The New Preventionalist Versus Medicine
I once read this quote from a former Trauma Chief of Surgery in Hospital: An Oral History of Cook County Hospital that always stuck with me, and so I’ll repeat it now:
To me, there’s something fundamentally wrong with an attitude of mind that says, “You’re sick, pay me.” The ancient Chinese had it much better–they said, “When you’re well, you pay the doctor; when you’re sick, the doctor pays you.” That’s a much better system–now you’re talking prevention.
The concept turns medicine on its head, and radically changes the way a doctor’s role is defined: keeping a person healthy, as opposed to healing a person that’s fallen ill. And it radically warps the incentives doctors have, as well; I’ve always been more than a little bothered by the fact that hospitals serve Burger King, Pizza Hut, and McDonald’s in their cafeterias. It’s a paranoid hypochondriac’s perfect conspiracy theory–the cardiologists keep the fast food joints around to ensure a plethora of business. (Okay, the cardiologists, and the stroke service, and the radiologists reading arthritis x-rays of obese patients, and the endocrinologists taking care of the diabetics, and the so on.) And props to Kaiser Permanente; their cafeteria food seems to be at least somewhat healthier, and their cafeteria vending machines offer juices, bottled water, and healthier snacks like granola bars, baked potato chips, and carrot/celery/peanut butter packs. More on Kaiser later.
This prevention doctor wouldn’t really work with the way that medicine is rooted in diagnosis, however. It usually requires a symptom (or some other strong piece of evidence) for a doctor to start to evaluate a patient, and for a patient to even go see a doctor. There’s also a statistical piece–you only want to do tests on people you suspect might have a certain disease, because of high numbers of false positives and risks associated with all tests. You wouldn’t want to do colonoscopies on all healthy 22 year-olds. (And I’ll guess that no healthy 22 year-olds want colonoscopies, either.)
But I’m not ready to rule out this alternate view of medicine and use of prevention. What if there’s a role for another person in the health care system–the health prevention professional. (I know, there are public health folks and prevention medicine physicians, but they usually act on a community or society level. Hear me out.) Imagine people saw a health prevention expert twice a year. This person would do some basic screenings, figure out risk factors, and give patients goals–and help to achieve them. Maybe they’re also a nutritionist, so they can suggest healthier foods. And they have practice managing diabetics. And they do vaccinations, check cholesterol levels, and refer for treatment, smoking cessation, all that jazz.
I know what you’re thinking–what kind of socialist, hippie world does this idealistic medical student think we live in? But what if this health prevention is mandatory: for insurers and for patients. What if all health insurance companies had to provide these appointments to patients… and what if patients had to go?
News flash: insurers often don’t provide coverage for some types of preventative care. Great examples for diabetes here. And to a company controlled by shareholders and bottom lines, this makes economic sense, unfortunately. I’ve read that because people change jobs so often, and because jobs are tied to insurance, the average American will bounce between multiple health insurance companies during their lifetime. For insurers, this means that they don’t have a reason (in the short-term) to provide preventative care–the mildly sick patient now won’t be a member of Company X when they’re the very sick patient. Insurance companies do everything they can to minimalize how many older, sick patients can join their coverage, but if they’re all trying to do that, I’d imagine on average they all have X many sick patients who’ve gotten worse during the years, bouncing from insurer to insurer. So if we require all insurance companies to provide this preventative care, it’ll be an investment in their bottom lines in the coming decades. (Kaiser Permanente of Northern California offers relatively better preventive care; since Kaiser is specific to a region and not a company, odds are if you have Kaiser insurance at one job, you might have Kaiser insurance at another job. They therefore have an incentive to keep their patients healthy.)
But maybe patients need a kick in the pants to get them into prevention, too. Consumer health plan advocates say that patients don’t know about health care prices, and that’s why they spend, spend, spend. But what if it’s not about prices. What if it’s just about taking responsibility? What if you had to see your preventionalist twice a year, as a part of your health insurance plan? What if insurers could drop coverage for patients who don’t go to their bi-annual visits (but couldn’t deny care for pre-existing conditions)? Requiring patients to see a “preventionalist” would send a number of important messages:
- Doctors don’t have magic pills. We can treat some things, but other diseases–many of the toughest we’re facing today–develop over decades.
- Patients have to take an active role in their health, and the everyday choices they make influence their health. The cheeseburger you eat today, and the one next week, and the week after that, put you at risk for a heart attack.
- Patients have control, and can change the course of their health, if caught early enough. Even if caught late, in some cases.
- The medical system is here to help patients improve their health; it recognizes that it’s hard to change behaviors, but it’s devoting a lot of time, money, and energy to helping people do better.
This is just meant to be a framework. This is not meant to be a white paper, or an implementation, so any nit-picking will be promptly ignored. It’s supposed to be a new concept in how health–and health care–work.
Brilliant. Something like this would send such a clear message to both doctors and patients that maintenance is more effective than repair! While patients often want to play a more active role in preventing illness, they don’t always have the knowledge to do so (and many doctors are too pressed for time/don’t have the inclination to offer preventative advice). Or alternatively, patients can’t be bothered taking control of their own health and need to be made more aware, and this idea would work for both classes of patient. I think that we have proved that the healthcare system in its current form is unsustainable, so an idea like this is more than worth a go. Thanks for putting something a bit revolutionary out there! (but perhaps a more snappy name would be required….’preventionalist’ is a bit of a mouthful – sorry to nit-pick!)
Is this concept really that revolutionary? It seems to me it’s rather the ideal idea of the yearly physical done by a family practice physician. These docs actually do all of the above already, including scheduling screenings based on risk factors, manage diabetes, suggest lifestyle modifications, and refer out more serious problems. The only issue is how motivated patients are to get to the doctor and do what he/she suggests.
This concept is what primary care physicians do. If this concept were implemented, how would the orthopedic surgeon, general surgeon, interventional cardiologist, and other specialists earn a living? As an orthopedic surgeon I saw patients who had been referred by PCP’s or by the emergency room when they had a fracture, degenerative joint, ruptured disc and so forth. How would the surgical specialist enter into the “preventative” scheme of things? In the past I have heard of other students with similar idealistic ideas, who seem to forget their idealism very quickly when the necessity of paying rent, employees, and in recent years, student loans becomes reality. Our system needs to change but I don’t think this is a concept that will ever become reality.
Motivating patients to see their PCP for preventative care is very difficult. Recently, there have been a series of articles in the NT Times(on line) about the epidemic of diabetes in NYC. One of the recurring themes has been the fact that many diabetics do not accept the fact that they have a serious disease because they can’t “feel.” It is only when they have serious complications of the disease that they really become concerned. Also, consider the epidemic of obesity. Motivation to prevent one from gaining weight is sadly lacking.
I guess I’m thinking of someone who can do more prevention than a 15 minute office visit has time for, especially when the person is at an office visit for some other reason.
And the preventionalist wouldn’t be a doctor–wouldn’t prescribe medications. And how many doctors–family practice or otherwise–have the time and skils to manage planning a diet like a dietician can?
As an MPH student, I totally agree with what you are saying about the importance of maintaining health as opposed to repairing the body/curing diseases. On a sidenote, Loma Linda University offers a doctoral degree (DrPH) in Preventive Care. The curriculum is more clinically oriented and they are well-grounded on lifestyle modifications, nutrition, etc. I am interested in earning this DrPH degree but I am concerned about job prospects after finishing the degree. It is not even nationally recognized as of now and I believe only Loma Linda has this type of degree. Dr. Thompson is also correct in what he was saying for many patients may not even be interested in it.
Sometimes I wish there was some type of gimmick that people had in medicine that we have in dentistry. Everyone hears or knows that dental golden rule ‘visit your dentist 2X a year’. This originated from a toothpaste commercial. I love the idea of a preventionalist but in the mean time if there would be some way to hammer to the public some general rule in the media in a PSA for example, for visiting a family physician maybe some would take it into mind.
BTW, this is one the arguments for a national healthcare system. It would be more motivated towards preventative care than private insurance companies. Of course, there are many problems with such a system as well. I really don’t want my doctors having to worry about their finances.
While I’m at the gym exercising, I’ve often thought that it would also be worth the while of insurance companies to pay for gym memberships and in some cases, personal trainers (when something like obesity, joint or back problems is involved). This would be cheaper than insulin dependence or surgery.
Heck, they could own the gyms and the juice joints, day spas, and day care attached and actually make it a profitable venture.