Friday, September 30, 2011

Too much care?

The US healthcare system is in a state of crisis. At this point, we’re starting to sound like broken records. Increases in healthcare premiums have been outpacing increases in wages for several years now. A National Academy of Sciences slideshow I saw gave projected prices for staple foods had their prices increased at the same rate as healthcare costs – picture paying $134 for a dozen oranges. What is absolutely certain is that this is not going to be an easy fix, and that cutting costs is going to involve trimming in many sectors.

Interest in reducing healthcare costs resulted in a recent survey of primary care physicians, which found that many primary care docs are over-treating their patients because of current factors in health care. At first read, most people would probably react negatively to these findings, for after all, most Americans feel that they’re receiving substandard healthcare and paying increasingly more for it. In my experience, patients feel their visits are too short, and that their doctors just order labs and write prescriptions without spending the time to listen or answer questions. I often joke that I could base my entire practice as a naturopathic physician around explaining to people how to read the labs their other doctors have ordered.

It turns out that patients and doctors agree on this topic. The results of this survey, published in the prestigious Archives of Internal Medicine, indicate that physicians feel they aren’t given enough time with patients, aren’t able to follow up with patients by phone or email as much as they would like, and have to order lab tests and imaging studies more aggressively than they would like. Most primary care physicians surveyed would prefer to treat more conservatively and spend more time with their patients than they do currently.

There are two main messages I think are important to take from the survey. The first is that both doctors and patients agree on what they want from the doctor patient relationship. Patients want to be heard, and doctors want to listen. This sets us a goal for assessing the quality of healthcare delivered.

The second message is this: the doctors surveyed were very clear about the factors they felt interfered with their ability to deliver quality healthcare. One such concern was fear of malpractice litigation, which was causing doctors to over-prescribe and over-diagnose for fear that they would be sued. Also high on the list were concerns over insurance reimbursement. It’s a sad truth that insurance doesn’t reimburse for quality time spent with patients, but rather for referrals to specialists, procedures, prescriptions, and for seeing lots of patients for shorter periods of time. The article concludes that the quality of healthcare could be improved by reforming malpractice liability and modifying financial incentives to reward quality time spent with patients.

Of important note is the fact that the article’s lead author works for the Veteran’s Administration, an organization that currently provides its physicians greater protection from malpractice suit and doesn’t offer the same financial incentives, but which has traditionally performed very high when it comes to patient satisfaction and quality of care.

Go back now to the slideshow I mentioned earlier – the section titled ‘How Much is Waste?’ highlights some ways that healthcare dollars could be saved. Here we see that $210 billion dollars were spent on ‘Unnecessary Services’, due in part to defensive medicine – overly aggressive treatment done to avoid lawsuit or other repurcussions. Similarly, $55 billion dollars were misspent on ‘Missed Prevention Opportunities’, probably because doctors don’t have the time to spend with their patients discussing prevention. I bring this up to point out that the same factors that get in the way of delivering quality care are also driving up healthcare costs.

Doctors and patients want the same thing. They want quality healthcare and they want a system that works. This survey showed that doctors want to give patients the time and care that they deserve, rather than just rushing them out to see a specialist, and it turns out that it would save the country money as well. A few years ago, we missed a real opportunity to make fundamental change in the country’s healthcare system – it looks like the topic is coming around again soon. Let’s see if we can do a better job this time.

Friday, September 23, 2011

How much exercise should I get?

For years, I got very little exercise. I broke my kneecap when I was thirteen, had it immobilized for months, never got rehabbed afterwards, and was pretty much resigned to no sports for years afterward.

When I finally decided to start biking again (a low impact form of exercise I figured would be easier on my knees), I found that I had to work through significant tendonitis pain brought on by suddenly using a joint that had been inactive for years and which was damaged to begin with. Ultimately, perseverance saw me through this, and I’m back on track and training for a half marathon – not bad for someone who dropped out of his high school cross country team.

Anyway, I only provide this story to illustrate a point. Not every seemingly sporty young person you see out jogging on the weekend is a born athlete. Everyone has to start somewhere, and some of us have a slightly higher hill to climb before we can get there. So take those as words of inspiration as we discuss exercise.

At this point, everyone knows that exercise is good for you. It helps prevent a number of chronic diseases, including high cholesterol, some cancers, high blood pressure, osteoporosis, diabetes, and depression, to name a few. A few weeks ago, I blogged about a study showing that regular exercise is one behavior that can help you live longer, too. But how much should you get and what counts as exercise?

The current consensus is that every adult should get 150 minutes a week of moderate aerobic activity and strength training twice a week, or 75 minutes a week of vigorous aerobic activity and strength training. These guidelines have been by numerous high-profile organizations, including the CDC, the US Department of Health and Human Services, and the American Heart Association.

OK, so what is ‘moderate aerobic activity’? According to the folks writing the guidelines, this category includes brisk walking, water aerobics, light biking, ballroom dancing, or general gardening. 150 minutes a week breaks down into 30 minutes five days a week, and many of the websites also suggest that this can be done in 10-minute chunks. Doesn’t sound so bad, right? An afternoon of gardening and a walk around a local pond has you well on your way. Biking to work also counts. If you walk your dog daily, you may be pretty much covered. And heck, if you go out ballroom dancing, well then you win style points in addition to getting exercise.

What about ‘strength training’? Here things are a bit vaguer, as no time or weight guidelines are given, but examples include push-ups, sit-ups, and weight training, which some people find imposing, as well as everyday-life activities, such as lifting heavy loads and doing heavy gardening.

‘Vigorous aerobic activity’ covers most of what we think of as ‘exercise’, including jogging, running, swimming laps, playing tennis or other sports, vigorous biking, or hiking. When discussing this level of activity, most NDs say, ‘Some activity which causes you to break a sweat.’ For those who want more information, the CDC’s website provides excellent resources about the benefits of higher amounts of exercise as well as how to measure the intensity of your physical activity.

The general theme with these activities is to make using your body part of your routine. It doesn’t need to be elaborate, regimented, grueling or strenuous, but it’s important that you do it regularly. You don’t have to be a trained athlete to prevent chronic disease, but you can’t be sedentary. Our bodies are built to move, so get out there and do what generations on generations of your ancestors did – move around and have some fun!

Friday, September 16, 2011

Vaccinations, the GOP, and Naturopathic Medicine

Michele Bachmann’s recent comments in a Republican debate regarding the HPV vaccine have drawn a lot of attention from both health professionals and the media. For those who haven’t been following the recent events, Rep. Bachmann criticized Governor Rick Perry of Texas for issuing an executive order requiring preadolescent girls to receive the HPV vaccine. Initially, I assumed that her qualm was with the fact that HPV is sexually transmitted, and that vaccinations against HPV (the causative factor of cervical cancer) would somehow remove deterrents against sexual activity for teenagers. However, it turns out that her complaint is that the vaccination can cause mental disorders, a claim she backed up by saying that an audience member at a previous debate had told her that her daughter had developed mental disturbances following the HPV vaccination. Taken in concert with some social conservatives’ denial of the theory of evolution, and the widespread denial of climate change, it’s sparked debate about the Republican party’s, ‘uneasy relationship with science’.

So why bring it up in my column? The question of vaccination has long been a hot button topic for naturopathic doctors, one that causes considerable debate between NDs and MDs, as well as within the naturopathic community. I’ve heard many NDs say that they are asked about their stance on vaccinations as a litmus test to determine whether or not they are ‘real’ doctors. Likewise, I’ve also been present for heated debates between naturopaths on the subject of vaccinations, with some arguing fervently in favor of them, and others aggressively opposed. I guess you could say that the naturopathic community has an, ‘uneasy relationship with vaccines’.

The benefits of vaccination to the general population cannot be denied. Diseases that were once commonplace and had potentially severe outcomes (smallpox or polio, anyone?) are now all but extinct in the US. As a public health effort, then, vaccination as a whole has been hugely successful. Nonetheless, vaccinations are not without risks, and a historically, certain proportion of the population does suffer negative effects from vaccinations. This is not a radical or outlandish statement, but a commonly accepted fact, and indeed the CDC has set up a Vaccine Adverse Event Reporting System to track adverse reactions to vaccines in an effort to make them safer. In fact, vaccines have undergone significant improvements over the past several decades in an effort to make them more effective and reduce negative side effects.

As a naturopathic physician, it is my firm belief that our profession should not continue to court a similar ‘uneasy relationship with science’. Already accused by our critics of being unscientific, I believe it’s important for the naturopathic profession to adopt the stance of helping to improve and expand science, rather than opposing it on points such as vaccination.

By the nature of our profession, naturopathic doctors see a self-selecting group of patients. One significant group of patients that seek out NDs are those who are somehow harmed by traditional medicine, be it vaccines, surgeries or pharmaceuticals. Given our extensive experience with these types of patients, and desiring to protect their patients against negative outcomes, some naturopathic doctors recommend against vaccination. However, I believe that solutions can be developed that take into consideration both the risks and benefits of vaccination, solutions that could draw on the extensive experience of naturopathic doctors who have treated those harmed by vaccination.

Throughout my education and experience, I’ve noted that the tools for predicting adverse reactions, even for established vaccines, are not very strong. Basic guidelines exist, which warn physicians not to administer immunizations in certain circumstances, but nonetheless, these guidelines miss a percentage of patients who then go on to experience adverse events. I think we can do better, and that we can develop algorithms that help to identify patients who are more likely to suffer negative outcomes, based on existing information on vaccines and patient outcomes.

Likewise, naturopathic docs have a great deal of experience in helping those harmed by vaccination to rehabilitate. There is currently little reliable information available for those seeking to recover from chronic or residual negative effects they may have sustained from vaccines. Even at naturopathic school, when vaccines are discussed, we argue back and forth about them, but talk little about how to aid patients who may have been harmed. In this case as well, I think we can do better.

On the whole, vaccination programs worldwide have been remarkably successful, but are not perfect yet – a compromise between the needs of the population and the needs of the individuals hasn’t been finalized yet, but hopefully further research and a better understanding of vaccine reactions can help solve that.

Friday, September 9, 2011

A Great Study Proving The Obvious

Reading studies can be a tedious process. Even before you get to the actual information being presented, you have to wade through a quagmire of technical language, statistics, and graphs, all of which may or may not be worth reading for your average clinician. Once you do finally sort out what the paper says, you have to determine whether or not it has any real life applicability to your patients – a lot of studies test cell types in isolation rather than tracking symptoms in living people, or will assess blood tests rather than clinical outcomes. In addition, even if you find a study that shows that a certain substance or herb was helpful for certain symptoms, or the course of a certain illness, you face the additional challenge of being able to help patients find that substance in a dose and form that they can take and will be effective, making sure of course to verify quality. That’s why I love it when a study comes out that gives clear instructions and correlates it to significant health outcomes.

Time Magazine reported on the study using the title, “Eat Well, Move Often, Don’t Smoke, Drink a Little – And Live Long,” a title that sums up the findings of this study very clearly. A group of four researchers took the data compiled in the NHANES III study, a study which tracked over 16,000 people over twenty years, and sought out the lifestyle factors most strongly associated with a low risk for overall mortality. The four factors linked to the lowest risk for dying from any cause are: eating a healthy diet, exercising regularly, not smoking, and low to moderate alcohol consumption. The study found these factors were also specifically linked to a low risk for dying from cancer (of any type), cardiovascular disease, as well as a generously broad category called ‘other causes’. On average, it found that individuals who observed all four of these behaviors lived about a decade longer than people who observed none.

I love this study because it’s uncomplicated and clear. We all know how to do the things they found correlated to a low risk of dying. The study didn’t suggest complicated or elaborate diets, or rigorous exercise regimens, but rather told us to eat well, move around, don’t smoke, and drink moderately. What could be simpler?

Just in case you need a bit of a reminder on how to do this, here’s a brief primer:

1. Eat a healthy diet. A plethora of fad diets abound in modern America, promising all sorts of health benefits, but when we get down to it we all know what a basic healthy diet looks like: eat plenty of vegetables, eat whole grains, eat low to moderate amounts of meat, and avoid junk food and fried food. The subjects in this study weren’t following elaborate diets, low fat diets, high fiber diets, or anything else, they were just self-reporting that they ate healthy diets. As I said, we all know what this means. If I were to plug a specific diet, I recommend a Mediterranean diet, because it’s closest to this, and is based on how people really eat.

2. Exercise regularly. A spectacular amount of science has also been devoted to exercise and it’s effect on health, but again, the longest-living subjects in this study were just self-reporting that they exercised regularly, not engaging in specific exercise programs. Exercise can be a sore topic for a lot of people, but the take-home message from this study is not that strenuous or elaborate programs are necessary, but rather that we should all move around regularly, no matter what our fitness level. Whether it’s walking, jogging, biking, swimming, playing a sport or running a marathon, we all need to move around regularly at a level that works for us. Exercise carries with it many benefits, and according to this study, it can bring a few more years of life as well.

3. Don’t smoke. We’ve come a long way from the days when doctors would endorse certain brands of cigarettes. We’ve known for decades that smoking causes emphysema, lung cancer, heart disease, and myriad other problems. For those who have never smoked, well done. For those who do and need help quitting, resources are available. This study found that smoking featured as the most important determining factor on mortality.

4. Drink moderate amounts of alcohol. This is the only dicey topic in this study, and one that requires a bit of explanation. A few studies have shown certain beneficial effects associated with moderate alcohol consumption compared with abstinence. This study did not demonstrate that. Rather, this study demonstrated that moderate or low alcohol consumption was more beneficial than high alcohol consumption. Like quitting smoking, this should be clear. For those currently in the low to moderate group, which is defined as up to but not exceeding 2 drinks per day, well done. Some can moderate their drinking more easily than others, and while problem drinking is beyond the scope of this article, resources are available.

So here’s the conclusion: You already know how to live a healthy lifestyle that could add an extra decade to your life. Eat your veggies, don’t eat junk, get some exercise, don’t smoke, and moderate your alcohol consumption. That said, we all need some help along the way, and if we were all able to do this without a problem, our country would be a healthier place. NDs, MDs, DOs and other health professionals are out there to help you on this, so reach out and get moving on this – your prize is years of healthy living on this planet.

Friday, September 2, 2011

A Wake-Up Call About Cancer

When two-time Pulitzer Prize-winning columnist Nick Kristof writes, I pay attention. He's written on a wide variety of topics, mainly focusing on social issues and human rights abuses, and won his Pulitzers reporting on Tiananmen Square in 1989 and Darfur fifteen years later. Recently, his on-the-ground reporting from the upheavals in Tunisia, Egypt, and beyond were indispensable to those seeking accurate information. Needless to say, when he reported on a new report from the President's Cancer Panel, I was all ears.

The President's Cancer Panel is a three-person committee appointed by the US president, which publishes annual reports on the state of cancer treatment and research in the US. Their new report, which Kristof reported on, but is not yet publicly available, is strongly critical of the US government for its lack of regulation and testing of the thousands of chemicals to which Americans are exposed every day.

While naturopathic doctors (and some MDs as well) have been concerned about chemical exposures for some time, the mainstream medical community has been reluctant to adopt a strong stance on the topic, and so this report represents a potentially landmark change in the way we think about preventing cancer. While cancer screening has become a routine part of medical care in the US, in the form of mammograms, colonoscopies, etc., this report suggests we push the cancer prevention mark even further back, back to the factors that cause the formation of cancer cells in the first place. While screening exams have increased survival rates by helping to find cancerous growths early on, when they are still very treatable, any oncologist worth his salt will tell you that the majority of diagnosed cancers, even those caught early, had been growing for years before they were found. This is why, for example, an exposure to asbestos during World War II may not result in diagnosable mesothelioma until the 1990's or beyond.

This new report suggests that we be more aware of preventing cancer before it starts, by avoiding chemical exposures that cause the gene mutations that lead to cancer. Some may read this and be intimidated, scared even, to know that the world around them is awash in potentially cancer-causing compounds. While this is true, it's also true that there are solutions to the problem. One important solution is that the government be much more forceful about the testing and regulation of the chemicals that it's citizens come into contact with. Initiatives are already underway to ensure this, and this report is likely to bolster such efforts.

Additionally, however, there are steps that we as individuals can take to reduce our chemical exposure. Some of the steps suggested in Kristof's article are simple, such as eating food grown without the use of pesticides or chemical fertilizers, drinking filtered water, and taking steps to prevent tracking chemicals into the house that one may have been exposed to at work. He also suggests some websites that help consumers find 'safe' products. At the very least, we should all be taking these simple steps towards cancer prevention in our daily lives.

This report is potentially game-changing because it readjusts the goal-line for cancer prevention. Currently, we work to find cancer when it is small and treatable. This new report suggests that we do more to stop cancer from forming in the first place. This is also a landmark report because many of these compounds have health effects extending far beyond cancer, to include neurological effects and endocrine effects, among others. However, all of that is still further down the road from where we are now. If you're interested in taking stronger steps towards preventing cancer now, I recommend finding a naturopathic physician in your area, as NDs are trained in active prevention of disease, including cancer. Many naturopathic physicians are members of the AANP, and can be found through their website, but many others are members of the OncANP, an organization of naturopathic physicians specifically devoted to the study of cancer.