Shift from intervention to prevention
By Stephen D. Dow, MD
Major changes in the health care delivery system over the past few years have had a significant effect on our orthopaedic practices. In response to these changes, many orthopaedic surgeons have reassessed, and in many cases, modified their orthopaedic practice patterns. The changes with which we have been most concerned are the economic changes resulting from managed care and decreased Medicare reimbursement.
In our surgery lounge discussions the word "crisis" often comes up. The Chinese symbol for crisis is made up of two symbols, one representing danger, and the other opportunity. There is another parallel change impacting the health care delivery system, a change which, if recognized and responded to by orthopaedic surgeons, may represent a huge opportunity for us to restructure our practices in a positive way.
The change to which I am referring is the major paradigm shift which is resulting from some 77 million baby boomers who have, or will soon, enter their fifth decade and whose major concern with respect to health is wellness management rather than illness management. Americans now spend $6 billion annually on nutritional supplementsvitamins, minerals and herbs. They spend $30 billion each year in the quest to loose weight, and since 1992, fitness equipment sales have doubled from $1.6 billion to $3.1 billion in 1998.
Philip Santiago, MD, writing for Anti Aging News, under the heading of "What do the boomers want?" states that, The New England Journal of Medicine recently published results of a survey concerning patients personal health strategies and what they say they want from their doctors.
Not only are our patients more interested in good health and fitness, they also have a rapidly growing interest in longevity. A new medical organization came to life rather inauspiciously in 1993 with only 12 initial founding members. Today, the American Academy of Anti-Aging Medicine has more than 8,500 members, annual meetings, a very active web site, several publications and is offering written and oral board certification examinations.
As I recently completed my 35th year of orthopaedic practice, I found myself taking a retrospective and introspective look at my practice. For many years I have been a strong advocate of the importance of patients taking more personal responsibility for their own lifestyle habits in achieving and maintaining their individual level of health and fitness.
Not only do patients need to take more responsibility for their own health, but they need to take more financial responsibility as well. A few years ago I wrote a column in this publication advocating Medical Savings Accounts as an appropriate means of restoring financial responsibility to patients for their healthcare needs. As a member of the Board of Councilors and the Healthcare Delivery Committee, I also strongly supported this concept.
In the 1970s I helped organize, and for several years, was chairman of a nonprofit organization, the Nevada Heart Fitness Institute. In 1976, we sponsored the first Silver State Marathon and Health-Fitness seminar. We conducted several free community exercise and fitness clinics. We developed and managed the first cardiac rehabilitation program in Nevada. For several years I wrote a regular column for the Reno newspaper on running and fitness.
Today, some 25 years later, in spite of the growing interest in health, coronary artery disease, cancer, obesity, hypertension, stroke and diabetes all remain as the leading causes of death. This is true in spite of the fact that these are all, to a great extent, preventable by adopting and adhering to appropriate lifestyle choices. As orthopaedic surgeons we recognize that many of the conditions which we treat are partially caused or at least worsened by inappropriate lifestyle choices. We know that patients with cardiovascular disease, hypertension, obesity, and type 2 diabetes present an increased risk for surgical intervention and are associated with a more guarded prognosis in terms of outcome results and complications, not to mention adding significantly to the cost of medical care.
Therefore, as I recently took a reflective look at my practice, I had to admit that, in spite of my strong convictions, I like most orthopaedic surgeons have placed a major emphasis upon the diagnosis and treatment of disease and injury and perhaps not enough emphasis on health promotion. My major focus has been on intervention rather than prevention.
Consequently, I recently made a decision to devote more time to my patients so that I could more strongly emphasize to them the importance of appropriate lifestyle modification. I developed informational material for my patients including a brief questionnaire, which helps me, along with appropriate laboratory evaluation and physical assessment, to identify major risk factors that would be amenable to lifestyle modification. I became a member of the American Academy of Anti-Aging, Medicine, attended their annual meeting, and am working toward board certification.
As a result of these and other resources I have been able to be more proactive with my patients in recommending to them exercise, dietary and nutritional supplementation programs. And my patients have responded in a very positive way to this new focus. Although most physicians are aware of the importance of appropriate nutrition and exercise, few have taken the time to become well informed enough to counsel their patients. And, in particular, with respect to the importance of nutritional supplements, most physicians knowledge base is lacking.
Back in 1953 when I was a college student, one of our guest lecturers was Linus Pauling, PhD, two-time recipient of the Nobel Award. It was Pauling who first proposed that supplementing your diet with micronutrients higher than the minimum required to prevent deficiency syndromes might be beneficial to health. Since the early 50s I have had an interest in nutritional supplementation. That interest was reinforced two years ago by the keynote speaker of our annual Academy meeting, Ken Cooper, MD. Twenty years ago when we were developing our Nevada Heart Fitness Institute programs we did a site-visit to the Cooper Clinic in Texas and received very valuable input in structuring our programs. At that time, Dr. Cooper was far ahead of the medical profession in
recognizing and promoting the importance of aerobic exercise. Today, he remains far ahead of the medical profession in recognizing the need for appropriate nutritional supplementation.
I agree with Dr. Cooper who states in his book. The Antioxidant Revolution, that "The amount of antioxidant vitamins you should take is higher than you have been led to believe." Dr. Cooper goes on to state that "appropriate nutritional and antioxidant supplementation will provide the following benefits:
Even the federal government, as slow as it is to recognize and promote new important health initiatives, has been far ahead of most physicians in recognizing the importance of nutritional supplements. In the National Dietary Supplement Health and Education Act of 1994, Congress made the following specific findings regarding nutritional supplements:
Unfortunately, many physicians continue to have a myopic point of view with respect to preventive health. Physicians complain loudly about cut backs in Medicare and managed care reimbursement, but do not seem to recognize that if they took a more proactive role in counseling their patients and helping them identify and correct risk factors, there would, as a consequence, be far less chronic disease and far more funding for medical treatment and surgical procedures. I recently met Barry Sears, author of The Zone Diet, in Chicago and he gave an excellent example of how a health plan saved a huge amount of money by simply identifying their diabetic patients and providing them with appropriate dietary counseling.
Finally, physicians need to recognize that in order to successfully motivate their patients, they themselves must set a good example by adopting and adhering to appropriate lifestyle habits of their own. During the past couple years, I personally have made this effort and have been rewarded not only by the encouragement and appreciation of my patients, but also by enhancement of my own health and quality of life.
James D. Dow, MD, is in private practice in Reno, N.V., and is clinical assistant professor at the University of Nevada School of Medicine.