Monday, March 5, 2012

Are You Really Okay If You Think You Are?

"If you feel okay, maybe you are okay" is the title of an op-ed piece written by Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice. The piece was published in the NY Times a few days ago. 

Here's the link. 

The gist of Dr. Welch's piece is that doctors are spending too much time on screening tests and not enough time on treatment. Furthermore, many of these screening tests contribute to false positive results which create unnecessary anxiety and lead to many additional costly and superfluous procedures. In summation, his basic premise is that patients who don't have problems should not see doctors. I both agree and disagree.

I have often read and heard how preventive medicine doesn't work. The reasons often offered mirror those of Dr. Welch. Tests done in healthy patients may lead to more unnecessary tests. The problem I have with those pronouncements is how the pundits are defining prevention. Most doctors in America think of prevention as a battery of diagnostic tests I don't and I am not alone. 

To me primary prevention is and should be a focus on health risk assessment of one's lifestyle contributors to chronic diseases. Contributors include how you eat, stay physically active, manage stress, ensure good sleep, etc. Chronic diseases include diabetes, obesity, heart disease, dementia, and cancer.  We know that 70% of Americans die from these diseases often before their time.  We also know that 2 out of 3 Americans are overweight and 35.7% are obese. We know that the number of patients with pre-diabetes is growing rapidly.

As Dr. Welch states, the answer is not more testing. People don't need more information. They need only look into the mirror or at the scale to know there is a problem. They need only look down at their snacks and meals to know they will have a problem. They need only take their blood pressure to know trouble is brewing.

So that's where Dr. Welch and I diverge. Like him, I am not a fan of haphazard testing for the sake of testing. Less invasive and much less costly measurements like blood pressure, the scale, and waist circumference give one plenty of actionable information. Patients, however, need help to act on this information. Pills may not always be the best first response. However, to avoid quick prescriptions, I think doctors need to spend considerable more time counseling patients on how to avoid problems and  help patients navigate through the solutions to address these problems. 

The good news is that Medicare agrees and established a new service last year called the Annual Wellness Visit (AWV). The AWV represents the first time Medicare is paying doctors to do a health risk assessment and develop a prevention plan. It also requires proper referral to outside resources to put the plan into effect. When the plan requires further testing, it's easy enough for a patient to get diagnostic testing elsewhere because it is covered by Medicare. Unfortunately, the biggest problem patients have with their lifestyle usually revolves around food. That's a big problem because Medicare typically doesn't cover nutritional services and that leaves most patients in the lurch. Doctors have no one to refer their patients.

My organization, MDPrevent, has offered Medicare a solution to this problem. We submitted a grant request to fund a program we call Intensive and Integrated Behavioral Therapy for Lifestyle Modification. We partnered with the American College of Preventive Medicine in what we believe will be landmark work. We will find out at the end of this month if we get to pioneer a new innovative team approach to chronic disease development by helping people headed in that direction never reach their destination. Stay tuned.

I think it's a shame that Dr. Welch didn't use his op-ed piece to take up the clarion call for more coverage of behavioral counseling to prevent chronic diseases. If he did, perhaps there would be a decreased need for routine diagnostic testing. As chronic diseases are years in the making, just because you feel okay doesn't mean you will be okay in the near future.

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