The Biggest Skeleton in Your Doctor's Closet
by Vicki Rackner MD
I'll let you in on a dirty little secret. We doctors know very little about keeping you healthy. I can stop internal bleeding after a car accident, fix a hernia or remove a cancerous colon. Yet, ask me how to prevent colon cancer, and I'll refer you back to your grandmother's wisdom.
 Your doctor's fluency in the treatment of disease and relative ignorance in the promotion of health are the causes of our health care system's perilous state. The focus of on disease in our healthcare system shows up in three major ways:
1. Absence of health promotion
Here is something I never learned in medical school, and neither did your doctor. Most disease doesn't have to happen. Over 75% of the diseases we treat are potentially preventable by making better lifestyle choices. It's not news that smoking causes cancer; however, it was news to me that equal numbers of cancer deaths could be avoided with better dietary choices and exercise as with tobacco cessation. In 2004 we spent about $1.6 trillion on healthcare in the US, and over 75% paid for the management of potentially avoidable chronic diseases; less than 2% of the total health care spending was invested in prevention.
2. Broken promises of cure
We have waged war on diseases, like cancer, and we have largely lost. Our focus on how the body malfunctions, while ignoring the ways in which our bodies maintain balance, has limited our progress in restoring health. For example, we thought we had licked bacterial and viral infections. Now infections have returned with a vengeance in the forms of drug-resistant TB and AIDS just to name a few. The number of bacteria in your colon exceeds the number of cells in your body, and many of these bacteria cause disease. Even though the barrier between the contents of your colon and the rest of your body is only a few cell layers thick, you remain healthy. Because we focus on waging war, we have little understanding about how our bodies promote peace in what can be a hostile world.
3. Cure at the expense of healing
A medical cure means elimination of disease through a doctor's intervention, like medication or an operation. While cure involves taking something away, healing is the process of making whole. Cure changes the way in which your body functions; healing changes your experience of your body's functions. Many of my patients have said, “Getting breast cancer is the best thing that ever happened to me.” They're saying this wake-up call resulted in living each day with greater meaning. Cure, while the optimal outcome, is not always possible. Healing is always possible, with or without cure. A technically flawless cure in the absence of healing can feel heartless. I call this “heart disease of the healthcare system.” It is the biggest silent epidemic we face.
I don't know exactly when we lost sight of health. It's one of those insidious choices that was made without realizing we were making it. I assure you, though, it was done with good intentions.
Doctors who appeared in cigarette ads thought they were helping patients. When more information became available and doctors realized that smoking caused illness, their recommendations about smoking took the form of a warning label on a cigarette pack. We have more information about the consequences of the medical establishment's focus on disease rather than health. The evidence shows that it's time to do things differently.
Consider this your medical guide to the diagnosis and treatment of our ailing health care system that leads to so much suffering. I address four questions in this order:
1. How well is our current health care system working? I examine the evidence that measures how effectively our disease-oriented health care system achieves health.
2. How did we arrive at a health care system that focuses on disease? Our health care system did not develop in a vacuum. I look at forces that have shaped our current approach to illness and health.
3.What are the day-to-day consequences of focusing on disease? I show the manifestation of concentrating on disease rather than health.
4. Is there another way to manage health? I offer concrete suggestions that help you can embrace health and get the health care you want, even in this flawed system. I believe that a grass-roots movement will lead to the transformation of our health care system. And this is not about sweeping lifestyle changes; small steps that you take today can make a huge difference.
Through this structure I provide answers to the following questions:
1. Is the health care system really that bad, or is this just media hype?
2. What's the secret to getting the health care you want?
3. What are the biggest mistakes people make when seeing their doctors?
4. What's the cure for the “heart disease” of the health care system?
5. What's the one thing you should never do as a patient?
6. What's the biggest mistake patients make when it comes to making medical choices?
7. What should I know about my health story?
8. Can I make a difference?
9. What's it going to cost me to do this?
10. Is there hope for a better tomorrow?
Here's a question you may be asking right now. “I'm healthy. I'm busy. Why should I continue reading?” Here's why: Your health will be challenged at some point in the future. It's part of the human condition. The best time to learn about restoring health is when you're healthy, just like the best time to take CPR training is before someone chokes in front of you. In addition, the ideas presented in this essay may help you avoid illness and bounce back more quickly.
How well is our health care system working?
We celebrate the stunning achievements our health care system. We can offer a second chance at life through a heart transplant or a first chance at parenthood through in vitro fertilization. Fifty years ago gallbladders were removed through the 10-inch incision LBJ proudly displayed and then the patients stayed in the hospital for six weeks. If you have your gallbladder out this week, you will have four half-inch incisions and avoid the pain and disability of cutting through the rectus (abdominal wall) muscle. You may go home the day of the operation, although most go home the next day.
If you are the direct beneficiary of breakthrough technology, the system worked well for you. What if you're a healthy person, or your have a condition for which you take a medicine or two or you have a chronic medical condition? You may not be so gracious with your praises. In fact, you rarely hear anything good about the health care system. While this may be an extension of our natural tendency to focus on what's wrong, strong evidence suggests our health care system is simply not working fro most people. Here is some data that dispels common myths.
Myth: United States, the wealthiest nation in the world, invests in the heath care system, so its citizens enjoy the best health care in the world.
Fact: We spend more per capita on health care than any other nation; yet, we don't have the best care.
- The U.S. spends more per person for health care than any other developed country. According to the Centers for Medicare and Medicaid Spending, health care spending in 2004 was $1.6 trillion, or $5440 per person. This is an increase of 9.3% from the previous year, compared to an overall economic growth rate of 3.6%.
- Using five quality indicators, the World Health Organization ranked 191 countries' health systems. Despite the belief that we have the best health care in the world, the U.S. ranked 37.
Myth: You can count on getting high quality care, especially if you go to an academic center for your treatment.
Fact: The quality of care varies tremendously in the U.S., and it's not always easy to figure out how to asses quality and value.
- According to a Rand study published in the journal Health Affairs, fewer than 60 % of Americans get quality treatment that is demonstrated to be most effective. Some got too much treatment, others got too little treatment and some got the wrong treatment. World-renowned medical institutes fared no better than community hospitals. Highly educated wealthy patients were as likely to receive sub-optimal care as those with fewer resources.
Myth: You know your doctor took an oath to “First, do no harm”, so you can trust that good doctors won't harm you.
Fact: Even if your doctor does everything perfectly, there's still a chance you'll get a bad outcome. Making medical choices is like investing in the stock market. You always hope to win, but you invest knowing you can lose. Further, doctors, nurses and other health care professionals are human like you, and they make mistakes like you do. We go not have a safety net that protects when people make mistakes.
- According to the Institute of Medicine's ground-breaking report “To err is human: building a safer healthcare system” up to 100,000 hospitalized patients die in the hospital each year from preventable medical errors, more than die of breast cancer, AIDS or car accidents in a similar time interval. By conservative estimates, medical errors represent the eighth leading cause of death in the U.S.
Myth: Drug companies are to blame for uncontrolled prescription drug spending.
Fact: There are many factors that have contributed to prescription drug spending. The question we're asking is “How do we get cheaper drugs?” More promising unasked questions like, “How can we support lifestyle changes so that patients do not need drugs?” and “How can we help patients take medication responsibly?” hold the most promise.
- Prescription drug spending, the fastest-growing piece of the health care spending pie, increased 15.3% last year. Drug costs are expected to outstrip other health care spending for the next ten years.
- Affordability is only one piece of the prescription drug problem. According to the World Health Organization, about 50% of patients take medication as prescribed. Only 43% of patients take their medication as prescribed to treat asthma; 51% of patients take mediation to treat high blood pressure as their doctors ordered.
Myth: Insurance companies and employers are responsible for your health care bill.
Fact: There's no free lunch, and there's certainly no free health care. Ultimately it's you who pays for health care costs: through higher insurance premiums plus the increased price of all goods and services. You also pay for the care of the uninsured through higher medical bills and taxes. And you pay for malpractice settlements because the fees your health care providers charge must cover the cost of malpractice insurance. Your medical bills are generated in the privacy of your doctor's office or hospital room, but you and your doctor rarely talk about money. And the system does not provide enough information for you to make fiscally responsible choices.
- About 20% of health care costs are paid out-of-pocket by patients. According to a Robert Wood Johnson survey (???) published in the Journal of the American Medical Association (JAMA) in August 2003, up to 75% of doctors and patients want to talk about out-of-pocket expenses, yet fewer than 35% engage in this conversation.
Myth: The cost of disease is measured by the cost of health care.
Fact: Comprimised of health has wide-ranging costs we're just beginning to measure. In addition to medical bills, there's loss of productivity at work, a compromised quality of each day and a diminished ability to contribute to your family and community. Sub-standard health care costs, too.
- Up to 13% of the workforce experiences a loss of productivity from common pain conditions, costing business $62.7 billion per year. A study published in the JAMA November 2003 issue concluded that over 75% of the lost productivity time was explained by reduced performance while at work and not due to work absences.
- The average cost of a preventable medical error for a hospitalized patient, according to a study in the New England Journal of Medicine, includes a 10 day increase in hospital stay resulting in a $40 thousand dollar increase in hospital costs.
Myth: There are just a few “squeaky wheel” patients manufacturing a problem that does not really exist.
Fact: Patients are increasingly dissatisfied with health care, as demonstrated by both their beliefs and their actions, such as seeking alternative medicine solutions:
- According to a study by the Agency for Healthcare Research and Quality, more than half (55 percent) of the respondents in a survey said that they are currently dissatisfied with the quality of health care in this country — as compared with 44 percent four years ago. In fact, 40 percent believe that the quality of health care has "gotten worse" in the past five years, whereas only 17 percent think it is better. And half are worried about the safety of their medical care.
- According to a new nationwide government survey, 36 percent of U.S. adults aged 18 years and over use some form of complementary and alternative medicine (CAM). CAM is defined as a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. When prayer specifically for health reasons is included in the definition of CAM, the number of U.S. adults using some form of CAM in the past year rises to 62 percent. Interestingly, the survey also found that about 28 percent of adults use CAM because they believe conventional medical treatments would not help them with their health problem; this is in contrast to previous findings that CAM users are not, in general, dissatisfied with conventional medicine
Myth: Technology, like computerized order-entry systems, will create a safer health care system
Fact: Your role as patient in contributing to a safer health care system is vastly underused. Yes, technology supports a safer health care system. A hospital computer order entry system can prevent medication errors caused by hard-to-read handwriting or unrecognized adverse drug-drug interactions. The right dose of the right medication given to the wrong patient still does harm. This is easily prevented by asking the nurse what mediation you're being offered, what it does and why you're getting it. Every time. Yes, let's embrace technology. And let's also recognize the power of low-tech , high-touch solutions like patients and doctors talking to each other so that they both understand what the other is saying, bringing a self-addressed stamped envelop to appointments so your doctor can mail you lab reports an being willing to asking health care professionals to wash their hands before they touch you.
Our current disease-focused health-care system model comes at a high cost. We pay with our pocketbooks, decreased productivity of our work force, and with a loss of trust that if we face illness we will get the health care we want.
How we arrive at a health care system that focuses on disease?
The focus on disease rather than health did not happen in a vacuum. Here are some forces that have shaped our health care system to be as it is today.
Human nature is fear oriented
Increasing numbers of scientists have identified the biologic basis of behavior in animal species, including our own. Neurophysiologists believe our brains are wired to register fear more sensitively than other emotions. This probably helped us survive as a species. Our focus on disease is an extension of our natural instinct to search on the horizon for what's wrong.
Further, we avoid pain and seek pleasure. Delayed gratification, more challenging to some than others, has becomes less valued in our fast-paced culture that seeks immediate responses. Choices that lead to health often involve deferring gratification, like honoring the commitment to eating healthier foods rather than tgiving into the pleasure of a rich chocolate tort.
Many fear change, most likely because of the possibility of more pain and less pleasure. This explains why most people ignore their health until it's threatened.
Sometimes making “healthy” choices feels like swimming upstream. Just as salmon swim upstream to assure their survival, we, too, can overcome our human nature so we can live longer and healthier lives.
Our culture favors high drama
Our health care system is a microcosm of our culture and values. Our society rewards and values dramatic, lifesaving interventions. Imagine watching your favorite medical TV drama where the surgeon races to the ER and cracks the chest to perform a dramatic life-saving intervention. This scene would get much better ratings than a show portraying a doctor giving patients a hug because they stopped smoking or stuck to a regular exercise regimen.
Advertising, a prominent part of our society, often entices you to make choices that do not lead to health.
Health promotion isn't easy
Choices that lead to health are often harder choices in the short term. It's easier to watch TV than go for a walk. It's easier to take a pill that treats symptoms rather than asking “What is my body telling me with the discomfort and pain?”
We lack “scientific” evidence that health promotion works.
Research about the benefits of health promotion is not published in peer –reviewed journals targeted for doctors. These journals publish the results of clinical studies that advance our understanding of what we already know and believe. Doctors, often snobs, do not trust studies published by non-physicians. So, health promotion simply has been ignored by doctors.
Goodies for being sick.
There are some good parts about being sick. Illness brings attention and sympathy. When I got my tonsils out, it was like going on a child's dream vacation. I had all the ice cream I wanted, a box of crafts supplies and meals served in bed in front of the TV. The truth is that some people focus on disease because on some level it works for them. Doctors describe this as “secondary gain.”
We fear success more than we fear failure.
Have you ever noticed that if you ask your friends about their problems, they wax eloquent? Then ask them about their gifts or what brings them joy or their most recent successes they stop dead in their tracks. Health-promotion elicits this fear of success.
What are the consequences of focusing on disease?
The focus on disease rather than health is a root cause of the dysfunction of our ailing health care system. It has lead to a culture of fear. We fear our own bodies, believing that that are vulnerable to break down and require the help of medical experts to heal. Evolving medical technology reinforces the notion that you need the help of your doctor to recover from illness.
Here are some of the manifestations of concentrating on disease rather than health, and their consequences. Just like gravity draws all objects down hill, so, too, our inability to promote health leads to a downward decline.
Cause: Focusing on what's wrong
The words “health care“ imply that your doctor cares for your health. This is just not true. Doctors treat diseases.
Do you remember the game in the Highlights magazine “What's wrong with this picture?” You look for the bike in the tree or the pelican flying with roller skates or the picture hung upside-down. The winner is the person who notices the most wrong things.
That's how our health care system works. Your doctor focuses on what's wrong. The first words out of your doctor's mouth are usually, “What seems to be the problem?” or “What brings you here today?” or “How can I help you?” All of these questions frame your visit as an opportunity to bring problems to your doctor for repair. Even a routine visit feels like a witch-hunt for the lurking disease.
Consequence: Not focusing on what's “right” with our health
For most doctors health means the absence of disease, a definition I find problematic. There's a qualitative difference between asking “Are you experiencing less pain?” and “Are you experiencing joy?” Compare two of my patients, Bill and Nancy.
Bill has had rheumatoid arthritis since he was a child. He loves the outdoors. So when degenerating hip joints prevented him from going on a hiking trip, he went kayaking. He has a full life complete with meaningful work, a loving family and active participation in his spiritual community. Bill and his rheumatologist confer on a regular basis to assure that he's taking the medications that will help him live most fully. Although Bill has pain most days of his life, I don't hear much about it. Sometimes he talks with great sadness about his limitations. But most days, Bill is focusing on all of the great things in his life.
In contrast, Nancy has a young, fit body. But, she is frequently overwhelmed with the fear that she has some life-threatening disorder. Doctors describe Nancy, and patients like her, as the “worried well.” Nancy's only disease is a possible anxiety disorder.
We don't universally agree on words that describe the difference between Bill and Nancy. Bill has a chronic disease; while the medical establishment says Nancy has none. However, I think of health as the way in which we bring meaning to our lives. So, in my book, Bill enjoys greater health than Nancy.
Cause: Believing that your body is vulnerable to illness
Our focus on disease instead of health fosters the fear that disease lurks everywhere, so illness is inevitable. The truth is that health is your natural state. If you have a cut or a scrape, it will heal without a single action on your part. Your body is designed to heal itself.
I have performed thousands of operations, and the incision healed every time.
I would love to believe that my patients had good outcomes because of my surgical skill. However, one day I was jolted back to reality when I ran over the garden hose with my lawn mower. I used every trick I had ever learned in the course of sewing together blood vessels and bowel to affect a repair. On the way to the hardware store to buy a new hose, I realized, with humility, that I made a significant but not an exclusive contribution to my patients' recovery. I can do things to speed up or slow down my patients' healing, but ultimately it's their bodies that do the healing.
Your journey from sickness to your home of health is your own personal Wizard of Oz, sharing many features in common with Dorothy's quest to return to Kansas. Traveling the Yellow Brick Road, she faced many challenges as she tried to get the all-powerful wizard to work his magic and send her home, just as many patients seek the magical powers of their doctors. Like Dorothy, patients are often angry and disappointed to learn that all this time they had the resources to get “home.” Once she knew about the powers of the ruby slippers and learned how to activate them, she was on her way.
You, too, have extraordinary powers that we are just beginning to understand. You can work with your doctor to learn how to harness and activate the healing powers that you already have.
Consequence: Believing a doctor needs to cure you
If you go to the doctor and feel dissatisfied if you don't get a prescription, you're not alone. Consider a special class of pills: placebos or sugar pills. A large number of patients who receive placebos benefit just as much as those taking the active/ ingredient. I sometimes wonder how much of what doctors do is simply activating the “doctor within.”
Further, you might have unrealistic expectations for your doctor, as Dorothy did for the Wizard of Oz. Here's what behind the curtain of Dr. Oz
Doctors make mistakes
The Institute of Medicine estimates up to 98,000 patients died in the hospital in 1999 as a result of preventable medical errors. That's more patients than died from car accidents or breast cancer in the same year. This isn't about ”bad doctors.'' Mistakes happen because the health care system is complex, health care is delivered by people and people make mistakes. The title of the Institute's report is ”To Err is Human.'' Proactive and vigilant participation in your diagnosis and treatment is your best protection.
Doctors don't have crystal balls
Have you asked a doctor a question like, ”How long will my father live?'' and received the response, ”At his stage of disease there is a 70 percent chance for five-year survival.'' That means that if there are 100 patients just like your dad, 70 will be alive in five years. The answer you really want to hear, though, is whether your father will be alive in five years. It's impossible for your doctor to say with certainty. Statistics from clinical studies only describe what happens with groups of people; they do not predict what will happen to an individual patient.
Doctors don't have magic wands
The miracle drug that offers a cure without any risk simply doesn't exist. Complications from aspirin take more lives than AIDS each year. Make sure you know the possible risks before you agree to any treatment or diagnostic test. And be suspicious of any product that claims to offer a cure for a wide variety of illnesses.
Doctors don't know everything
Medical knowledge is advancing at an exploding rate, so no one person can keep up with everything. You may know more about your medical condition than your doctor does! Sometimes it's best to get a second opinion from a doctor who has a special interest in patients with your condition.
Doctors spend a limited amount of time with you
Most doctors are employees of clinics that set productivity goals for your doctor to see a certain number of patients each day. Frequently it does not seem like enough time -- to you and to your doctor. Prepare for your appointments so you can make the most of the time you have. Prepare a written list of questions so you can address them efficiently and not forget to ask about an important issue. You can also ask for a longer appointment or consultation.
Doctors are people too
Doctors get angry, sad and frustrated just like you do. The reaction from your doctor may be a response to something other than you. A doctor that seems impatient might be thinking about the critically ill patient in the ER. A doctor who asks you the same question twice may have just received a worrisome call from a family member. A comment from you such as, ”You seem distracted today,'' can be a real gift of understanding.
Doctors are not mind readers
Your doctor will not know what you think or how you feel unless you tell him or her. If, for example, your doctor does not seem concerned about your fatigue you can say, ”Being tired all of the time is a big problem for me. I want to have more energy. I'm also worried that my fatigue could be a sign of cancer.'' There is no need to be embarrassed or shy; your doctor has heard it all before.
Doctors don't have 'The Answer'
When you face a medical choice, there is no ”right answer'' -- there's an answer that is best for you at that time in your life under those conditions. You may decide to treat your heartburn with medication, while a neighbor with the same condition chooses an operation.
our relationship with your doctor is important
Sometimes something magical happens between a doctor and patient. A surgical patient of mine said, ”Thanks, I feel so much better,'' when all I did was listen to her story. Your doctor is more than a technician who fixes you. Your doctor cares for you in large part by caring about you.
You have a job, too
You are responsible for doing the things you say you will do. If you say you will start walking every day or that you will take your medications as prescribed, then follow through on your commitment to your doctor and, more importantly, to yourself.
Cause: Applying rapidly evolving technology
You get better health care as a result of better technology. If Christopher Reeve sustained his spinal cord injury 50 years ago, chances are he would have died within weeks. With technological advances this real live superman demonstrated on the Larry King show his voluntary movement of his finger, something doctors would have said is impossible.
Technology allows us to both diagnose and treat a wider spectrum of diseases. Cure rates for many diseases are now higher. Sicker patients have a better chance of successful treatment.
Despite the shining achievements technology brings, there's also a dark side. Here are some of the untoward consequences of our growing dependence on technology.
Consequence: Abdicating personal responsibility
You might place tremendous faith in technology. You may believe that there is a test that will diagnose every medical condition, and that all diseases can be cured. While advances in medical technology have made huge strides, we still have a long way to go before these dreams will be realized.
Ask a group of young adults why they're smoking or eating a high-fat diet, you might hear, “By the time I'm sick, there will be a pill to cure me.” The belief that technology will fix everything makes illness risky behaviors seem much less risky. The ounce of prevention has been and always will be a better investment than the pound of cure.
Consequence: Curing at the expense of healing
The emphasis on cure at the expense of healing, largely driven by technology may be the darkest chapter in modern medicine. Your doctor's goal is this: make a diagnosis and offer treatment that will eliminate disease. In the past your doctor talked to you and examined you to arrive at a diagnosis. Your doctor can still arrive at an accurate diagnosis about 80% of the time just by listening to your story. Lab tests and special x-ray studies allow you and your doctor to arrive at a diagnosis with greater speed. Here's the rub. Telling your story and experiencing the warm touch of your doctor's examining hand does much more than guide a diagnosis and a treatment. It is healing. Think of a time someone listened to you with full attention and you were heard. It's a powerful and increasingly rare event. When I did this with my patients, without ever uttering a word, I often heard, “Thanks. I feel so much better.”
I think of healing as a process of acceptance. Like forgiveness, healing means looking back at the events of your life without needing them to be any different. It does not mean that you like what happened or would have intentionally bring them about. Healing means that you are not a victim of your illness. You have your illness rather than your illness having you.
You experience your doctor as a healer when you're heard and seen and touched. Latex gloves are another example of the many new layers between you and the warm touch of your doctor. When “connection” with your doctor is absent, medical care feels incomplete. For example, Sharon got technically flawless care for her infected gallbladder. But when she heard her surgeon describe her as “the hot gallbladder in 230,” she felt devalued as a person. She would have preferred to be referred to as the woman in room 230 who had her gallbladder removed.
Consequence: The loss of respect for the “art of medicine”
Medicine is an art as well as a science. The doctors who are most respected among peers are those with the great clinical hunches. They have finely-honed clinical judgment founded on years of experience. Our increased emphasis on technology has diminished our respect for the art of medicine. After all, the “art” cannot be transmitted on the Internet.
Consequence: Needing new questions.
The question in medicine has often been, ”Can we do it?” Can we restore vision? Can we come up with a better drug? Can we safely operate on an octiginarian? Technology allows us to do more and more things. We need to ask “Should we do it?”
We need to consider ethical as well as quality of life issues, as our ability to save or prolong life improves. We need to exercise new discipline and ask, “If we get the results of that test, what we will do differently with the answer. As my patient who had gotten the maximal treatment for his lung cancer said, “Why should I get monthly x-rays to see if the cancer's come back. The only thing my doctor would do is tell me not to renew my magazine subscriptions”
Cause: Believing cure means absence of illness When I started medical school 20 years ago, I felt like I had signed up for the medical army. We “waged war” against cancer, and boasted of “victories” over disease and death. We won when we “defeated” the enemy.
Consequences: Brushing aside the chronically ill and incurable
Patients with incurable diseases lost more than the hope of cure; they often felt abandoned by their doctors. The uncured and the dying, a reminder of doctors' limitations, were often avoided. Despite the beliefs of my gray-haired professors, death is not optional.
Cause: Believing pain is the enemy
Pain serves an important function. Pain is like the warning lights on your car's dashboard. It alerts you to something that needs investigation. It's your body's way of saying, ”Pay attention.''
We all try to avoid pain When your pain is severe enough, or worrisome enough -- or lasts long enough -- you will make an appointment to see your doctor. Then, ideally, you and your doctor can determine what's causing the pain and fix the underlying cause. The most satisfying encounters for both you and your doctor occur when the pain points to a clear diagnosis, you're treated and the cause is cured. A good example is a cough and pain in the chest when taking a deep breath leading to the diagnosis of pneumonia that can be cured with antibiotics.
Consequence: Believing your goal is to get rid of the pain
The key for you and your doctor is to eliminate not the pain, but rather the cause of the pain. If you treat low back pain with aspirin you are not doing something to avoid pain in the future. Unfortunately, removing the symptom is like putting tape over the dashboard in your car so you won't get distracted by the flashing red trouble lights.
The next time you experience pain, listen to your inner voice that tells you pain is the enemy. Then remind yourself that your pain can also be your friend alerting you to a problem or warning you to take better care of yourself.
Cause: Differing definitions of “health promotion” and prevention
In many cases, your doctor's idea of preventive care is different from your idea of health promotion. When doctors talk about colon cancer prevention, for example, they mean looking at the colon lining to make an early diagnosis of cancer, because early detection can prevent cancer deaths. In contrast, you want to know how you can modify your diet or exercise to prevent the development of cancerous colon cancer. That's true health promotion.
Consequence: Offering incentives.
The two motivators for change are fear of punishment (the stick) and anticipation of the reward (the carrot). Most doctors use the stick: telling you to stop a habit like smoking to prevent a disease. While the stick works for some, the carrot is often more effective. In fact, the word discipline comes from the root disciple which means “to follow in love.” Exercise may be the closest thing we have to a medical miracle. Your doctor may tell you to exercise because it will lower your risk of heart attack and cancer, as well as other conditions you wish to avoid.
Here's why I exercise: When I exercise, I have a higher level of energy, I manage stress more effectively and every organ in my body seems to work better. So, if you come home tired from work, which is the more compelling reason to go out for a walk: to prevent colon cancer or the trust, based on past experience, that you will have a better evening and sleep better if you exercise.
You may believe that it's your doctor's job to do things to you and for you to keep you healthy. This is not entirely true. Ultimately it's your job to get well with help from your doctor. Have you ever disagreed with something your doctor said, but told yourself, “Oh well, the doctor must be right. My doctors are the experts.”
Cause: Believing your doctor is the expert
Have you ever disagreed with something your doctor said, but told yourself, “Oh, well, the doctor must be right. My doctors are the experts”
Consequences: Distrusting your intuition
Dale was an elderly man who had a stroke several months before his bout with severe abdominal pain. His doctor saw him twice and told the family the pain was from the flu. His wife knew that this was something more than the flu. The patient could hardly speak after the stroke, but he made it clear to his wife of over 50 years that something serious was happening. However, being a military family, they didn't challenge authority. When their doctor said, “flu,” they acquiesced. A few days later, Dale died of ruptured appendicitis, a death that most likely could have been avoided with an earlier diagnosis.
While doctors may have more formal education than you do about how the body works, you are the ultimate expert on you. Your intuition provides information that's as valuable as any lab test or x-ray study. In fact, you ignore your intuition at your peril.
No one will ever know your body as well as you do. Your job as a patient is to tell your story to your doctor, understand your doctor's diagnosis and recommendations, and make the choices that best serve you.
There is another way
“I'm a victim in the health care system, pure and simple.” Larry said. “I'm just one person going up against the mammoth health care monster. There's nothing I can do to make things any different.”
That's where Larry is wrong.
Larry, like each patient, has tremendous power to influence his own health and his health care. His day-to-day health choices are each forks in the road. At each fork he can head in the direction of health or toward illness. His overall health picture is a score card, reflecting the sum of his choices. Conservatively, 75% of the diseases that doctors treat could be prevented with better lifestyle choices.
Here's another tightly-held secret. Patients have tremendous influence in teaching their doctors how to treat them. For example, doctors have learned about nutrition and complementary healing techniques because patients have demanded it.
The best hope for innovation of our health care system is you. You have tremendous power to shape both your health and influence the care you get from your doctor. I believe that it will be this kind of innovative grass-roots movement that will heal our ailing health care system. Here are some ideas:
Promote your health
Gandhi offers direction for healing our health care system: ”Be the change you want to see.” You can decide that from this day forth, you will live your life in faith about the wonders of the human body, rather than fear of disease. You will focus on what's right with your life. This means both shifting your perspective in your inner world, and making different choices that affect your body. You will teach these skills to your children. You might even bring a culture of health into your business.
Get to know yourself: Your body has tremendous wisdom, and it will tell you what it needs. It will alert you when something is wrong. Unfortunately, we have been trained since childhood to ignore the messages from our bodies.
Our growing obesity epidemic is an example of people disconnecting with their bodies. From birth, most of infants' needs are met with food. During my own childhood my parents became the experts about the food that went into my mouth. They decided what I should eat, how much and when. When I met my own physical and emotional hunger with food, my weight soared. Then I turned to dieting experts to tell me how to loose weight. It wasn't until I finally listened to my body that I took off this weight and kept it off. When I'm hungry I ask myself what I want instead of just standing in front of the open fridge. When I'm lonely I call a friend. When I'm scared I take a deep breathe and think of the heroics of my own patients.
I'm frequently asked, “What's the right diet?” My answer is, “Listen to your body and it will tell you.” Just as each person has a different taste in music, so, too, each body functions optimally under slightly different circumstances.
Ask yourself frequently, “What do I want?” Start with small things and get in the habit of consulting with yourself..
Treat yourself with compassion: There's a reason for everything you do. Sometimes the reason is not obvious. Sickle cell anemia is a condition in which the red blood cell take on a crescent shape that can plug blood vessels, leading to episodes of severe pain in children. Some children don't make it into adulthood. Why is the DNA coding for this disease still in the gene pool? It turns out that Sickle Cell trait is protective against malaria.
Sometimes the conditions that lead to a certain behavior changed, but we keep the behavior. We can always reevalaute and doing things differently.
We need to be compassionate with ourselves as we look at our current health care system. There were good reasons to focus on disease rather than health; it's time to re-asses and do things differently.
Identify your gifts. Yes, you do have gifts! They're usually the things you do so effortlessly that you can't believe that it's not a snap for everyone else. Get to know when and where you feel most alive. Then spend more of your time engaging in activities that use your strengths and gifts.
Tell the truth: I know this seems like strange advice coming from a surgeon. Our evolving field of psycho-neuro-immunology states that your mind and your body are connected. That's why you blush when you're embarrassed or your heart beats faster when you're nervous. You may get an unpleasant physical sensation in your body when you lie. Choices that lead to health are founded in the truth. Always.
Catch 'em doing something right. A parenting coach offers the most effective strategy to change a child's' behavior: “Catch your kid doing something right.”
Health means noticing what's right. There are lots of things that are right about your present life. How about at a regular family meal, a wellness effort in itself, sharing something good that happened during the day. How about starting every business meeting with success stories.
Focus on what's right, and the successes mushroom.
Make health a habit: We like predictability. That's one reason why up to 90% of our actions are based in habits. Your health is a consequence of your actions. If you have the habit of eating more calories than you use, you will gain weight.
Changing just one habit can make a huge difference in your life. What one small change can you make? Taking deep breaths when you're stuck in traffic instead of releasing toxic stress hormones by getting angry? Using olive oil instead of butter? Taking the stairs instead of the elevator?
Who do you call…stress-busters Up to 80% of office visits to primary care doctors are to treat stress-related symptoms. Your doctor treats your symptoms; you can also look at the root of the problem. You can take medication to manage stress-related acid reflux; a more effective strategy is to develop better stress management tools.
Favorite stress-busters include laughter, exercise, writing in a journal, listening to music and deep breathing. How about making a list of your favorites, have your children do the same and hanging the lists on the fridge?
Connect with others: Healthy relationships contribute to your overall health. There are medical consequences to loneliness. People who are lonely are more likely to smoke, overeat and abuse drugs. They are also 3 to 5 times more likely to experience premature death from all causes as compared with people connected in the community.
Reconnect to family. Deepen relationships with friends. Be involved in your community.
Exercise: Just do it Exercise is powerful medicine that has direct health benefits. You enjoy greater vitality, avoid disease, recover more quickly if you're sick and lengthen your days. You don't have to spend 3 hour each day in the gym to enjoy the benefits of exercise. You'll see great things happen with twenty minutes of walking four times a week. How about going out for a ten minute walk today and each day this week?
Speak Sweetly About 40,000 thoughts pass through your mind each day, and they're most likely not “Go, Girl” and “Atta Boy” A child hears NO 350,000 times by age 3.
Thoughts are powerful. They're like a computer program that your mind comes to believe. More good news… you can re-program your computer with positive thoughts that you repeat..often. I make cards with short affirmations stated in present tense. “I'm invigorated by my daily exercise.” “I effortlessly make healthy food choices.” “I give and receive with love and joy.”
Strengthen forgiveness muscles. Choosing to forgive is a huge step in the direction of health. Anger and resentment are poisons, just like cigarette smoke. Forgiveness not happen naturally, and it's a skill well worth nurturing. How about forgiving one person for one thing today? Maybe the person you forgive is yourself.
Charge your batteries Self-care is a gift you give to yourself…and to others. You function best when your batteries are charged. Make a list of things that charge your batteries and commit to doing at least one every single day. People-pleasers who take care of others at the expense of themselves pay a huge health price. And they don't serve others as well as people who take care of themselves.
Plug energy drains There are things in your life that drain your energy, like excessive worrying or toxic people or the nagging project on the home-repair list. Plug energy drains by springing into action. Clear the clutter from the garage. Replace worry with information and support. Learn to say “no” to the friend who routinely calls and complains, but never makes positive changes. Reduce the amount of time you associate with people who upset you or make you “crazy.”
Adopt an attitude of gratitude: Each day I recognize and thank someone who makes a difference in my life. It might be the garbage man, a teacher or a stranger who has just done something kind. Saying thank you keeps your focus on what you do have, and avoids thinking about what you don't. How about making a commitment to thank one person every day for the next 30 days.
Live in abundance You have a choice about whether you live in scarcity, or live in abundance. Abundance isn't about how much you have; you can choose to live in abundance by shifting your perspective. Health means living in abundance. The best way to experience abundance is to give what you want to have. If you want to be treated with respect, give your respect. If you want more love, give your love. Giving benefits the recipient and it you will enjoy greater health.
The healthy way to be sick.
Even if you do everything right, illness will strike. That's because there are factors that you cannot control, like genetics, your environment and plain old bad luck. Your body is resilient. For example, surgeons can remove three quarters of the liver and it will regenerate and look just like the original. The same actions and ideas that promote health will also help you bounce back more quickly to health.
Partner with your doctor effectively: Your relationship with your doctor is one of the most important in your life. You get the best care when you and your doctor work well together as a team. Historically the interactions between doctor and patient looked like those between a parent and a child. We're evolving into an adult-adult collaboration. You can expect both cure and healing with the right doctor partner.
I invite you to imagine the qualities that you would like in your “ideal doctor.” Maybe you could even write a job description and here's a possible starting point:
“Wanted: Caring professional with excellent communications skills, solid clinical judgment and honed technical abilities whom I can proudly call 'My Doctor.' You collect key medical and personal information and put the puzzle pieces together in a way that makes sense. You recognize that I am the expert on my own body, and offer insights based on your knowledge and experience that guide me to my choices that make most sense for me. When we don't see eye-to-eye, we respectfully agree to disagree. I deeply trust you. One day my life could be in your hands”
How about your own job description of “patient?”
“I'm in the driver's seat in my journey to health. I recognize that all choices can lead in the direction of health or disease. I want to make consistent choices that lead to health. . If I get sick, I collaborate with my doctor to restore my health. While I appreciate the many things my doctor does for me, I know that ultimately my health is in my own hands.”
You get the best, safest and most cost effective health care when you take your health into your own hands. Ask not what your doctor can do for you; ask what you can do with your doctor.
Trust your body's ability to heal: We are just beginning to understand how to harness the power of the body's innate healing. Although we currently wage war on disease, the most promising areas of scientific exploration involve mimicking the body's built-in mechanisms for achieving balance. I predict that learning how to do what our bodies already know how to do will be a topic of increased research.
Know your story: You have a unique health story. Telling this story plays a central role in your health care. There's more than one version of the story. Your doctor puts information together to arrive at a diagnosis and treatment. This story is contained in your medical records. Your story includes your experience of your illness. Your family medical history becomes part of your story. Ask about it at the next family gathering. It's a great way to learn new things about your relatives.
Maintain copies of your medical records: Good medical care is based on access to complete and accurate medical information. The best way to assure that your doctor has the complete record is for you to bring it with you to the appointment. You have a right to get copies of your medical record. Just call the office and say, “How do I get copies of my medical records?” Bring a self-addressed stamped envelop to each appointment and request records be sent to you.
Tell your doctor how you're feeling: Your doctor may understand how the gastro-intestinal system works, but you are the expert on what you feel. Your feelings convey information that is as important as a lab test or x-ray result. If your doctor doesn't understand how important something is to you, speak up! If you tell your doctor about the nausea with your new mediation and your doctor brushes it off and moves on to the next topic, say, “For me nausea isn't just a little annoyance. It's a big deal. Are there other medications that will work?”
Get second opinions: The apple tree in my yard will produce apples even if it is neglected; but pruning increases its yield. As I stand away from the tree I can identify the braches that need to be cut. When I get under the tree, though, I loose perspective so it's hard to identify the same branches that I saw so clearly from a distance. I find myself cutting a branch or two and then stepping back to make sure I'm on track.
You want to enjoy the fruits of your health. You can let nature take its course and hope for the best. So, too, you can get a better “harvest” of health by taking proactive steps. Undergoing a medical intervention is much like pruning. Getting a second opinion is like stepping back away from the tree and making sure you're on track. Just as the cut branch is lost forever, some medical interventions cannot be undone.
Manage medical information: Information treats two of the most painful conditions in medicine: fear and confusion. Just as with any other medication, you need to take the right dose. Take too much and you can experience toxic effects. Take too little and you will not experience its benefits. You have your own optimal dose when it comes to medical information. One patients said to me, “Doc, I don't want to hear about side effects. I'll get every one.” Another patient came with a hundred sheets of papers that summarized her research.
There is no FDA that regulates the quality of medical information. Anyone can say anything on the Internet. Be careful of your sources. Last, let your doctor help you decide how a clinical study relates to you and your life.
Let your doctor be your doctor: Good health care is not an end in itself; health care is a means to a healthy life. Active participation in your health care does not means that you must become your own doctor. You still need the skill, experience and advice of your trusted doctor.
Make smart medical choices: When it comes right down to it, your job as a patient is to make medical choices that best serve you. This process, called informed consent, means weighing the risks and benefits, so you can compare different options. I suggest, that there is a choice that's best for you at any given point in your life, and that you're the best person to make that choice. For example, an elderly woman with a failing heart may make a radically different choice about cancer treatment than a young mother that has an identical cancer.
Set cure and healing as goals: Of course, if you're sick you want to be cured. That may or may not be possible. Healing is always possible, though. The surest way to healing is by telling your version of your story. This takes time. When you call for an appointment , ask, “How do I set up a half-hour consultation?” Offer to pay out of pocket for time your insurance company won't cover. It might be the best investment you ever made.
Recognize promising frontiers: Take advantage of some of the revolutionary things the health care system is doing right. Here are just a few:
Evidence-based medicine:. When I started medical school I was told, “About 50% of what you're about to learn is wrong; unfortunately, we don't know which 50%.“ Many things in medicine are done because that's the way it's always been done. We are in a new era in which doctors are trusting science to answer the question, “Does this 'intervention' really help patients?”
Quality-of-life data: Traditional clinical studies look at measurable outcomes such as length of life and complication rates. The question you want to know is whether an intervention will help you live a better life. Finally, your question is part of medical research.
Clinical performance reports: We know that not all doctors get the same good outcomes, and that in general you will get better outcomes from certain doctors and hospitals that treat patients like you frequently. There is an evolving movement to offer information so you can select the best provider for your care.
Genomics: Genomics is the diagnosis and treatment of disease on a genetic level, before the disease does any end-organ damage. While there still are technical and ethical concerns to sort through, this field holds great promise.
Be accountable: Your doctor is your health consultant. Ultimately, you are in charge of your health. In large part, your overall health picture is shaped by your day-to-day choices. If you get sick, though, you are not to blame. However, you do have a choice about how you will respond to illness.
My hope
The ailing health care system can be healed, and you are the most promising healer.
A life of health is within your reach. The prescription is simple: Make health your focus. Make consistent day-to-day choices that promote and support health. Small changes make a huge difference. Heart disease, our number one killer of both women and men, occurs when cholesterol-laden goop accumulates between the layers of your blood vessel wall, decreasing its diameter. Small lifestyle changes can reverse the disease by decreasing the goop and widening the blood vessels. If every American walked for 10 minutes each day we could eliminate half of the health care spending.
So, too, our ailing health care system can be turned around. There's a healthy way to be sick, and it's an application of the same principles that promote health. This transformation will not happen through traditional health care reform that typically does more of the same with greater efficiency. We need to start doing things differently. The driving force of change will come from you, our patients. While you may feel like the silent victim in the health care system, you are about to take your rightful place as the guest of honor.
Over the course of treating thousands of patients, I have learned to trust the resiliency of the human body, mind and spirit. I am optimistic that you can expect a better tomorrow.
Health means being in top functioning shape. While making life-style changes is simple, it's not always easy to make them. Why invest in your health? Because you have special gifts and a unique contribution to make. We all benefit when you reach your fullest potential.
Everyone is counting on you.
Copyright © Vicki Rackner MD, 2005
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