Saturday, October 27, 2012

One Size Does Not Fit All When it Comes to Health Care.

Two hundred and fifty years, if you happened to live in the “colonies,” now the United States, you had a life expectancy of around 43 years.. Interestingly though, if you managed to make it through childhood, childbirth and avoid infectious diseases and accidents, your life expectancy could be considerable. The life style of the day (whole foods, strong community, and built in daily activity) is one that promotes longevity. Health care was provided by the midwife, local herbalist, mothers and wives, as there were few doctors (probably a good thing given that blood letting was the norm) and almost no hospitals. Paying for health care was nominal in most families and often times, bartering was the norm. This was very much a patient/family driven approach, where health practices were quite diverse depending on who was delivering the care.

 The 19th century laid the foundation for the incredible strides made in life expectancy in the 20th century. Organized medicine starts to take center stage, with the establishment of medical schools, and hospitals. It’s the dawn of the scientific age, and public health becomes more established. However, average life expectancy is only increased by about four years.

At the beginning of the 20th century, the majority of people are continuing to die from acute illnesses, and so medicine is practiced with the idea of the patient getting better or dying. However, by the end of this century, it has significantly changed.  There has been no century like this as life expectancy jumps 62%, from 47.3 years of age in 1900 to 76.8  in 2000. MMWR 5/20/11 

These gains came about largely through the following:
• Public health (immunizations, motor vehicle and work place safety, control of infectious diseases, tobacco control etc/)
• Social programs, such as Social Security helped to meet basic human needs of food, clothing and shelter
• Government sponsored health programs such as Medicare, Medicaid
• A more scientific approach to health care resulting in better treatments for conditions that were once untreatable.

In addition to advanced life expectancy, the 20th century achievements came with a very high price tag. In addition, the old acute “medical care model” no longer works as the majority of people will die with a chronic condition-therefore requiring care for many years.. Lots of things are being tried to reduce costs and extend life expectancy.

In September, the Institute of Medicine of the National Academies issued a report “Best Care at Lower Cost: The Path to Continuously Learning Health Care in America.” This report starts off by saying America's health care system has become far too complex and costly to continue business as usual. Pervasive inefficiencies, an inability to manage a rapidly deepening clinical knowledge base, and a reward system poorly focused on key patient needs, all hinder improvements in the safety and quality of care and threaten the nation's economic stability and global competitiveness. Achieving higher quality care at lower cost will require fundamental commitments to the incentives, culture, and leadership that foster continuous "learning”, as the lessons from research and each care experience are systematically captured, assessed, and translated into reliable care. 

Among the “sacred cows” of 21st century medicine are yearly physicals and preventive testing, such as PSAs for prostate cancer and mammograms for breast cancer. “Well child” visits have been very important in reducing childhood death and disease, as they involve immunizations schedules, testing for things like lead poisoning and TB, normal growth patterns etc. Prenatal care has significantly improved outcomes for pregnant women, resulting in healthier babies, so it would seem logical that yearly physicals for adults would yield similar results.

Earlier this month, the Cochrane Library published a new study “General Health Checks in Adults for Reducing Morbidity and Mortality for Adults.”  Sixteen randomized studies from primary care or community settings were reviewed in the aggregate and the bottom line was that having a yearly exam did not reduce the risk of dying from serious illnesses like cancer and heart disease, and in fact caused unnecessary harm. One of the  studies reviewed found a 20% increase in diagnoses among those being regularly screened but it ultimately did not translate into better health outcomes. Long story short, there is no convincing evidence that general health checks are beneficial. How long do you think it’s going to take for that message to filter down?

It seems almost weekly there is new information about how things thought to be bad for us (like chocolate) actually have value-I have one friend that keeps saying, “come on red meat”-and things we believed to be important- like routine yearly mammograms and yearly physicals- may not be as helpful as originally believed.

Screening for disease to prevent it makes sense, but the latest evidence, from government health groups such as the United States Preventive Services Task Force (USPSTF), shows that the data don't always support the idea that screening leads to better health.

As my good friend and mentor Dr. Seymour Leven always says, “We are each unique so therefore medicine must be tailored to the individual.” So here in lines the important points of this post:

• The 20th century was able to eliminate many of the diseases that shortened the lives of people 250 years ago. However, the lifestyles of the early settlers were probably a lot healthier than today. The best example of how lifestyle promotes longevity can be found in the Blue zones project.  The “Power 9” to increase longevity include: Natural movement; sense of purpose; stress reduction; plant based diet and not eating until full; wine (not to excess); social belonging; and faith of some sort. 

• A large percentage of the life expectancy that came about in the 20th century occurred because of public health and social programs. The 21st century needs to build on what we’ve learned, continuing to apply good public health and social programs, but recognize the needs to develop new strategies to deal with chronic conditions and the need for medicine that makes sense for the individual.   "...When contemplating screening, practitioners should focus on tests that are targeted to the patient's age, sex, and specific risk factors, and that are supported by high-quality evidence. All screening tests (general health checks or focused screenings based on age, sex, or specific risk factors) have potential for benefits and harms, so consideration of patient preferences is critical, especially for those tests where such preferences vary between individuals or where the overall benefit:harm ratio is less favorable."
• To obtain the individual care that you need, establish a good working relationship with your primary care provider and the person you see for your chronic condition, if different than your primary care provider. Discuss with them what really makes sense for you to be tested and treated for and how often you need to be seen. Be clear about what you realistically can afford to do and are willing to do. 

Be an e-patient,  so you can learn from others with similar health issues and share your data with them.  This is the new wave of health care.

  For more tips read Healing the Whole Person: Ways to Increase Well-Being 

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