decade, an individual's chances of getting sick, or dying, change.  This may sound morbid, compared with our current somewhat evasive way of treating patients--avoiding discussions about potential death, or serious diseases.  There are times, for instance, when I say to a patient, "Your risk of getting cancer is..." and the patient interrupts me, cupping a hand over his or her mouth, imploring me not to say that word--as if speaking about death and disease were equivalent to bringing it on.   This kind of superstition must change.  Patients who are able to look at their lives honestly are more likely to alter their behavior in the small ways that can make a huge difference.  We physicians should be helping them do this.
     Family physicians are trained to think this way, but when we leave residency programs and get out into "the real world," many of the basic tenets of our education are abandoned as we're swept into the tornado of acute symptoms, billing and coding, hurry-up visits, the threat of lawsuits, insurance audits, and our patients' expectations of the doctor...or collusion with the doctor when it comes to avoiding serious problems.
    These serious problems include:  the fact of every patient's mortality, domestic abuse, childhood sexual abuse, guns, alcohol, drugs, suicide, homicide, depression, bad driving, marital discord, psychological immaturity, anger management, bad eating and exercise habits, poor organizational skills, and an inability to resolve personal difficulties.  These are health problems, and psychological problems, which physicians are poorly equipped to handle, or disinclined to broach.  But they are responsible for a great deal of suffering and, I think, many somatic symptoms that end up being classified as bodily illness--and costing society dearly.
     For example, we know that women who have been sexually molested as children (one in three, according to statistics in Diane Russell's 1986 study on incest, published in The Secret Trauma)--suffer from pelvic pain, depression, anxiety, and sleep disorders as adults--and are more frequent victims of rape/violence, STD's, and early pregnancy--compared with their age mates who were never molested.  If physicians and counselors took the time to talk with families and children, at the twice-yearly visits, the "secret" wouldn't be so secret, and early interventions might reduce later health problems that cost society so much not only in doctors' visits, but in women who cannot live full lives.
     The most common age for sexual abuse is nine.  Therefore, a knowing and unafraid physician with sufficient time would ask more careful questions about a child at the six-month visits up to and around this age, as a way of allowing parents and children to speak the truth.  Perpetrators of abuse, including incest, would also be able to ask for help without fear of the terrible repercussions that currently exist, and perpetuate a culture of silence.
     When patients visit my office, my first thought as I examine and question them is:  What is each of these individuals likely to die from, and when?  I also ask:  What is likely to cause this person's next health problem, and how can I prevent it?  This, I believe, is the correct way to think about patients and their long-term health--and to save them, the medical system, and all of society a lot of suffering, and a lot of money.
     If my 86-year-old mother were to visit such a physician, for instance, the answer to these key questions would be:  Your biggest risk is a fall, followed by a fractured hip, after which your likelihood of dying in the next six months would be one in three.  My mother has osteoporosis, for which she has steadfastly refused my advice that she take bisphosphonates once a week to reduce her chance of a fracture.  She also refuses to take calcium or vitamin D, use a cane or walker, or wear the 911-alert necklace purchased for her.  I wish that her doctor would address her risk of dying in a bold and candid discussion, because then she'd be more likely to listen, and go to physical therapy to improve her strength, and use a cane or walker, and have someone else drive her where she wishes to go, and take the medicine that could prevent a hip fracture and the ensuing, risky hip replacement surgery.  If she saw a physician twice a year for the express purpose of reducing her risks for death, she'd probably live longer.  If the doctor reviewed, at the same time, an expanded living will, her death, when it comes, could be peaceful, and pain-free--without the shock and expense of "unexpected" catastrophes, for which heroic, ridiculous treatments (often in Intensive Care Units) are automatically doled out, as though not doing everything in these final days would be tantamount to not caring about our elders.
     On the other hand, if my 21-year-old son were to show up for his semiannual visit with the doctor, I would hope he'd be required to take a safe-driving course, and join a safe-sex group with others his age.  The biggest risk of death at this age is automobile accidents, followed by suicide, HIV, and drug overdose.  If he were African-American, it would be homicide.  Counseling young people to reduce these risks would reduce suffering, save the penal system, and prevent accidents.  
     A physician meeting with my 57-year-old brother who smokes would help him quit, and require that he join a smoking cessation group, and make sure he has the tools and support to quit forever.  Instead, he's on his own in this effort.  Because he has smoked all his adult life, his biggest risk for death is a heart attack, so a stress test might motivate him to think about his heart, and to exercise. In the meantime, he could undertake life changes to negate some of the adverse effects of smoking, such as upgrading his diet, meeting with an exercise specialist, or taking selected supplements.
     Most of us have health risks that have their origin in genetics, family dynamics, cultural factors, or exposure to environmental toxins.  Our six-month doctor visits would include a calculation of our (mathematical?) risks, and our overall life expectancy-- followed by suggestions for counterbalancing the risks, reducing illness, identifying diseases like cancer early, and living longer and better.
     Such frank discussions between doctors and patients seem tactless, and, perhaps for that reason, are too rare.  But they are essential for preventing illness, calamities (many of which are foreseeable), and accidents.  It has been said that family doctors are better than actuaries at predicting their patients' life expectancies.  We just haven't been motivated to do this.
     Doctors would have to be paid for the time it takes them to assess risk and to put together a plan for reducing it.  Then, other healthcare specialists could meet with patients individually or in groups to monitor how well patients are doing in their endeavors to live better, or more safely.  The goal would be to identify dire, life-threatening problems so early we could, as a team, reroute them.
     Would these early interventions cost money?  Yes.  Does it cost much more to wait for the consequences of not providing anticipatory care?  I think so.  Would there be calculable gains to society because large numbers of people would continue to work (and pay taxes) (and contribute their talents), rather than spend time being ill, or disabled?  Of course.  Could we celebrate how many people didn't get chronic diseases, or haven't had accidents, or aren't depressed and suffering with somatic problems as a consequence of not being able fulfill their potential?  Why not?
     It's harder to measure what doesn't happen in a system, than what does.  No one has ever calculated, for example, how few of my patients, over the years, have suffered heart attacks or strokes, or how seldom my patients have been diagnosed with terrible disease states or been in accidents as a result of my time-consuming, interventional style of medical care.  But that would be the proper way to appraise our healthcare system, and to measure savings both in dollars and in a viable workforce.  As for the contentment quotient of those who don't get sick--just think of the downstream benefits to us all, of a citizenry with powerful bodies, a vigorous metabolism, and buzzing brains.

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