Thursday, January 5, 2012

Making Every Visit Count

Last month, a report appeared in the British Journal of Cancer reporting that nearly half of all cancers in the UK were due to lifestyle choices, and were therefore preventable. As if in response, the NHS Future Forum released a report last week recommending that NHS providers talk to their patients about diet, exercise, smoking, and alcohol consumption at all visits, even if the patient was coming in for an ‘unrelated illness’, in an effort to tackle a dramatic rise in obesity and cancer in the UK. I’d like to take today’s column to laud this initiative and discuss some of the objections that have been raised.
First, though, let’s set the stage. For those not familiar with healthcare in the UK, the UK enjoys a publicly-funded healthcare system, the National Health Service, which was set up after World War II to create a coherent, nation-wide healthcare system. Though some private insurances exist in the UK, the majority of Britons receive their care through the NHS. Because of the scope and size of the NHS, there is an ability to set a national healthcare agenda in a way that is more difficult to achieve here in the States. Our medical system, because it is privately-funded and not fully integrated, allows for doctors to have much more individual freedom in the way they practice, for better or for worse. The way the NHS works means that this recommendation would hold considerable sway in the way docs practice in the UK, should it become an official policy.

Now on to the part where I sing the praises of these recommendations. I blogged earlier this week about the aforementioned study showing that a significant portion of cancers are due to preventable lifestyle factors, factors these recommendations are meant to modify. Additionally, I blogged over the summer about a study which showed that, in combination with each other, smoking, excessive alcohol, poor diet and lack of exercise take about a decade off a person’s lifespan. The imperative of promoting healthy lifestyle to reduce death and disease is clear.

The main objection that has come up against this proposal is that patients would view these questions as intrusive, and may decline to seek medical care for fear that they would be badgered about their habits. While I think there’s a reasonable point to be made here, it’s a poor comment on the clinical skills of clinicians if they are viewed as ‘lecturing’ their patients or ‘intruding’ on their lives. I’d like to think that all doctors, no matter their own personal styles, can learn to communicate in ways that encourage open conversation and partnership with their patients, rather than the moralizing and lecturing we might have expected from our Victorian forebears. The NHS Future Forum’s head, Professor Steve Field, said in an interview to the Guardian that the policy would not create a ‘nanny state’, and I agree, and likewise agree that the practice of healthcare workers asking their patients about health habits need not be overbearing when conducted in a spirit of cooperative problem solving.

The main issue I would raise with the report is that I believe it has an unfortunate misconception at its core. I know this is a large accusation to levy at a report that I’ve just touted very loudly, but I think it’s a true one. Here’s the misconception: that some diseases are unrelated to diet, exercise and other health habits. It’s true that some diseases are more directly caused by environmental and lifestyle factors, but the body’s ability to combat nearly any given illness is largely determined by its nutritional status, how efficiently its organ systems operate, it’s overall antioxidant status and other factors that are strongly influenced by issues such as smoking, diet, exercise, etc. So really, doctors shouldn’t be checking up on these topics even if they are unrelated to the presenting illness, but because they are almost certainly related to the current illness. Not only does checking in on the health habits give the provider an opportunity to help prevent future chronic disease, but it helps the provider deal with the patient’s current illness, whether it be elevated liver enzymes, chronic back pain or the common cold.

The interrelatedness of health habits and disease also goes some of the way to solving the objections raised. Yes, it’s nosy to ask about topics that are unrelated to the current illness, but when you’re asking about factors that are related to the current illness, you’re doing your job as a health care practitioner.

To wrap things up, I think this is great news. By inquiring about health habits at all patient encounters, the NHS would start to shift from a disease-management system to a health-promotion system. A reactive system that deals with problems once they have come up is playing a losing game, because it’s always chasing what has already happened. A proactive system, one that looks down the road, predicts potential pitfalls, and takes action to prevent future problems is positioned to win. As I’ve said, the current proposal is imperfect, but laudable, and it could mark a significant step forward in the fight against diseases both acute and chronic.