Upstream Medicine

A good friend and colleague of mine who is the current secretary general of the World Council on Cardiovascular and Pulmonary Rehabilitation likes to tell the story of a young cardiologist. He was standing on the edge of a riverbank enjoying the view when he spotted a man flailing in the water, being carried down the rapids toward a 1,000-foot waterfall that would mean certain death. He immediately took his shoes off, jumped into the river, and pulled the man to safety. As he was catching his breath back on the riverbank, he heard a scream coming from the river. Looking back, he saw another man being swept toward the edge of the great waterfall. He fearlessly dove back into the frigid water and grabbed the second man, courageously dragging him back to safety. Amazingly, within minutes the same scenario repeated itself a third time. An onlooker, seeing this incredible sequence of events, approached the heroic doctor. “My,” he exclaimed in awe, “you’ve just risked your own life to save three strangers! That was an amazing display of selfless courage and skill! Do you mind if I give you some advice?” “Why no, not at all” said the exhausted doctor. “Well,” continued the bemused observer, “did you ever consider walking upstream to see who’s throwing them in?”

Like the young doctor, traditional “Western Medicine” is noted for practicing “downstream medicine.” Our system, which has historically focused on disease care, is undeniably the most sophisticated and technologically advanced in the world. It is also the most expensive. According to the 2004 report of the U.S. Department of Health and Human Services, we spent $1.9 trillion on healthcare, or 16 percent of our country’s GDP. That’s $6,280 per man, woman, and child. 2008 data from the Organization for Economic Cooperation and Development reveals that we spend approximately twice as much on healthcare as every other industrialized nation in terms of both percentage of our country’s GDP and dollars per capita. That would be fine if our healthcare and/or quality of life outcomes were equally notable. But that’s simply not the case.

Unfortunately, our country’s overall healthcare outcomes do not match our world dominance in either technology or spending. In fact, according to the latest statistics of the World Health Organization (WHO), the United States ranks 37th among the world’s 191 member countries for overall quality of healthcare. Although critics cite this data as flawed, it is nonetheless an alarming statistic and should give us pause to consider what healthcare we’re providing for our patients’ medical buck. According to the 2009 CIA World Fact Book, we have slipped to 50th in the world in average predicted life expectancy. And, we currently rank 24th in the world in the WHO’s data regarding “Healthy Life Expectancy” — the number of years one can expect to live in “full health.”

One thing does seem clear. The majority of our healthcare dollars are spent taking care of medical concerns that are directly related to our patients’ lifestyles. Our choices of health-related behaviors are now the biggest etiologic factors in creating premature disease, chronic medical conditions, and disability. According to the U.S. Public Library of Science, in 2005 there were eight risk factors that accounted for approximately 80 percent of all deaths in the United States: smoking, physical inactivity, excess alcohol intake, diets high in salt and low in fruits and vegetables, elevated blood pressure, high cholesterol, and being overweight. The key point here is that there are effective interventions for every one of these risk factors! So we have a wonderful opportunity to influence our patients in terms of their health-related lifestyle choices.

The question is, can our interventions really be effective? Dr. Earl Ford from the Centers for Disease Control and Prevention and his colleagues completed a study of 23,153 middle-age people, focusing on four healthy-lifestyle factors: smoking, obesity, exercise, and diet. Eight years later, as reported in the Aug. 10–24, 2009, issue of the Archives of Internal Medicine, those in the group who adhered to not smoking, having a BMI less than 30, eating a diet high in fruits, vegetables, whole grains and low in meat consumption had some astonishing statistical benefits. The hazard ratio for developing a chronic disease decreased progressively as the number of healthy factors increased. Participants with all four factors at baseline had an overall 78 percent lower risk of developing a chronic disease than participants without a healthy factor (diabetes was reduced 93 percent, myocardial infarction 81 percent, stroke 50 percent, cancer 36 percent).

The truth is that most of our patients know the majority of information regarding what constitutes healthy behaviors. The problem is getting them to adhere to more healthy practices on a regular basis. I’ve personally come to the conclusion that for most patients, we cannot scare them into health. A recent study at the University of Sheffield revealed that the least effective strategies in getting patients to successfully change behaviors involved instilling fear. The second least effective method was to instill guilt for past choices. Not surprisingly, the most effective strategies consisted of education, coaching, partnering, goal setting, and establishing methods of accountability. Norman Cousins, in his book Anatomy of an Illness, noted that the most important thing his doctor did for him in assisting him in his recovery from a supposedly terminal illness was to treat him as a “respected partner” in his journey back to health. I think that’s our challenge: How do we become that respected partner for our patients?

In my practice, we focus on a three-step process: education, motivation, and life restyling. We do pay attention to the readiness-for-change model with each patient, attempting to approach each patient with the most appropriate strategy based on his/her level of knowledge concerning risks and rewards and whether or not there is motivation for change around the issue involved. For some we just educate. We find that most people are truly unaware of the actual prices they are already paying for the choices that they’re making. Once informed, many would like to change if they can be convinced that they could actually be successful and if they feel like they have someone who will respectfully guide them along the way. For others, they just need a plan. Some need motivation, and some just want someone to hold them accountable. Most already feel some sense of guilt, shame, or failure around past efforts to change. The last thing they need or want is any additional feeling of perceived negative judgment. So we try to provide a safe environment where patients are surrounded by a team that truly cares about them, wants them to succeed, and celebrates their successes. We emphasize progress, not perfection. It’s a process, and the key is to not give up. Like the rocket ship to the moon, our patients are always a bit off course. But with established and mutually agreed upon goals, objective feedback regarding key indicators of success, and timely redirection, many achieve remarkable progress.

The most effective first step in a wellness program is increasing physical activity. Fewer than 25 percent of Americans get the exercise they need. On average, we watch 170 minutes of television and movies, but spend less than 19 minutes a day exercising. Yet studies are clear that exercise promotes self-esteem, increases energy, assists in normalizing the balance of brain neuropeptides, improves sleep, enhances immune response, assists in stabilizing mood, lessens sarcopenia, and helps to control weight, blood pressure, serum glucose, lipids, and the metabolic syndrome. It also lessens the overall risk of chronic diseases and is one of the most potent initiators of brain neurogenesis. In the Nov. 21, 2007, issue of JAMA, a review of 26 studies was published that showed that, overall, pedometer users increased their physical activity by 26.9 percent over baseline and decreased their BMI by 0.38. The simple act of giving patients a pedometer with a suggested goal of 10,000 steps per day may well be one of the most powerful interventions possible. It’s a good example of “what gets measured becomes addressed.”

My experience is that the more specific our exercise recommendations are, the more credible and influential they become to our patients. Dr. William Foege, former director of the CDC, validated the importance of an active lifestyle thusly: “Physical activity may provide the shortcut we in public health have been seeking for the control of chronic diseases, much like immunization has facilitated progress against infectious diseases.”

Motivating patients to alter ingrained lifestyles is difficult at best. It often takes a painful or frightening experience to convince someone that it’s indeed time to pay attention to lifestyle. One of my patients referred to his wake-up call as a “cosmic goose.” Significant change rarely occurs without clear intention and purpose. I encourage my patients to develop a personal mission statement, clarifying what each one sees as his or her purpose in life. Then it’s not a big leap to reason that only by maximizing both health and performance can their mission be truly accomplished. And all unhealthy behaviors can be seen as personal choices that undermine the mission. The next step is development of true mindfulness regarding significant choices and encouraging patients to develop a passion for rigorous honesty concerning their own truth. A well lifestyle is then developed over time much like a successful business plan evolves.

People who practice healthy lifestyles have developed a set of wellness skills that they learn to employ, self-monitor, and correct as needed over time. As demands change, they develop new compensatory skills that allow them to stay on track. The really successful ones generally have nourished relationships with other successful people who act as mentors and coaches. And here’s the best part: Patient surveys have repeatedly established that the most influential person in many patient’s lives in determining whether or not they adopt healthy lifestyle choices is their physician. One such survey concluded that the single most important person in determining whether or not the involved patients began an exercise program was their primary care physician. So it was disheartening to learn that more than 80 percent of those patients also said that they had never heard their doctor mention exercise to them.

Clearly, we have our work cut out for us. We owe it to our patients to be their guidepost regarding healthy lifestyles. We have an obligation to provide for them informed consent regarding the risks and rewards of health-related behaviors. But that’s not enough. We owe them an individualized, prescriptive plan for success. The future of our nation’s health will largely depend on the developing willingness of our physicians to be effective patient advocates, educators, and mentors. And oh, by the way, in order to be credible professionals, we must, as they say in the airline business, “First put the oxygen mask on yourself. Then, you can help others!” Time to go for that walk!