Heart disease, prevention - Eureka! Measuring Physical Fitness to Bridge Gap between Wellness and Sickness Systems of Care

In the course of writing Obama, Doctors, and Health Reform, I’ve become acutely aware of huge differences between how physicians practice in the worlds of wellness and sickness.

Many reform activists have observed that the only sure way to reduce costs is for physicians to practice and teach wellness to their patients rather than concentrating strictly on treating disease and for patients to take responsibility for their health to achieve a state of wellness and health.

Easier Said Than Done

This, of course, is easier said than done. Physicians are trained and reimbursed for treating sickness, patients may not comply with physicians’ orders, wellness is a patient responsibility conducted beyond the reach of physicians and the health system, and wellness tends to be subjective rather than objective and varies with the beliefs of the beholder.

The Eureka Phenomenon

In a 2006 essay, the late Isaac Asimov observed that the Eureka phenomenon , conceptual breakthroughs, usually come while one is relaxed and distracted rather than when one is under stress.

My particular Eureka moment came when I was visiting an amiable and perceptive cardiologist during a follow-up. During our relaxed conversation, he asked, seemingly off-hand but intently, “All symptoms aside, are you feeling well? Do you have a sense of well-being? In my experience, that’s the important thing?”

Measuring Well-Being

The thought flashed through my mind, “If only we doctors could measure well-being, that would be a breakthrough. A sense of well-being, of course, is an amalgam of emotional , situational, and physical well-being – not easily reduced to a single measurement and not reimbursable in the current climate of reducing health costs.

On the other hand, physical well-being is closely linked to emotional well-being, a sound mind in a sound body. If you’re in sound physical shape, you’re likely to have a feeling of emotional well-being.

With Chronic Disease, a Sense of Mal-Being

It’s well-known that 5% to 10% of chronic diseases take 70% to 80% of total health costs. If you give the matter any thought at all, you’ll realize the major chronic diseases - coronary artery disease, heart failure, diabetes, obesity, chronic obstructive lung disease, asthma, even depression – occur in individuals in suboptimal physical condition. Those afflicted with these conditions often have a sense of mal-being – an un-ease, or dis-ease.

If only, I thought, we had some objective measure of physical capacity to use as a baseline measure of physical wellness, understood by patients, physicians, nurses, and other caregivers, that measurement could bridge the gap between the worlds of wellness and sickness. For the physician that measurement would have to reimbursable, for there is no such thing as a free lunch, or a free doctor visit, or a free measurement to gauge a state of well-being.

Talk of Prevention as Part of Health Reform

There’s a lot of idle and often unproductive talk these days about prevention as a health reform means of saving money and resources, the ounce of prevention is worth a pound of cure philosophy. There’s some dispute whether prevention can save money for the system, or if merely postpones cost to inevitable end-of-life illnesses, which are more expensive than earlier-in-life preventable illnesses.

Nonetheless, prevention – through the right diet, the right dietary supplements, right exercise, controlling blood lipids and blood pressure, and ceasing smoking and excess drinking – is the right thing to do and is the fundamental foundation of most wellness programs. Many businesses are going to the extreme of rewarding or punishing or hiring or not hiring based on health or non-health or taking or not taking corrective health measures.

Brother, Can You Paradigm?

During the Great Depression, a popular saying was “Brother, can you spare a dime?” I would like to suggest that, during this, the Great Recession, we might alter that saying to be “Brother, can you paradigm?” In other words, why can’t we, as medical professionals in the greater health system, adopt a new medical mindset devoted to measuring wellness rather than just talking about it in theoretical terms. This is not as radical as one might think, for sickness would represent a deviation from that measurement and would be treated in a traditional fashion.

The Heart (and Lungs) of the Matter

This brings me to the heart (and lungs) of this discussion. I’ve been working with and writing about a company in St. Paul, Minnesota, called Shape Medical Systems(www.shapemedsystems.com). Off and on over the last 30 years, and more intently on the last three years or so, the principals of Shape have been working on a device, or perhaps more accurately a low-risk approach, to evaluate and measure heart and lung fitness, hence the name SHAPE, an acronym of System of Heart and Pulmonary Evaluation.

This device or approach consists of a one-step staircase, an electrocardiogram, a snorkel-like device with an attached breath gas analyser, and an attached lap top computer with a database of thousands of patients and a predictive modeling algorithm capable of predicting levels of fitness and statistical risks of hospitalization and/or death.

The FDA has approved the Shape system, and the Mayo Clinic and others have tested it on thousands of patients. Shape is portable, can be easily carried from one site to another, including the home, can be set up and conducted by minimally trained personel, carries no risk, and can be repeated often to measure the effect of drugs, heart monitoring devices, the progression of a disease.

Perhaps most important, Shape is acutely sensitive to the early onset of preventable diseases heralded by decline in physical fitness. In their early stages, many chronic diseases are reversible, or their progression can be halted. Because of its easy to interpret reports, Shape lends itself to common understanding by all engaged in the health system, in health reform, and those in ill health and of the physiological state of health that contribute to a “sense of well-being” – and how to measure it, maintain it, and interpret it in the trajectory of from onset of disease to shortness of breath to death.

Medical Blogger Forum Before National Press Club

Yesterday I learned from Kevin Pho, MD, of KevinMD. Com blogging fame that on July 17a gaggle of bloggers will appear before the National Press Club in July 17 to discuss health reform. I know now that medical blogging had come into its own as an effective means of communication. Val Jones, MD, author of the popular blog. “Val Jones and the Voice of Reason,” www.getbetterhealth.com, organized the forum.

Here is Dr. Jones’ announcement of the event.

Health Care Reform: Putting Patients First

Elected Officials Join America’s Top Medical Bloggers to Discuss the Real,
Clinical Impact of Health Care Reform

WHAT: As the health care debate heats up on the Hill, join Representative Paul Ryan as he sits down with top medical bloggers from across the country to discuss health care reform and its impact on practicing clinicians. This keynote discussion will be followed by two panels of physician and nurse bloggers who will highlight the importance of putting patients first. Topics covered will include key barriers to health care quality, affordability, and access as well as the potential pitfalls of a new public plan and ways to fix the current system without investing billions in a new one.

WHEN: Friday, July 17, 9:00 a.m. to 12:00 p.m.

WHERE: The National Press Club, Broadcast Operations Center 4th Floor, 529 14th St. NW, Washington, DC

WHO: Keynote: Representative Paul Ryan, (R-WI), House Budget Committee Ranking Membe Moderator: Rea Blakey, Emmy award-winning health reporter and news anchor, previously with ABC, CNN, and now with Discovery Health

Host: Val Jones, M.D., CEO and Founder of Better Health

Policy Expert: Robert Goldberg, Ph.D., co-founder and vice president of the Center for Medicine in the Public Interest (CMPI)

Primary Care Panelists:

Kevin Pho, M.D., Internist and author of KevinMD

Rob Lamberts, M.D., Med/Peds specialist and author of Musings of a Distractible Mind

Alan Dappen, M.D., Family Physician and Better Health contributor

Valerie Tinley, N.P., Nurse Practitioner and Better Health contributor

Specialty Care Panelists:

Kim McAllister, R.N., Emergency Medicine nurse and author of Emergiblog

Westby Fisher, M.D., Cardiac Electrophysiologist and author of Dr.Wes

Rich Fogoros, M.D., Cardiologist and author of CovertRationingBlog
And Fixing American Healthcare

Jim Herndon, M.D., past president of the American Academy of Orthopaedic Surgeons and Better Health contributor

My Particular Interests

I have a particular interest in this event for three reasons.

One, I have followed Val Jones’ evolution as a power in the blogging word since her brief career as a mover and shaker at the Revolution Health portal and her winning of the Best Medical Blogger of 2007 award. Her shtick has been providing consumers with the best information to attain better health.

Two, I devote a chapter in my book, Obama, Doctors, and Health Reform, called “View of the Nation’s Number One Physician Blogger,” to Kevin Pho. Kevin has been a physician blogger since 2004 and a general; internist in a five person group in Nashua, New Hampshire. He has developed physician blogging into a fine art.
and a commercial success.

Three, I am in the process of making my own blog, www.medinnovationblog,blogspot. com more widely known and influential. After entering my 885th blog since November 2006, the other day I learned more than 7100 other blogs are directed towards me and linked t me. . I’m not sure what this means, but I’m anxious to expand my sphere of influence and to learn what contribution I can make to the worlds of health reform and medical innovation.

Helath Care and the Economy, Health care employment -Does Health Care Hurt or Harm the Economy?

President Obama has repeatedly said health costs undermine global competitiveness. But while thinking globally, he may be forgetting what is happening locally. As I observe in my book, Obama, Doctors, and Health Reform, the health sector is often the only growing segment in many local economies.

In chapter six, “Another View, Positive Impact of Private Practice on the Economy of Georgia, I cite a study by the Georgia Medical Association, in which it was shown each practicing physician directly or indirectly supported or generated.

• 13 additional jobs
• $640,000 in personal income
• $1.5 billion in total economic activity
• More than $1.2 billion in state revenues
• $1.5 billion in local government revenues.

And in chapter 17, “ A View of Chief Executive Officer of the Texas Medical Association,” Lou Goodman, the CEO, cites studies indicating that each family physician has a total economic impact of $2.9 billion, in Florida each family physicians accounts for an impact $3.9 billion, in Ohio $2.4 billion and in Texas $5.4 billion.

These are numbers not be sneezed at. And in the Wall Street Journal, I read that the health care industry has surpassed the auto industry as the largest employer and revenue generator in that beleaguered state. Now out of the Wall Street Journal blog comes this report.

July 14, 2009

Health Care Job Growth: Not Just Doctors and Nurses

By Jacob Goldstein

We didn’t have to read the new jobs report from Obama’s Council of Economic Advisers to know that health care’s going to add a lot of jobs over the next several years.

But we were interested in the report’s finding that the biggest job growth of any category in the economy would come not for doctors, nurses, or nursing home workers, but for a broadly defined group called “other medical services and dentists.”

The report defines that group as “a broad category including the ever-expanding home health care, outpatient care, and medical and diagnostic laboratories subsectors,” and projects more than 2 million new jobs per year for the group, on average, between 2008 and 2016.

A separate projection looks at the growth of health-related jobs versus all other occupations between 2000 and 2016. The finding: 12% growth for “other occupations”; 35% growth for “health practitioners”; and 48% growth for “health care support.” Health care support includes physical therapists, physical therapist assistants, medical social workers and home health care aides, the report says.

The projections are based on current trends and don’t account for any changes that may come from the Washington health-reform debate, by the way

Rationing, Data-Driven Care - Comparative Effectiveness as a General Proposition - Worth A Damn?

I dare say that I have worked off my fundamental formula on you that the chief end of man is to frame general propositions and that no general proposition is worth a damn..General propositions do not frame concrete cases. The decision will depend on a judgment or intuition more subtle than any articulate major premise.

Oliver Wendell Holmes, Jr., 1841-1935

As a general proposition, cost effectiveness studies appeal to Medicare officials as cost-cutting tools. These studies are neutral, objective, and data-based. Yet as I talk to physicians in the trenches, they tell me clinical decision-making, and interactions between doctors and patients on the ground and behind closed doors, are more complex and variable than to-down bureaucrats and data mongers imagine.

Indeed, in my book Obama, Doctors, and Health Reform, I argue complexity is one of the fundamental obstacles slowing health reform, “American health care is a whirling Rubik's Cube, with millions of interrelated moving parts, institutions, and people, each with agendas, axes to grind, and oxen to gore.”

I conclude a chapter on complexity with these words,

“To understand health care and its complexities, you must examine its concavities and convexities, you must know what occurs at its edges, in the midst of the prickly hedges. Reality is never as simple as it seems, and you cannot always 'quantify' what matters through computer algorithms, which is why you, as a patient who uses the health system, should regard 'free health care,' as provided by the government, with deep skepticism. It may come with hooks – long waiting lines and restriction of choice of doctors.”

Take prostate cancer treatment options as a case in point. Here are the options and the costs.

Average Spending Over Two Years of Various Prostatic Cancer Treatments (Source: Alan Garber and Daniella Peffroth, Stanford; Dana P. Goodman, the RAND Corp.)

$2,436 – Watchful waiting, no intervention, with tests and exams – This makes sense in 75 year old with borderline PSAs and focal cancers. But what about younger patients with high PSAs and aggressive cancers? Do you tell them to take their chances because of lower costs and greater government savings? I don’t think so.

$12,224 – External beam radiation therapy, multiple doses of radiation over several weeks – This is relatively painless, noninvasive procedure with good outcomes. For this and other reasons, recommended by many doctors and accepted by many patients.

$22.921 – Complete surgical removal of prostate gland – Of great appeal to those patients and doctors who belong to the school “When in doubt, take it out.” To them it’s definite and offers the best hope of complete cure. Usually preceded by workup to make sure cancer has not spread.

$28,871 – Brachytherapy, implantation of radioactive seeds – Many recommend this approach as an effective shotgun approach to eradicate a multifocal cancer.

$51,069 – Advanced radiation beam therapy (I.M.R.T.) – This is a state-of-the-art high tech approach, and many hospitals are installing equipment to deliver the therapy. May be part of competitive hospitals’ marketing strategies to deliver the latest and the best.

One of the underlying appeals of a government-run system is its simplicity. The government pays for “everything,” but maybe not anything, depending on cost and effectiveness. Given the complexities and variables of prostate cancer and the desires, needs, and expectations of patients and desires of patients to please patients and deliver the proper therapy, the moral of this tale may be, “Seek simplicity but distrust it.”

Tea Party Revolt, Conservative Revolt, - Something's Going on Out There with Health Reform

There’s something going on out there on health reform.. I can’t quite put my finger on it, but it’s there.

Recent polls indicate twice as many Americans consider themselves as conservative rather than liberal. There’s growing concerns about the economy vis a vis health reform, as unemployment nears 10%. There’s a sense that the $787 billion stimulus isn’t stimulating.

Three conservative books or at or near the top of the New York Times best seller book list: #1 Catastrophe: How Obama, Congress, and The Special Interess are Transforming…A Slump into a Crash, Freedom into Socialist5m, and a Disaster into A Catastrophe, by Dick Morris and Eileen McCann, #2 Liberty and Tyranny: A Conservative Manifesto, and The Last Best Hope: Restoring Conversatisim and America’s Promise, by Joe Scarborough. And among respected pundits – David Broder, Michael Barone, George Will, and Al Hunt – there’s general agreement that President Obama will not get a health care bill to sign by the August recess, maybe not even by the end of 2009.

What May Be Going On

What’s going on, I believe, are public fears that.

• Big government spending and huge federal budget deficits imperil their future (in the words of Robert Samuelson in the July 13 Newsweek, “We face the consequences of much bigger government. Certainly higher taxes for future Americans. Probably a less robust economy. The CBO notes that elevated deficits would penalize saving, investment and income, while unprecedented tax burdens could "slow the growth of the economy, making the (government's) spending burden harder to bear." To such warnings, Americans' collective response is: Go away.”

• Government bureaucrats, not doctors, will dictate who get care and what that care will be.

• Rationing of care, disguised as “efficient care” or “evidence-based care,” will result in age cut-offs for procedures like cataracts, cardiac stents, or joint replacements, or treatments for cancer.

• Replacement or loss of current private coverage or limits of choice or “freedoms” to choose one’s doctor or hospitals or caregivers.

These may well be unrealistic concerns, but they are there. As Gertrude Stein would say, there may be no there there. But uncertainties and growing lack of confidence are there, and that’s what counts in politics.

There’s another concern as well. And that is, that President Obama is defying certain fundamental universal laws.

• The Law of Isaac Newton, that for every action there is an opposite and equal reaction, in this case, the mobilization of lobbyists for hospitals, doctors, health plans, and drug companies, who stand to be badly hurt by Obama’s sweeping proposals to restructure the entire health care industry, the largest single employer and the only growing employer in the American economy.

• The Laws of Thermodynamics, which say there is only so much energy in any system, there is always waste (entropy), and the system never goes to absolute zero. Translated, this means we can never find the money or wring out or bring to zero all the waste, fraud, and abuse to finance free entitlement systems like Medicare and Medicaid (J.K. Iglehart, “Finding Money for Health Reform – Rooting Out Waste. Fraud, and Abuse, “ NEJM, July 16, 2009)

• The Law of Gravity, which states that everything that rises too high or hovers over the ground must ultimately come back to earth. This applies to politics, where it called the end of the political honeymoon.

Conclusion

According to Rex Murphy in the July 13 Globe Mail, President Obama is a political trapeze artist. He has flown above the rest of us with the greatest of ease, a daring young man on a flying trapeze.

In six months, President Obama has (a) transformed the U.S. economy by massive federal government interventions, (b) taken an owner's stake in the automobile industry, (c) changed the rules of America's energy economy, (d) promised to institute a national health-care system. And he has done all of these things simultaneously and in the midst of a financial meltdown.

He has done this with cries of absolute urgency with reckless and daring haste, passed massive bills before political opponents had time to read them, and he has pushed a swollen political debt beyond all previous records.

Obama has executed the greatest trapeze act in the history of American politics, but now, with nothing to show for it in stimulating the economy, with unemployment still rising, his vaunted health reform act in gridlock because of no plausible plan of how to pay for it, and concern growing about the magnitude of federal debt, the law of gravity is beginning to kick in.

Physician Culture - Observations after Three Private Doctor Visits

This week as a patient I visited three doctors – a cardiologist, a dermatologist, and an ophthalmologist. The cardiologist was in a group of eight, the dermatologist in a group of two, and the ophthalmologist practiced solo but was part of an eye surgery center founded by a number of ophthalmologists.

As part of my visit, I carried a copy of my book Obama, Doctors, and Health Reform as a spark for reform discussion. The book led to lively discussions about reform in general and about specific reform recommendations of others. These recommendations included eliminating fee-for-service, decreasing the number of specialists, and use of electronic records to facilitate care, affords diagnostic support, and decrease waste.

Not surprisingly, was their agreement that ending fee-for-service was an impractical fantasy, that mandatory electronic medical records were overkill and would do little to improve care, and that shortage of doctors in their specialties was imminent. None of these specialists had an electronic medical record system. The cardiologist thought such a system was inevitable but greeted the idea with a notable lack of enthusiasm. The dermatologist and ophthalmologist said installing EMRs in their practices made no sense, and added it would be cheaper to take a penalty rather than install a system.

All shared the opinion that a centralized command and control system could not possibly control all the variables, permutations, and combinations of patient-doctor interactions that went into decision making on the part of patients and doctors. Most thought a centralized government-run system would continue to decrease reimbursement and would lead to rationing.

All were fatalistic about decisions made in Washington, and all doubted any federally-directed system would improve care on the ground. Most thought Medicare fee reductions were likely but were arbitrary and capricious and had little relation with their cost of doing business. All, however, said they would continue to see and accept new Medicare patients, even if Medicare reimbursement did not cover their costs.

This is a small, perhaps even a meaningless and certainly not a statistically significant sample, but it is relevant to the current debate. In my option, it reflects a general resistance and skepticism about federal intervention. Among doctors, there are no miracles among friends, and no expectations of silver bullets being fired from Washington. These physicians have a free market mindset - an intricate voluntary system of economic, social, and cultural interaction representing desires and needs of individual patients and doctors.