People come to me for answers, and my profession pitches doctors as the ones with answers. We fix problems.
This, of course, is not true — a fact that I have come to see as a core problem in the practice of medicine in America, and a reality that (as everything seems to do) comes largely from the way we pay for medicine. We are paid to fix problems. How do we fix problems? With procedures.
The best evidence for this are the things at the heart of health care: codes. There are three types of codes that dominate the financial and clinical lives of anyone in health care:
- ICD codes: codes for medical problems
- CPT codes: codes for medical procedures
- E/M codes: codes used by doctors who don’t do procedures so they can get paid for office visits
What this encourages from the medical profession is predictable: lots of problems treated by lots of procedures. This is good for doctors who do procedures, especially ones that are cutting-edge (like robotic surgery) or ones that seem particularly dramatic and/or heroic (open heart surgery, heart stents). These are the things the headline consuming public is most hungry for. Just like it grabs more headlines to catch a terrorist plot just before it has its horrible effect than to prevent it early in the process, it’s a lot sexier to do a procedure to treat heart disease than to simply prevent the disease in the first place. Which is the better outcome? Preventing heart disease. Which is paid more? Not even close.
The problem with problems
A more subtle (and perhaps more significant) effect of this mindset is the way in which everything is labeled as “problems” or “diseases.” A recent ruling of the AMA that obesity is a “disease” stirred up quite a bit of controversy. The AMA ruling does nothing to change the nature of obesity, and clearly is more a discussion of semantics, politics, and funding, than it is a true medical question. In reality, I used to not be able to bill the ICD-9 code for obesity and get paid, but now I guess I could (if I did that kind of thing any more). I suspect this opens the door for more procedures to be paid for by insurers, as the response to any problem is always a procedure in our system.
There is pressure now to respond to each “problem” with a procedure, or at least a thing to eliminate it as a problem. Examples:
- Sinus infections are routinely treated with antibiotics despite no evidence that it actually helps. Having marketed our profession as problem-fixers, we are met with patients expecting a fix to their problem. They are disappointed (and even angry) when we don’t “do something” for a “problem” that will resolve on its own, even if the intervention probably causes more harm than benefit. Problem: sinusitis. Procedure: antibiotic. Check.
- Cholesterol treatment is another example of this. High cholesterol, be it LDL, total, or triglyceride is seen as a “problem,” even in people who are not at risk for heart disease. I’ve seen many low-risk patients come to my practice on cholesterol medication that does little more than improve their numbers. The evidence shows that certain high-risk people benefit from being on certain medications which lower the cholesterol. For folks outside of those high-risk groups, the medications simply make numbers look better (at best) and potentially harm them (at worst). Problem: High cholesterol. Procedure: cholesterol drug. Check.
- Depression and anxiety are normal emotions. Life is painful and unsure. There only are two ways to avoid these emotions: die or get stoned. My personal experience (some fairly recent) is that the times of life most marked by anxiety and depression are accompanied by significant personal growth. Before everyone gets mad at me for saying these aren’t diseases, I must add that there are cases of both of these emotions that are terribly destructive and potentially fatal if not treated. But we physicians have lowered the price of admission to treatment, including people going through hard times as those who have clinical depression. Responding to TV ads about “that pill that will make me happy,” we are met with patients expecting us to “fix their problem” — a problem that is not really a problem; it’s life. Problem: anxious and depressed people. Procedure: medication. Check.
A better way
I think there’s a better way to look at things. I’ve said this before, but I am coming to grasp just how radical this approach is and just how much it undermines our health care system. There is something far more important than problems:
When someone comes to my office with chest pain, my thoughts do not go to the question: “what is going on?” A more important problem comes first: “is this a dangerous situation?” I want to know if the person is ready to die from a heart attack or other serious problem. This is true in nearly every decision I make as a doctor when faced with a condition. Could that cough be latent lung cancer? Could that headache be a brain tumor? Could the depressed man kill himself?
Risk reduction also rules how I approach disease. I treat cholesterol and hypertension, not because they themselves are problems, but because they can lead to heart disease, stroke, and other problems. High cholesterol is not, in my opinion, a “disease” for most people; it is a risk factor. I treat diabetes mainly to prevent the complications. Do I care if a 90-year-old has an A1c of 8? No way. It doesn’t increase their risk enough to matter.
This does not mean we approach “prevention” like the system presently does: throwing procedures at it. The health care system doesn’t reward having healthy patients, it rewards doing procedures reported to prevent problems. Yet the system is not addressing the true goal of prevention: risk reduction. We are “rewarded” by ordering tests, whether or not they reduce risk. PSA testing is a perfect example of this, as are many other misguided attempts to treat prevention as another problem to fix with a procedure.
The problem with this, of course, is that it far more to the financial benefit of doctors (and drug companies) for us to address every problem and show we are giving “good care” by checking off the box next to each problem. In the bigger picture, risk reduction makes the jobs of future cardiovascular surgeons (and drug companies) much less secure. It attacks the revenue stream of most doctors and hospitals (and drug companies) right where it counts: you can’t make nearly as much money off of healthy people as you can people with “problems.”
This is why, I believe, any system that profits more from people with “problems” than those without is destined to collapse. Our system is opposed to the goal of every person I see: to stay healthy and stay on as few drugs, have as few procedures, and avoid as many doctors (and drug companies) as possible.
What would happen if we prevented disease? What would happen if people didn’t have medical problems? For society it would be great. For the health care industry it would be a huge problem.
Rob Lamberts is an internal medicine-pediatrics physician who blogs at More Musings (of a Distractible Kind).
- Are You Surprised That Depression Is Identified As A Risk Factor For Heart Disease? (123mymdblog.com)
- Unhealthy lifestyles should be targeted by healthcare providers (medicalnewstoday.com)
- For childhood cancer survivors, preventable risk factors pose serious threat to heart health (medicalnewstoday.com)
From the 11 October 2013 post at Cardiac Exercise Research Group - The K.G. Jebsen Center for Exercise in Medicine’s blog about exercise and cardiac health
There remains little doubt that lack of exercise and a sedentary lifestyle represent key health problems in today’s modern society. A quick search on the World Health Organisation’s (WHO) website and you’ll find that physical inactivity ranks 4th in the global leading risk factors for mortality, with many countries around the world demonstrating a trend for women to be less active than men. While health organisations around the world are making a concerted effort to encourage the general public to incorporate exercise into their leisure and free time, this may not be the only period of our day that is dominated by sedentary behavior. Work forms one of the largest segments of sedentary time for employed individuals, and current trends have shifted parts of the working population into less active, ‘sitting’ jobs.
But what does this mean for our long-term health? One study, published last month in PLoS ONE, aimed to answer this question by assessing the impact of occupational sitting on the risk of cancer, cardiovascular disease, and all-cause mortality from a large number of British men and women. Stamatakis and colleagues gathered data from identical health surveys conducted in England and Scotland between 1994 and 2004. Subjects (5380 women, 5788 men) were classified based on whether the majority of time in their job was spent walking, standing or sitting. Subjects were further categorized on levels of physical activity during free time, alcohol intake, smoking, socioeconomic status, and whether they had cardiovascular disease or cancer at the time of the survey. The mortality rate (number of deaths) was then monitored over a 13 year follow-up period.
The major findings reported by this study were that standing/walking occupations carried a lower risk of mortality from either all-causes or cancer, in women but not men. When the researchers further compared groups based on free-time physical activity levels, they found that in both men and women, high levels of free-time physical activity coupled with a standing/walking occupation was associated with a lower risk of cancer and all-cause mortality versus low free-time activity coupled with sitting occupation. At first glance, it could be easy to take the results at face value, but there are limitations to the study design which the authors themselves highlight: Much of the data is self-reported, which may introduce bias, especially when it comes to levels of physical activity during free-time. In addition, there was no information available on how long individuals had been in their current jobs, nor was there any data for people switching jobs during the 13 year follow-up, which may have eventually placed them into a different category. The findings are also surprising given that a similar study published earlier in the year, found that even moderate free-time exercise was enough to reduce the risk of both cardiovascular and all-cause mortality, regardless of levels of physical activity in work.
The issue still seems unresolved, and it has also been discussed here on the blog earlier. Current exercise recommendations from the Norwegian Directorate of Health suggest daily physical activity levels should be at least 30 min, a total 3.5 hours per week, which has been shown in a number of studies to confer significant benefits to health and an overall decrease in mortality rates. However, a busy lifestyle, coupled with raising a family may make this target difficult to reach during our leisure time, making activity levels at work a significant factor in overall health. Everything is better than nothing, and maintaining a physically active lifestyle outside of work hours will contribute significantly to achieve the health benefits of exercise. However, if you’re still worried and have been sat at your desk for the last few hours, when you reach the end of this sentence, why not stand up and take a walk?
Allen Kelly, post doc at CERG.
- Are Sitting Occupations Associated with Increased All-Cause, Cancer, and Cardiovascular Disease Mortality Risk? A Pooled Analysis of Seven British Population Cohorts (plosone.org)
- Exercising in free time may keep blood pressure healthy (medicalnewstoday.com)
- Exercising During Leisure-Time Tied to Reducing High Blood Pressure Risk (counselheal.com)
- Exercise: What the Research Says (gymlion.com)
- Leisure-time Exercise Could Lower Risk of High Blood Pressure? (ivanhoe.com)
- How Being Sedentary Can Affect Your Health – and Back (badbacksblog.wordpress.com)
- Exercise Statistically As Effective As Drugs For Heart Disease, Diabetes And Many Other Diseases (naturalblaze.com)
Underinsured CVD patients die sooner than patients with private insurance, irrespective of race…
Insurance status is a better predictor of survival after a serious cardiac event than race, and may help explain racial disparities in health outcomes for cardiovascular disease. A new study by Derek Ng, from the Johns Hopkins Bloomberg School of Public Health in the US, and his team shows that race is not linked to an increased risk of death but being underinsured is a strong predictor of death among those admitted into hospital with a serious cardiac event. Their work appears online in the Journal of General Internal Medicine, published by Springer…
g and colleagues looked at whether the risk of early death was associated with insurance status or race. They took into account the potential effects of neighborhood socioeconomic status and disease severity. They analyzed data from a sample of patients admitted to one of three Maryland hospitals for three specific cardiovascular events: 4,908 with acute myocardial infarction (or heart attack); 6,758 with coronary atherosclerosis (or furring up of the arteries); and 1,293 with stroke.
They found that underinsured patients died sooner than patients with private insurance, whereas the survival rates were comparable between whites and blacks. More specifically, underinsured patients had a 31 percent higher risk of early death after a heart attack and a 50 percent higher risk after atherosclerosis. This survival effect was independent of race, neighborhood socioeconomic status and disease severity.
The authors conclude: “Among those admitted to the hospital with an acute cardiovascular event, there was an increased risk of mortality among subjects who were underinsured compared to those who had private insurance. Given the recent changes in health insurance and healthcare reform, these results underscore the need to closely investigate the factors relating to health insurance that may explain these disparities. Indeed, targeting these factors may relieve the burden of mortality disproportionally affecting those who are underinsured.”
- Those who are covered, recover (eurekalert.org)
- Those who are covered, recover (medicalxpress.com)
- Medicaid. Again. (washingtonmonthly.com)
- Every person deserves access to health care (bangordailynews.com)
- U.S. health centers get $11 billion boost (upi.com)
For older adults, loneliness is a major risk factor for health problems — such as cardiovascular disease and Alzheimer’s — and death. Attempts to diminish loneliness with social networking programs like creating community centers to encourage new relationships have not been effective.
However, a new study led by Carnegie Mellon University’s J. David Creswell offers the first evidence that mindfulness meditation reduces loneliness in older adults. Published in Brain, Behavior & Immunity, the researchers also found that mindfulness meditation — a 2,500-year-old practice dating back to Buddha that focuses on creating an attentive awareness of the present moment — lowered inflammation levels, which is thought to promote the development and progression of many diseases. These findings provide valuable insights into how mindfulness meditation training can be used as a novel approach for reducing loneliness and the risk of disease in older adults.
“We always tell people to quit smoking for health reasons, but rarely do we think about loneliness in the same way,” said Creswell, assistant professor of psychology within CMU’s Dietrich College of Humanities and Social Sciences. “We know that loneliness is a major risk factor for health problems and mortality in older adults. This research suggests that mindfulness meditation training is a promising intervention for improving the health of older adults.”…
Yoga reduces stress; now it’s known why – UCLA study helps caregivers of people with dementia (EurkAlert)
Six months ago, researchers at UCLA published a study that showed using a specific type of yoga to engage in a brief, simple daily meditation reduced the stress levels of people who care for those stricken by Alzheimer’s and dementia. Now they know why.
As previously reported, practicing a certain form of chanting yogic meditation for just 12 minutes daily for eight weeks led to a reduction in the biological mechanisms responsible for an increase in the immune system’s inflammation response. Inflammation, if constantly activated, can contribute to a multitude of chronic health problems.
Mindfulness Meditation Reduces Loneliness in Older Adults (westallen.typepad.com)
- Older adults who meditate feel less lonely (holykaw.alltop.com)
- Reducing Loneliness in Seniors Is Possible Through Meditation (news.softpedia.com)
- Mindfulness reduces loneliness in older adults (lonelinessblog.com)
- Older adults who meditate feel less lonely (futurity.org)
- Mindfulness meditation reduces loneliness in older adults, Carnegie Mellon study shows (eurekalert.org)
- The High Price of Loneliness (newoldage.blogs.nytimes.com)
- Yoga reduces stress; now it’s known why (sciencedaily.com)
- Loneliness linked to serious health problems and death among elderly (eurekalert.org)
- Yoga reduces stress; now it’s known why (scienceblog.com)
(I will continue to floss, tho, for the sake of my gums. However it is a relief to know there is one less thing to think about when it comes to heart health)
Despite popular belief, gum disease hasn’t been proven to cause atherosclerotic heart disease or stroke, and treating gum disease hasn’t been proven to prevent heart disease or stroke, according to a new scientific statement published in Circulation, an American Heart Association journal.
Keeping teeth and gums healthy is important for your overall health. However, an American Heart Association expert committee — made up of cardiologists, dentists and infectious diseases specialists — found no conclusive scientific evidence that gum disease, also known as periodontal disease, causes or increases the rates of cardiovascular diseases. Current data don’t indicate whether regular brushing and flossing or treatment of gum disease can cut the incidence of atherosclerosis, the narrowing of the arteries that can cause heart attacks and strokes.
Observational studies have noted associations between gum disease and cardiovascular disease, but the 500 journal articles and studies reviewed by the committee didn’t confirm a causative link.
“There’s a lot of confusion out there,” said Peter Lockhart, D.D.S., co-chair of the statement writing group and professor and chair of oral medicine at the Carolinas Medical Center in Charlotte, N.C. “The message sent out by some in healthcare professions that heart attack and stroke are directly linked to gum disease, can distort the facts, alarm patients and perhaps shift the focus on prevention away from well known risk factors for these diseases.”
Gum disease and cardiovascular disease both produce markers of inflammation such as C-reactive protein, and share other common risk factors as well, including cigarette smoking, age and diabetes mellitus . These common factors may help explain why diseases of the blood vessels and mouth occur in tandem. Although several studies appeared to show a stronger relationship between these diseases, in those studies researchers didn’t account for the risk factors common to both diseases….
“We already know that some people are less proactive about their cardiovascular health than others. Individuals who do not pay attention to the very powerful and well proven risk factors, like smoking, diabetes or high blood pressure, may not pay close attention to their oral health either” Lockhart said. [Janice's emphasis]
Statements that imply a cause and effect relationship between periodontal disease and cardiovascular disease, or claim that dental treatment may prevent heart attack or stroke are “unwarranted,” at this time, the statement authors said.
The American Dental Association Council on Scientific Affairs agrees with the conclusions of this report. The statement has been endorsed by the World Heart Federation.
- No proof gum disease causes heart problems (cbc.ca)
- Health: New Research Says No Proof Gum Disease Linked To Heart Disease (washington.cbslocal.com)
- Heart Association: No link between gum disease and heart disease (cbsnews.com)
- Health: New Research Says No Proof Gum Disease Linked To Heart Disease (tampa.cbslocal.com)
- Health: New Research Says No Proof Gum Disease Linked To Heart Disease (connecticut.cbslocal.com)
- Health: New Research Says No Proof Gum Disease Linked To Heart Disease (baltimore.cbslocal.com)
- Is There Proof Gum Disease Causes Heart Disease? (webmd.com)
- No proof that gum disease causes heart disease or stroke (eurekalert.org)
- No Proof That Gum Disease Causes Heart Disease, Experts Say (news.health.com)
- Gum disease doesn’t lead to heart attack or stroke – WANE (drugstoresource.wordpress.com)
- Health: New Research Says No Proof Gum Disease Linked To Heart Disease (philadelphia.cbslocal.com)
Harvard researchers suggest optimism, happiness and other positive emotions may help protect heart health and lower the risk of heart attacks, strokes and other cardiovascular events. It also appears that these psychological well-being factors slow the progress of cardiovascular disease.
The findings are the result of the first and largest systematic review of its kind, and are reported in the 16 April online issue of Psychological Bulletin, by lead author Julia Boehm, a research fellow, and senior author Laura Kubzansky, an associate professor, in the department of society, human development, and health, at the Harvard School of Public Health (HSPH) in Boston, Massachusetts….
- Positive feelings may help protect cardiovascular health (eurekalert.org)
- Positive feelings, optimism protect heart (upi.com)
- Do Happy People Have Healthier Hearts? (webmd.com)
- Study: Optimism reduces heart attack, stroke risk (cbsnews.com)
- Positive feelings may help protect cardiovascular health (medicalxpress.com)
- Study Says Optimism Can Help Protect Your Heart (washington.cbslocal.com)
- Study Says Optimism Can Help Protect Your Heart (tampa.cbslocal.com)
- Study Says Optimism Can Help Protect Your Heart (connecticut.cbslocal.com)
- Study Says Optimism Can Help Protect Your Heart (baltimore.cbslocal.com)
- Optimism Might Cut Your Risk for Heart Attack (news.health.com)