New Direction for Healthcare?

[facetguy]

With the looming crises in healthcare and seeming unsustainability of the current system, changes will obviously become necessary. One trend that seems to be evolving is taking more seriously the notion of keeping people healthier to begin with instead of just treating them once they are sick. Efforts are underway to collect data on new biomarkers for health/disease which will hopefully enable us to predict who is at risk. Taking a more systems-based approach is at the center of this model, with an emphasis on integrating complex information from multiple sources instead of 'single-disease single-pill' focus. Advances in genomics, epigenomics, nutrigenomics, etc will play a large role as well.

Several institutions are moving forward in this regard:

Institute for Functional Medicine: www.functionalmedicine.org

Emory/Georgia Tech's Predictive Health Institute: https://www.phi.emory.edu/

"Prospective Medicine": http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

I have read predictions that these concepts will become incorporated into med school curricula and some residencies, and that new non-physician healthcare providers will develop in this model.

I think it makes sense, as healthcare reform shouldn't be about who has access to the same ol' healthcare and who will pay for it, but instead making changes in the healthcare itself.

Is anyone involved in these efforts? Any thoughts/predictions?

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[docB]

I predict that the American public will be very resistant to embracing preventative measures just as they have been to quitting smoking, exercise and weight loss.

 

[cpants]

I think these topics are increasingly being incorporated into medical school curricula. I know at my school risk factors, both environmental and genetic, are discussed for every major pathology we cover. Of course we have a long way to go toward understanding all of the genetic factors which contribute to disease, but I don't feel that the medical establishment has been resistant to trying to learn more and to incorporate what we already know into screening and treatment protocols.

 

[Miami_med]

I don't think that these things save money in the long run. They are good for the patient, but they don't save money. If you prevent a heart attack for 10 years, you use 10 more years of preventative services before you then require hospitalization for the heart attack. If you prevent the heart attack completely, you let the patient live long enough to get cancer. Furthermore, your chances of surviving the heart attack go up as you age, so you are then more likely to survive and require follow up for all of the ongoing post-MI complications. Preventative measures are largely only cost saving in a sub-group of patients that are already sick (ex: Heart Failure compliance to prevent exacerbations and trips to the ER).

Not that I'm advocating this as a national policy, but the ideal patient from a cost perspective is someone who never goes to the doctor and then drops dead at 65. Preventative medicine is a good policy to protect individuals, but it is certainly not more cost effective at the national level.

 

[cpants]

I do think preventative measures can help with cost saving. While changing or postponing the cause of death will not have much benefit, reducing the incidence of chronic illnesses can pay off in a huge way. Reducing diabetes for example...while that patient may still die of a heart attack some day, he may not have to be on intensive glucose management for decades and suffer all of the other non-lethal, yet expensive complications that go along with the disease. Preventing the spread of HIV, which is now a chronic disease managed with extremely expensive drugs, could save us billions.

 

[facetguy]

I can't say that I've studied the economics issue in any depth, but I do find it hard to believe that preventing disease wouldn't be cost-saving. And can we really assume that we would just 'swap out' one disease for another, as in miami-med's example?

As docB said, we do unfortunately have to rely on patients doing their part in all of this. You can't keep smoking, eating doughnuts and laying around on the couch and expect to become healthy. However, as we are able to better personalize/individualize these prevention approaches, it may be easier for people to follow.

 

[Hippias]

I do think preventative measures can help with cost saving. While changing or postponing the cause of death will not have much benefit, reducing the incidence of chronic illnesses can pay off in a huge way. Reducing diabetes for example...while that patient may still die of a heart attack some day, he may not have to be on intensive glucose management for decades and suffer all of the other non-lethal, yet expensive complications that go along with the disease. Preventing the spread of HIV, which is now a chronic disease managed with extremely expensive drugs, could save us billions.

I agree. The US spends more than any other country on health care, and also has very poor preventative care compared to other countries. I think there is a connection there.
There are many other factors of course. Many countries would not try to save some lives the American health care systems would, which saves them money at the time and also prevents the need for expensive health care through the remainder of the survivor's life, but I think preventative care ranks in as one of the major factors in helping to lower health costs.

 

[Miami_med]

I agree. The US spends more than any other country on health care, and also has very poor preventative care compared to other countries. I think there is a connection there.
There are many other factors of course. Many countries would not try to save some lives the American health care systems would, which saves them money at the time and also prevents the need for expensive health care through the remainder of the survivor's life, but I think preventative care ranks in as one of the major factors in helping to lower health costs.

The connection is that other countries spend money on preventative care instead of a lot of the high cost low yield activities that are common here. If the argument is that we might save more people by spending money on smoking cessation over getting a CT brain on every patient that gets a bump on the head, then yes, that is cost saving. However, association is NOT causation.

The types of preventative medicine about which everyone is talking (ie: preventing diabetes instead of controlling diabetes) is really barely even medicine. It's nutrition or physical fitness. When I say preventative medicine, I'm thinking more along the lines of controlling a diabetic's blood sugar or controlling a hypertensive's blood pressure. Smoking cessation is a good thing as far as long term health, but I'm not sure where the costs land. Neither does anyone else.

 

[facetguy]

The types of preventative medicine about which everyone is talking (ie: preventing diabetes instead of controlling diabetes) is really barely even medicine. It's nutrition or physical fitness. When I say preventative medicine, I'm thinking more along the lines of controlling a diabetic's blood sugar or controlling a hypertensive's blood pressure.

It's important to realize, though, that medicine is in the driver's seat in terms of influencing policies and funding. If medicine blows these things off as 'only' nutrition or physical fitness, then preventive measures will never gain the traction they deserve. I think that's the broader issue here, that these things ARE important and need to take center stage in health care.

 

[cpants]

It's important to realize, though, that medicine is in the driver's seat in terms of influencing policies and funding. If medicine blows these things off as 'only' nutrition or physical fitness, then preventive measures will never gain the traction they deserve. I think that's the broader issue here, that these things ARE important and need to take center stage in health care.

These things are important, and I think you will find few doctors who dispute that. The question is, what is a doctor's role in promoting these preventative strategies? In certain areas, vaccination for example, doctors have a prominent role. In others, weight loss for example, it just isn't too feasible. That doesn't mean we don't recommend weight loss, but economically it just doesn't make sense for someone as educated as a physician to be micromanaging patients' weight loss.

I don't know why you feel that these things do not have traction. They are hardly controversial ideas. Every 10 year old who has taken health class knows how important it is to be physically fit and that smoking and drinking are bad. It is not a failure of medicine that we are a fat culture, it is a failure of the individual fat people. What ever happened to personal responsibility?

 

[Hippias]

Although they're important, they're not currently under the jurisdiction of doctor, and I think in this 'new direction' they more and more will be. The American lifestyle is the problem, and there is no one more able to affect it than the physician. And honestly, how can you affect something as intangible as culture? The only possible way would be education by physicians for his/her patient on the 'why and how' of a healthy lifestyle.

 

[facetguy]

These things are important, and I think you will find few doctors who dispute that. The question is, what is a doctor's role in promoting these preventative strategies? In certain areas, vaccination for example, doctors have a prominent role. In others, weight loss for example, it just isn't too feasible. That doesn't mean we don't recommend weight loss, but economically it just doesn't make sense for someone as educated as a physician to be micromanaging patients' weight loss.

I don't know why you feel that these things do not have traction. They are hardly controversial ideas. Every 10 year old who has taken health class knows how important it is to be physically fit and that smoking and drinking are bad. It is not a failure of medicine that we are a fat culture, it is a failure of the individual fat people. What ever happened to personal responsibility?

As I stated earlier, personal responsibility will of course always be critical. But is it your position that the majority of Americans have suddenly decided to become less personally responsible and so are now overweight or obese? Could there be a little more at work here than just calories in/calories out? I think so.

Of course any physician will encourage his/her patients to quit smoking, so that's not the best example of what needs to change.

Perhaps someday (hopefully soon) what we now think of as 'preventative strategies' will just become standard medical practice. Like it or not, these things will need to become more central to the physician's role. If medicine continues to say that yes these things are important but no it's not my problem, then what will change?

 

[docB]

Perhaps someday (hopefully soon) what we now think of as 'preventative strategies' will just become standard medical practice. Like it or not, these things will need to become more central to the physician's role. If medicine continues to say that yes these things are important but no it's not my problem, then what will change?

Another hurdle to this under our current system is that the way things get done now is by linking reimbursement to them. Government and insurers have realized that urging docs to do something is futile while paying them to do it (or as is the case with medicine not paying them for not doing it) is effective. Historically they have been poor at choosing things that actually matter but that is the current paradigm.

The reason that's a problem is that the most likely way we'd see this happen is that our reimbursement would be tied to our patients following our directions toward prevention. In other words we would get paid based on our patients stopping smoking, losing weight, not smoking crack and so on.

If I'm going to have to wait on my patients to quit killing themselves I may as well throw in the towel and call one of those numbers telling me I can make $10,000 a month from home if I have a computer and a low IQ.

 

[cleoscat3]

With the looming crises in healthcare and seeming unsustainability of the current system, changes will obviously become necessary. One trend that seems to be evolving is taking more seriously the notion of keeping people healthier to begin with instead of just treating them once they are sick. Efforts are underway to collect data on new biomarkers for health/disease which will hopefully enable us to predict who is at risk. Taking a more systems-based approach is at the center of this model, with an emphasis on integrating complex information from multiple sources instead of 'single-disease single-pill' focus. Advances in genomics, epigenomics, nutrigenomics, etc will play a large role as well.

Several institutions are moving forward in this regard:

Institute for Functional Medicine: www.functionalmedicine.org

Emory/Georgia Tech's Predictive Health Institute: https://www.phi.emory.edu/

"Prospective Medicine": http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum

I have read predictions that these concepts will become incorporated into med school curricula and some residencies, and that new non-physician healthcare providers will develop in this model.

I think it makes sense, as healthcare reform shouldn't be about who has access to the same ol' healthcare and who will pay for it, but instead making changes in the healthcare itself.

Is anyone involved in these efforts? Any thoughts/predictions?

I know the general idea of this thread has shifted a little more toward the preventative side of medicine. Reading the opening post I cannot help but think of the implication that a person's genetics being used in disease prevention was the original idea. This would make sense as this is a much more controversial topic than the current topic of nutrition. As someone interested in the field of medical genetics I think that this is definitely the future of preventative medicine. Tailoring a specific regimen to a specific person based on their genetic profile would offer the most productive preventative medicine we have yet seen. However, we must be wary for this opens the doors to insurance companies selecting clients based on good genetics.

Have fun

 

[facetguy]

I know the general idea of this thread has shifted a little more toward the preventative side of medicine. Reading the opening post I cannot help but think of the implication that a person's genetics being used in disease prevention was the original idea. This would make sense as this is a much more controversial topic than the current topic of nutrition. As someone interested in the field of medical genetics I think that this is definitely the future of preventative medicine. Tailoring a specific regimen to a specific person based on their genetic profile would offer the most productive preventative medicine we have yet seen. However, we must be wary for this opens the doors to insurance companies selecting clients based on good genetics.

Have fun

The cool thing is that the intersection of nutrition and genetics is becoming better understood. Food and nutrients are not just calories, but they are information to which our genome reacts. And we are now learning that aspects of one's nutritional status can impact the very next generation of offspring (unlike genetic evolution which takes many years) via epigenomics. Perhaps this helps explain the rapid rise in overweight and obesity...time will tell. Nutritional manipulation can also help overcome the effects of some single nucleotide polymorphisms. So, in my view, yes it's genetics but it's more the environmental impact (diet/nutrition included) on genetic expression that is critical to understanding health promotion and disease prevention.

If medicine continues to see all this as not its problem and solely up to the patients to figure out on their own, then progress will be very slow.

 

[Pharmavixen]

Every 10 year old who has taken health class knows how important it is to be physically fit and that smoking and drinking are bad. It is not a failure of medicine that we are a fat culture, it is a failure of the individual fat people. What ever happened to personal responsibility?

But is it? No disrespect intended, but Americans are astonishingly fatter than the people of any other country in the world. This problem is too wide-spread (so to speak) to be the fault of individual Americans.

We have fat people here too, but there are people who move to your country and find they start putting on weight. There's something else going on.

 

[cpants]

But is it? No disrespect intended, but Americans are astonishingly fatter than the people of any other country in the world. This problem is too wide-spread (so to speak) to be the fault of individual Americans.

We have fat people here too, but there are people who move to your country and find they start putting on weight. There's something else going on.

Ok, whose fault is it then? Getting fat is an American culture thing, in the same way that acting like the victim and blaming all your problems on someone else is an American thing. Why do you think people are thinner in other countries? Because their doctors give better nutrition and exercise counseling? Give me a break.

 

[Pharmavixen]

Ok, whose fault is it then? Getting fat is an American culture thing, in the same way that acting like the victim and blaming all your problems on someone else is an American thing. Why do you think people are thinner in other countries? Because their doctors give better nutrition and exercise counseling? Give me a break.

Starting with the blatantly obvious, thinner people eat less and exercise more. In Europe, gas is expensive and cities are crowded and hard to drive around in, and people tend to do a lot of walking in their daily lives.

I imagine a lot of Americans get fat because, for whatever reasons, it's easier to get fat in America than elsewhere. And I agree that all these people who find themselves putting on the pounds could take some steps; blaming it on genetics, for instance, is beyond silly, considering that fat Americans are descended from thin Europeans, Asians, and Africans.

The last thing I'd say is that fat people are innocent victims of a culture that compels them to overeat. But at the same time, it's true that something about the American lifestyle makes over-eating all too easy, and if that were not true, there'd be no more fat Americans than fat French.

And I have to say, American restaurant portions are completely insane. Last time I was on holidays stateside with some family visiting from Britain, we fed eight people with a pancake breakfast the menu said was "for two."

 

[docB]

We are committed to this new direction in healthcare that will bring improved access to a comprehensive range of services for people using a one-stop-shop approach in our area.

That sounds like a mission statement. Are you actually doing anything and if so what?

 

[NonTradMed]

Starting with the blatantly obvious, thinner people eat less and exercise more. In Europe, gas is expensive and cities are crowded and hard to drive around in, and people tend to do a lot of walking in their daily lives.

I imagine a lot of Americans get fat because, for whatever reasons, it's easier to get fat in America than elsewhere. And I agree that all these people who find themselves putting on the pounds could take some steps; blaming it on genetics, for instance, is beyond silly, considering that fat Americans are descended from thin Europeans, Asians, and Africans.

The last thing I'd say is that fat people are innocent victims of a culture that compels them to overeat. But at the same time, it's true that something about the American lifestyle makes over-eating all too easy, and if that were not true, there'd be no more fat Americans than fat French.

And I have to say, American restaurant portions are completely insane. Last time I was on holidays stateside with some family visiting from Britain, we fed eight people with a pancake breakfast the menu said was "for two."

We are fat for the very reasons you listed: a car society that has access to cheap, calorie-dense foods.

Is it an individual's responsibility? Yes. But fat is also a society issue since society has to pay for the expense of taking care of people with coronary heart disease, diabetes and numerous other diseases associated with obesity.

 

[facetguy]

We are fat for the very reasons you listed: a car society that has access to cheap, calorie-dense foods.

Is it an individual's responsibility? Yes. But fat is also a society issue since society has to pay for the expense of taking care of people with coronary heart disease, diabetes and numerous other diseases associated with obesity.

It's also a society issue since obesity is multifactorial. McDonald's is thriving in the current economic climate because their food is cheap. Is it particularly good for you? No. But more people are eating it for financial reasons. That goes beyond simple personal responsibility.

 

[Miami_med]

It's also a society issue since obesity is multifactorial. McDonald's is thriving in the current economic climate because their food is cheap. Is it particularly good for you? No. But more people are eating it for financial reasons. That goes beyond simple personal responsibility.

Not really. The mere existance of McDonald's providing cheap food doesn't mean that people have to buy it. If they do because they are simply so poor that they can afford nothing else (which makes no sense as there are foods at the grocery store which are cheaper), then these are also the same people that theoretically wouldn't be able to eat at all if it weren't for McDonald's. If it is the only food they can afford that is. McDonald's is better than starvation. They could also eat less McDonald's, save money, and lose weight. It's a win-win.

 

[ZincFingers]

Personal responsibility is king. The ulimate factor in a patient's longterm health, is the patient. Adding on a dozen non-physician "providers" in the "medical home" won't change that basic fact, even though it is indeed the new fad in primary care.

It is also not cost effective. If Dr. Internist decides to add on a dietician, a diabetes educator, a nurse practitioner, a tobacco educator, a nurse case manager or care coordinator (not sure what the difference is), and whatever else they come up with, guess who has to pay their inflated salaries? That's right, the patient, via his insurance or Medicare premiums. And I assure you that putting the patient through an extra series of lectures, given by scolding nurses dressed up as doctors, every year during the checkup will NOT make him quit smoking and exercise.

 

[cpants]

It's also a society issue since obesity is multifactorial. McDonald's is thriving in the current economic climate because their food is cheap. Is it particularly good for you? No. But more people are eating it for financial reasons. That goes beyond simple personal responsibility.

Obesity is both a societal issue and a personal issue. In a lot of ways it's like smoking. It's societal in that it is widespread in our society and causes economic strain. But in every individual case of obesity it is a personal problem. That's to say, when an obese person walks into your office, it is not our society's fault he is obese, but his own personal fault. For each individual, the only way the weight will come off is through personal commitment and sacrifice.

As physicians we are actively looking for a cure to obesity. There is tremendous research into drugs, surgeries, and motivational strategies to help people to lose weight. We will continue to search. However, with what we have available to us right now, there is not a lot a physician can do to cure a person's obesity.

We educate. We explain the risks. We recommend diet/exercise. In extreme cases we can resort to bariatric surgery. We prescribe treatment to lower the person's risk for CAD, CVA, DM, and other complications. The bottom line is that the individual, not the society and not the doctor, is responsible for weight management.

 

[facetguy]

Personal responsibility is king. The ulimate factor in a patient's longterm health, is the patient.

I don't necessarily disagree with this, as it is certainly a major component. But, in your opinion, why have most Americans knowingly become less personally responsible (and thus overweight/obese) in recent years?

 

[Miami_med]

I don't necessarily disagree with this, as it is certainly a major component. But, in your opinion, why have most Americans knowingly become less personally responsible (and thus overweight/obese) in recent years?

Why have American's come from being the great society that survived the great depression to the society that sues when they spill coffee on themselves? Personal responsibility is failing everywhere, with obesity being a symptom.

One place that you might be able to blame society, is that we went from a culture where children played outside during recess and PE and teenagers kept physical jobs in high school (often on a farm in the early part of the century) to one where we sit in a classroom all day by government edict. Where the same jobs that used to keep teenagers fit and teach personal responsibility and self-sufficiency now "interfere with their education." I'm not sure that I'd say that this is purely society, but It's one place you could get a hold for your argument.

Also, the universal presence of food now means that individuals who were struggling to eat at all 60 and 70 years ago now qualify for food stamps and can afford food. They went from being malnourished to fat. The widespread availability of food is an amazing testament to success in society.

 

[DrYoda]

And I have to say, American restaurant portions are completely insane.

Indeed.

 

[facetguy]

To broaden your thoughts on the obesity issue, consider going to PubMed and searching "obesogen". Clicking on the first 2 studies will also provide you with related articles. You may find the work going on in those directions interesting. Obesity is not as simple as you may think.

 

[Miami_med]

To broaden your thoughts on the obesity issue, consider going to PubMed and searching "obesogen". Clicking on the first 2 studies will also provide you with related articles. You may find the work going on in those directions interesting. Obesity is not as simple as you may think.

I think that the argument that American's are becoming more responsible is different than one that says that we should blame our genes for something that suddenly popped up in the last 30 years.

 

[facetguy]

I think that the argument that American's are becoming more responsible is different than one that says that we should blame our genes for something that suddenly popped up in the last 30 years.

Wrong. Go back and read more closely. It's not about our genes suddenly changing. It's about the interplay between our ancient genes and our modern environmental exposures, be they our horrible diet or our exposure to all sorts of chemicals. Studies have already shown that chemicals that are everywhere today can act as endocrine disruptors. A good example appears to be bisphenol-A, or BPA. People with higher urinary BPA levels have more medical disorders (Lang IA, JAMA 17 Sept 2008;300:1303-10). BPA at normal exposure levels disrupts insulin sensitivity and thus promotes diabetes (Hugo ER. Environ Health Perspectives, Dec 2008;116:1642-47). Obese people are much more likely to suffer insulin resistance if they have high fat levels of organo-pollutants (Lee DH. Diabetes Care, March 2007;30:622-28). The list goes on and on.

The Environmental Obesogen Hypothesis: inappropriate receptor activation by organotins will lead directly to adipocyte differentiation and a predisposition to obesity and/or will sensitize exposed individuals to obesity and related metabolic disorders under the influence of the typical high calorie, high fat Western diet. (Grun F et al. Endocrinology 2006 June;147:S50-55)

What's worse is that we may unknowingly be setting our children up for problems in their future. What began as the Barker 'fetal origins' hypothesis has now evolved into what has been called 'Developmental Origins of Adult Health and Disease', which says that exposure to an unfavorable environment during development (either in utero or in the early postnatal period) programs changes in fetal or neonatal development such that the individual is then at greater risk of developing adulthood disease. Meaning these kids are facing an uphill battle with things like obesity right from the start! As one author puts it, "perturbed nuclear receptor signaling can alter adipocyte proliferation, differentiation or modulate systemic homeostatic controls, leading to long-term consequences that may be magnified if disruption occurs during sensitive periods during fetal or early childhood development". (Grun F. Rev Endocr Metab Disord 2007 Jun;8:161-171)

The emerging study of epigenetics has already shown that, for example, providing adequate methylation factors (folate, B12, B6) to pregnant Agouti mice markedly and immediately (that very next generation, not 1000s of years of genetic evolution) reduces obesity, diabetes and cancer in their offspring (which were thought to be genetically destined to suffer these disorders).

Yes, personal responsibility is important. But we have to get beyond the simple notion that obesity is solely due to laziness or moral inferiority.

 

[Josh L.Ac.]

Why have American's come from being the great society that survived the great depression to the society that sues when they spill coffee on themselves? Personal responsibility is failing everywhere, with obesity being a symptom.

Perfect.