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General interest items edited by Janice Flahiff

[Reblog] Health Care for Dummies (and Innovators): In search of a practical definition of health | The Health Care Blog

Health Care for Dummies (and Innovators): In search of a practical definition of health | The Health Care Blog.

From the 25 November 2014 post

flying cadeuciiFor a while now, I’ve been working on an ebook about making digital health more useful and usable for older adults.

(Don’t hold your breath, I really have no idea when it will be done. I can only work on it for about an hour every weekday.)

In reflecting on the health innovation conferences and conversations in which I’ve participated these past few years, I found myself musing over the following two questions:

1. What is health?
2. What does it mean to help someone with their health?

Three Components

After all, whether you are a clinician, a health care expert, or a digital health entrepreneur, helping people with their health is the core mission. So one would think we’d be clear on what we’re talking about, when we use terms like health and health care.

But in fact, it’s not at all obvious. In practical parlance, we bandy around the terms health and health care as we refer to a wide array of things.

Actually defining health has, of course, been addressed by experts and committees. The World Health Organization’s definition is succinct, but hasn’t been updated since 1948:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

A more recent attempt to define health, described in this 2011 BMJ editorial, proposed health as “’the ability to adapt and self manage’ in the face of social, physical, and emotional challenges.”

This left me scratching my head a bit, since it sounded more like a definition of one’s resilience, or self-efficacy. Which intuitively seem much related to health (however we define it), but not quite the same thing.

I found myself itching for a definition of health that would help me frame what I perceive as the health – and life – challenges of my older patients.

Also, it seemed impossible to articulate how digital health tools might help us care for an aging population, if one didn’t start with a practical definition of health.

So after doing an hour of research in the literature (and finding endless scholarly rabbit holes), I ended up trying to sketch a model of health that felt true to my experiences.

In this post, I’d like to share what I came up with, and get your feedback. Then in a follow-up post, I’ll write about what this might mean for defining health care, and our efforts to improve or facilitate health care.

What is health?

Health is a dynamic state. For an individual, it involves three core components:

• How are you feeling? How do your body and mind feel? Are you experiencing any pain? Bothersome sensations? Mental distress? This component of health addresses the individual’s experience of suffering.

• How well are your body and mind outwardly working? Are your body and mind working as you expect them to, or need them to, or want them to? Can you get around physically as you usually do? Can you manage your thinking tasks? Can you see, hear, speak, and otherwise communicate effectively with others? This component addresses the individual’s ability to leverage body and mind in order to manage one’s usual activities and life tasks.

• How well are your body and mind internally working? This component relates to one’s inner physiology and function. When we peer inside, whether with modern technology, via the careful pulse auscultation used in some cultures, or any other method, is anything awry? Do we find signs of disease, disorder, or disruption? In Western medicine, we consider the workings of organs and cells, but other cultures have their own “inner workings” that they assess when evaluating health.

These three components are in constant interplay with each other. Right now I’ll refer to them your wellbeing, your macrofunction, and your microfunction. (But I’m not sure those are best terms.)

These three components of health are also in constant interplay with our social and physical environments, as well as with our nutrition and our “lifestyle choices.” For instance, rich social encounters and purposeful work improve wellbeing, as well as immune function and other aspects of our microfunction. Air pollution might make us cough, and can negatively impact our lung function, along with other less visible parts of our health.

Are these many external factors, and our behavior choices, synonymous with “your health”? I would call them influences on your health, or in certain cases “health care”, rather than your health itself. (And they aren’t diagrammed above, although I’d like to add them eventually.) These factors are incredibly important, but we confuse matters when we conflate things that influence health — such as access to clinicians, clean water, walkable cities — with the actual health of an individual.

Why does a person’s health matter?

Better health is an important end in of itself.

But to a large extent, health is a means to a more important end: that of living life.

In other words, being able to do the things we care about, need to do, and want to do. Being able to do things that give purpose, meaning, and pleasure to our lives. Being able to do the things that make us feel like our selves.

This is kind of obvious, but it’s actually fairly easy to lose sight of this when we get immersed in the weeds of health and health care. (Which is why the Unmentionables at Health 2.0 is so fantastic: it’s a much-needed reminder that health serves life.)

[Caveat: There is a lot of overlap between the life activities, but I haven’t yet figured out how to diagram this. Graphic design is not my forte.]

What is a health problem?

As a doctor, my job is to help people address their health problems. And I’d like for the digital health entrepreneurs to create tools that work better for this purpose.

So what is a health problem? How to define what people seem to need help with? How to define what digital health tools should help us – whether we are a patient, a clinician, or a family caregiver – address?

Here is a practical definition: a health problem is anything that is “wrong” with one or more of the three components of health above.

For instance:
• Wellbeing Problems: Examples include being in pain, being fatigued, having insomnia, feeling depressed, feeling anxious, feeling short of breath, and so forth. Many symptoms, pains, discomforts, and any other forms of suffering fall into this category.

• Macrofunction Problems: These might include having difficulty walking due to arthritis, problems exercising due to shortness of breath, or problems thinking due to dementia. You could also include vision problems, hearing problems, and speech difficulties due to stroke. These issues often cause noticeable functional impairments.

• Microfunction Problems: These would include problems such as having impaired glucose metabolism, high blood pressure, osteoporosis, kidney disease, as well as early stage cancer.

You’ll notice that problems with wellbeing and macrofunction are primarily person-defined. It’s the affected person – sometimes known as “the patient” – who experiences suffering, or difficulties in how the body and mind are working. Whereas microfunction problems are generally “expert-defined”: nobody knows they have osteoporosis until clinicians tell them.

Many diagnoses, diseases, or health stressors will cause problems in all three parts of health. For example, cancer symptoms and the related functional impairments (e.g. problems doing anything you can usually do) are the consequence of the cancer cells running amok within.

Congestive heart failure might cause uncomfortable dyspnea, as well decreased exercise tolerance, such that a person has difficulty managing usual ambulation and activities.

Your Life

Of course, there is a lot of room to argue about what constitutes “wrong” with a given health component. Cultural and social factors influence how people perceive their own suffering, or overt impairments. And we could quibble endlessly about what is ideal blood pressure, and how we might otherwise assess how right or wrong a person’s body and mind are internally working.

Still, in many cases, if most of agree that something seems “wrong” with a given component of health, this should provide us with a decent practical starting point for identifying health problems.

Do we need to distinguish between microfunction and macrofunction?

I believe we do. Problems with macrofunction are the things that people notice in themselves (or in others, when it comes to cognitive macrodysfunction). These are what patients are often most concerned about.

Macrofunction problems, along with forms of suffering, are also what directly impacts people’s ability to participate in life tasks, and their short-term quality of life.

So helping people correct, mitigate, or adapt to these types of functional impairments is incredibly powerful, if you want to address health problems in a way that makes people’s lives materially better. This is an approach that is common in geriatrics, palliative care, physical and occupational therapy, and behavioral therapy.

Microfunction, on the other hand, is what people need technical assistance to assess. (Historically that assistance have been clinicians, but we’re on the cusp of seeing advanced diagnostic tools in the hands of the public.)

Much of the work that we doctors do in modern medicine, especially in primary care, is address physiologic problems that are scarcely perceptible to the affected person: high blood pressure, high cholesterol, type 2 diabetes, kidney disease, asymptomatic atrial fibrillation.

We do this work because we are trying to prevent or delay more overt health problems, such as those associated with suffering and macrodysfunction. So it’s certainly worthwhile work. But it doesn’t always feel satisfying or worthwhile to patients, especially if they are pre-occupied by other problems which are causing suffering or overt functional impairments.

In fact, it seems to be fairly common that patients and clinicians are focused on different aspects of health. A typical example: a doctor might decide to unilaterally prioritize tinkering with the microfunction, such as by prescribing more statins, even though a patient’s most pressing concern is falls or pain.

November 28, 2014 Posted by | Consumer Health | , | Leave a comment

Drugs From Nature, Then and Now – Medicines By Design

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From the article at the US National Institutes of Health,  last reviewed on October 27, 2011

Chapter 3: Drugs From Nature, Then and Now – Medicines By Design – Science Education – National Institute of General Medical Sciences

Long before the first towns were built, before written language was invented, and even before plants were cultivated for food, the basic human desires to relieve pain and prolong life fueled the search for medicines. No one knows for sure what the earliest humans did to treat their ailments, but they probably sought cures in the plants, animals, and minerals around them.

[The table of contents]

He found that the ingredient, called parthenolide, appears to disable a key process that gets inflammation going. In the case of feverfew, a handful of controlled scientific studies in people have hinted that the herb, also known by its plant name “bachelor’s button,” is effective in combating migraine headaches, but further studies are needed to confirm these preliminary findings….

July 2, 2014 Posted by | Educational Resources (Elementary School/High School), Educational Resources (Health Professionals), Educational Resources (High School/Early College( | , , , , , | Leave a comment

[Reblog] JAMA removes cover art, and why that matters

From time to time I glanced at JAMA cover art when working at various libraries.
Never quite understood the art. However, now I feel like part of JAMA’s soul is diminished….

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From the 6 November 2013 Kevin MD article by 

Beginning in 1964 the Journal of the American Medical Association (JAMA) started publishing full color images of art on its cover accompanied by insightful essays.JAMA’s former editor, George Lundberg, wrote that this was part of an initiative to inform readers about nonclinical aspects of medicine and public health, and emphasize the humanities in medicine. Now after almost 50 years of covers that displayed over 2,000 pieces of art, JAMA has taken a great leap backwards and replaced the cover art with a pedestrian table of contents. The cover art that once distinguished JAMA from an array of leading medical journals has been demoted to an inside page, eliminating one of the more visible, inspiring beacons that once linked the humanities to medical science.

The cover art was always important to me. As a teenager envisioning my future, I saw copies of JAMA on my uncle’s desk. He was a medical doctor, and for me the JAMAcovers joined the visual arts to the science of medicine and gave me inspiration. As the years passed, I enjoyed seeing the distinguished covers of JAMA in medical libraries, and frequently picked them up to read the commentary. Glancing from the scientific articles to the essays on the cover art, my vision of the combination of art and medicine was validated. Over the years I received JAMA in my office and tacked many of my favorite covers to the wall by my desk.

The art swept across the vast panorama of civilization and human history. Just about any painter you can imagine has been featured on a JAMA cover. In addition the covers displayed Japanese Ukiyo-E prints (February 4, 1998), a 15th Century Apothecary Treatise (September 8, 1999), and African bronze statuary (April 6, 2011). One of my favorites was the photo of the Lewis Chessmen, a set that was carved from walrus ivory in the 12th Century and found in the Outer Hebrides off the coast of Scotland (February 16, 2011).

Read the entire article here

November 20, 2013 Posted by | Professional Health Care Resources | , , | Leave a comment

People Fall Into Three Categories Of Gut Microbiota : Implications for Nutrient and Medicine Uptake

From the 21 April 2011 Medical News Today article

Every person’s intestinal system falls into one of three clearly distinguishable types of gut microbiota, comparable to blood types. These types are not related to race, native country or diet, according to a new metagenomics study

[Editor Flahiff’s note: Links only to abstract
for suggestions on how to get this article for free or at low cost, click here] 

by an international consortium of scientists including Jeroen Raes, of the VIB and Vrije Universiteit Brussel, published in Nature. Metagenomics is the study of the genetic material of complete ecosystems, in this case the human gut.

“The three gut types can explain why the uptake of medicines and nutrients varies from person to person,” says bioinformatician Jeroen Raes of the VIB and Vrije Universiteit Brussel, one of the two lead researchers in the study. “This knowledge could form the basis of personalized therapies. Treatments and doses could be determined on the basis of the gut type of the patient.” Improved knowledge of the gut types could also lead to other medical applications, such as the early diagnosis of intestinal cancer, Crohn’s disease and the adverse effects of obesity..

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April 21, 2011 Posted by | Consumer Health, Medical and Health Research News | , , , , , , , | Leave a comment

Is Preventive Medicine Really Overtreatment?

Is Preventive Medicine Really Overtreatment?

From the NPR Health News item

In Overdiagnosed: Making People Sick in the Pursuit of Health, Dr. H. Gilbert Welch argues that modern medicine is looking too closely for disease, and that unnecessary screenings, MRIs and CT scans turn healthy people into diseased patients, by revealing often harmless abnormalities….

….

But overtreatment isn’t just a problem for patients diagnosed with cancer. It could sometimes be a problem for healthy people, as my next guest writes in his book “Overdiagnosed: Making People Sick in the Pursuit of Health,” because even healthy people are subject to more and more tests every time they visit the doctor.

Think about it, what do you do? You get the normal tests. You get your cholesterol level, maybe your liver test if you’re doing statins, you have a PSA, you have a body scan, tests that are often they often result in treatment. And because the traditional dogma is, as my next guest writes, more early diagnosis means better medical care, which means more treatment; and more treatment means better health.

But is that traditional view true? Is it accurate? Should we still be thinking about it that way? Are all these tests and treatments actually improving our health or are we looking too hard for disease?….

FLATOW: Why is it because doctors can do all these diagnoses, all these tests that they do, do them?

Dr. WELCH: Well, certainly, part of it is what’s possible, and what’s possible is, of course, changed dramatically over the last year. But it’s also part of our ethos, if you will, that it’s always a good thing to look for early forms of disease. And, of course, that message just been sent out to the public through the media and other sources that, of course, the thing you want to do is look for early forms of disease.

But the truth is there are really two sides to the story. I think patients are used to thinking of treatments as having side effects, but so does testing. And the side effect of looking for early forms of disease is that we find, virtually, all of us have some. That’s because we all harbor some abnormalities. And we never know which patients are those that have abnormalities that are going to cause problems in the future. So we tend to treat everybody we find with an abnormality and that means we’re just treating some patients who can’t benefit from our treatment because they were never going to develop the problem at hand if they’re overdiagnosed.

FLATOW: But how do you say to the person, you know, that maybe in the minority, as you say, that you may have saved that person’s life by overdiagnosing them? Is that worth of maybe one in a hundred cases?

Dr. WELCH: Well, I think that’s the question we all need to face. And, you know, sort of, traditionally, doctors have focused on the one out of a thousand we might help by looking for early forms of disease. But we haven’t really asked the question, what happens to the other 999? And this problem was really demonstrated to us in prostate cancer screening, which is really a poster child for the problem of overdiagnosis.

20 years ago, a simple blood test was introduced. And 20 years later, over one million Americans have been treated for a cancer that was never going to bother them. That test was the PSA, or prostate specific antigen. And it turned out an awful lot of men had abnormal PSAs. Many were found to have microscopic cancers far more than whatever suffer from prostate cancer.

Now, you might say, does it matter? Yeah, sure it matters because most of these men were treated with either radical surgery or radiation. And roughly a third suffered side effects of treatment generally related to bowel, bladder or sexual function. Even a few have died from it.

So this is a problem. It’s a matter of finding the balance between the question of just how hard we should be looking for problems in well patients……

February 13, 2011 Posted by | Health News Items | , , , , , , , , | Leave a comment

   

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