Thursday, May 17, 2012

How Can We Help Our Patients to Stay Healthy?

     The previous blog was written somewhat tongue-in-cheek, but a judicious application of financial rewards and penalties would undoubtedly work to make patients give up unhealthy habits and take up healthy ones. Just think how the percentage of drivers who used seatbelts increased once tickets were issued for being unbuckled. In the same vein, if the penalty for jaywalking were a $1,000 fine, we would certainly see less jaywalking and, pari passu, fewer pedestrian deaths. In Arizona motorcyclists wear helmets, but in Utah, where there is no such law, most "donorcycle" riders do not. So how can doctors reach patients, to educate them and to change their habits, bearing in mind that most patients with unhealthy habits (e.g. smoking) know that the cigarette habit mitigates against a long or a healthy life, and will further cause them to be a burden to their loved ones and their relatives?

     I have long been convinced that our human brain is geared to avoid immediate (in the next 10 seconds) threats rather than time-distant threats. Hence "a bird in the hand is worth two in the bush", but "a stitch in time saves nine" is less frequently quoted. No one thinks that cigarettes are good for you. Even before the current studies directly linking cigarette smoking to an increased risk of heart disease, chronic emphysema and lung cancer we called them "coffin nails". But no cigarette smoker thinks that the cigarette that he or she is smoking right now will kill them, and that is precisely the problem.

     In a similar vein, no overweight patient fails to notice the increase in weight, or thinks that that overweight is healthy. I have repeatedly told my overweight diabetic patients that they could cure their diabetes or at least diminish the amount of medicine they take by losing weight, but to no avail. Why doesn't the average human, after noticing an increase in belt or dress size go on an immediate diet? The  majority of dedicated dieters in my practice are men after their first heart attack, which  is really locking the barn door after the first horse has left.

     If there is an immediate reaction to improper eating, then of course patients are careful. So patients with a peanut allergy, or lactose intolerance or celiac disease (gluten sensitivity) are very careful eaters. But even with the posting of the amount of calories in a given serving (this study was done in Taco Bell in Los Angeles) patients do not decrease the total amount of calories they eat. Why?

     When patients measure their blood pressure or blood sugar at home, they usually repeat the measurement several times to get a "good" number to show the doctor. Many patients swear that they eat nothing and can't understand their failure to lose weight, but when I ask them to write down everything they eat in a daily diary and then tally up the calories for them, they are invariable surprised. Maybe that is why the only proven method of sustained weight loss is surgical: stomach bypass surgery or stomach banding.

     Whenever I poll my medical residents, more than half of them stopped taking their antibiotic prescription before the bottle was empty. One study showed that 25% of patients who leave the doctor's office with a prescription never fill it, and of those who do dill it, 25% place the bottle in a drawer and never even take the first pill. The majority of patients believe that the more medicine they take, the sicker they are, so they try to taper or omit their doses of medicine, a habit that can have tragic results in an asthmatic or a hypertensive patient. What I am driving at is that it is not the lack of patient's disease knowledge or lack of patient education by the physician that is the problem, nor is it a lack of government guidelines. Rather, people just don't seem to think that the medical advice applies to them, or that failure to follow their doctors' advice will have negative consequences.

     We all have had patients who have suddenly decided to give up smoking, or to lose weight, or to exercise, and we can certainly help them in this task. But no one, not even even the patients themselves, knows what made them "throw the switch" and adopt a healthier life style. This is the real problem facing public health: how to motivate the population to act in healthier ways, and neither blaming the patient population for being ill-informed nor simply telling to give up unhealthy habits seems to be    the answer.

Monday, May 7, 2012

How to Improve Medical Care (and Save Money)

     I have been reading many articles recently about this plan and that plan to improve the medical care of patients, to reduce medical expenditures, and generally to make us a healthier society. All of these different suggestions have one point in common: they neglect basic human psychology. In what follows I list several interventions and modifications that should help all of us reach these lofty goals. And like any CEO, I am setting forth goals and techniques and leaving it to others to work out the nuts and bolts of implementation.

     It has been said many times that man is an economic animal, at least on an individual basis (so I am here neglecting mob psychology). A universal method that improves performance is the reward method and for humans, unlike Pavlov's dogs, the most successful reward has been money. There have also been several test programs, usually in inner schools with students who are less than interested in their schoolwork: when these students received a financial reward for not being late, or not being absent or doing all of their homework, their school habits improved. I would add the obvious statement that jockeys and college and amateur wrestlers and boxers  all seem to be able to keep their weight down, and in their cases the rewards are immense. Similarly, most runway models manage to remain ultra-slim, as do the majority of movie stars and stage actors.

    OTOH your brain is remarkable in its ability to maintain your weight by a continuous  process of homeostasis.  If we start to gain weight, our metabolic rate increases, in the brain's attempt to return us to where we were. Similarly, if we start to lose weight, the body's metabolism is slowed down by the brain, for the same reason. In addition, our metabolism slows by the equivalent of 3 to 5 pounds per year, so each year it becomes more difficult to lose weight (until about age 75 or 80). To realize how remarkably the brain does its job, consider that burning one pound of fat releases 3500 calories of energy. Thus  if you ate an extra 3500 calories in one year, you would gain one pound. This works out to micromanaging your caloric intake to within TEN calories per day, a feat that even Superman would be unable to do. So the brain is always on the job, micromanaging our metabolism to keep our weight as constant as possible.

     The Motz proposal for better health simply involves offering financial awards for achieving certain benchmarks. It makes much more sense to reward the patients, who are the direct agents, than to reward the doctors in a Pay-4-Performance program for what their patients do. We could award (possibly by income tax credit) patients who lost ten pounds in a year, or who had annual pap tests or mammograms, or had their blood pressure or cholesterol measured in the previous year. Then goals could be set, with an annual reward for achieving and maintaining a certain weight, or blood pressure, or average sugar.

     There are of course many details to be worked out and considered: should doctors also be rewarded? how and where is the weight and weight loss and annual blood pressure etc. measured and certified? Perhaps we could start a trial pilot program in a county with a low population since it would be easier to track behaviors. We would all lose 10 pounds for a reward of $1,000,000, but not for a reward of $0.01. The question then becomes: how much would they have to pay you for you to lose and keep off 10 pounds in the next year? And should these successful patients also get a medal, or ribbon, or have their names posted in the newspapers?

     I am certain that if we paid cigarette smokers $1,000/year to quit we would save much more than 60 x $1K = $60,000 in the future medical fees that would be caused by his/her continuing to smoke.



Tuesday, May 1, 2012

Irritable Bowel Syndrome

     Everyone has had irritable bowel syndrome at one time or another. Your entire digestive system from the rear of your mouth (actually the lower two-thirds of your esophagus) to the top of your rectum is under autonomic control. By that I mean that you have absolutely no voluntary control over  the rate of progress of food through your digestive tract. All the muscles involved are smooth muscle, and are controlled by a complicated interaction between  your sympathetic and parasympathetic nervous systems as well as a host of secretory hormones.  There is also a constant interplay between the spinal nerves and the muscles and digestive enzymes of the  gut, with modifications superimposed  by the vagus nerve from the brain and the secretion of adrenalin.

     We all have heard the expressions, and many of us have felt the sensation of "made me sick to my stomach",  "made me throw up", "turned my stomach" "gave me agida or heartburn", "left a sour taste in my mouth", "my mouth turned dry", or "my mouth watered" , and thus are aware of the mind-body connection between our brain and our gut. The validity of these expressions was verified beginning in April, 1822. A French trapper, Alexis St. Martin, was accidentally shot in the stomach on Mackinac Island, Michigan, and healed by a Dr. William Beaumont. The healing left a hole directly into his stomach through the abdominal wall. Dr. Beaumont performed many experiments which he documented, including observing the color of the interior of the stomach wall, and the rate of digestion of a piece of meat dangled on a string into the stomach through the hole. He observed that when the patient got angry or upset, the stomach wall blanched indication a decreased blood supply, and the stomach muscles either stopped squeezing back and forth, or went into spasm. Under normal conditions, the stomach wall was pink. When he lowered a piece of meat into the stomach, the walls became red as the local blood flow increased,  gastric juice was secreted, and gastric peristalsis was stimulated. If he made him angry or upset during this process, the gastric juice secretion and peristalsis markedly decreased and the stomach color grew paler.

     Problems at the other end of the gut  can also develop during stress. Some people develop diarrhea. Others become constipated. Often young children who are angry involuntarily refuse to move their bowels for  one or two weeks or even longer.  (The recorded record for an adult is a year and a day, and an operation was required, with the use of a hammer and chisel.)

     One way to recognize the presence of IBS is to realize that disease is not cognizant of  time, or the day of the week, or geography. So if you have GI problems during the week and not on weekends, maybe your job is stressing you out. If your stomach problems magically disappear when you are away on vacation, then maybe your daily responsibilities are causing a problem. Similarly, most people sleep very well on vacation, almost as if their insomnia decided to take a vacation along with their body. And of course if visiting someone or that someone visiting you distresses your gut, then that person is toxic for you for whatever reason.  When your emotions are stressed your brain reacts by causing  distress in your body, typically in  your gut, and this is the brain's way of crying for help and relief.

     And for the individual with functional bowel problems who says "I have nothing to feel stressed about", one can only hope that a kind and understanding family physician can help that person to understand the amazingly powerful mind-body connection.