Wondering what the 5000 hours are? Roughly: the amount of waking time per year that you are responsible for your own health and well-being.
Scary thought, right?(photo by Robbert Van Der Steeg used under creative commons license)
The article referenced here from the New England Journal of Medicine is about how to increase patient compliance when taking medications – which may or may not be of any interest to you. However, the issue of compliance (for anything: exercises, herbs, diet…etc) is something that is a huge part of healthcare, and wellness in general and is THE major roadblock in people taking care of themselves. This article got me thinking about some issues that are pretty near and dear to my heart – like that of reactive vs preventative medicine. As a healthcare provider my time with you is so limited compared to the rest of the time in your life – so how do I, as a provider, give you the tools and desire to change your lifestyle/behavior/diet in such a way that it improves your overall health and well-being?
The dominant form of health care financing in the United States supports a reactive, visit-based model in which patients are seen when they become ill, typically during hospitalizations and at outpatient visits. That care model falls short not just because it is expensive and often fails to proactively improve health, but also because so much of health is explained by individual behaviors, most of which occur outside health care encounters. Indeed, even patients with chronic illness might spend only a few hours a year with a doctor or nurse, but they spend 5000 waking hours each year engaged in everything else — including deciding whether to take prescribed medications or follow other medical advice, deciding what to eat and drink and whether to smoke, and making other choices about activities that can profoundly affect their health.
-via Automated Hovering in Health Care — Watching Over the 5000 Hours — NEJM. [emphasis mine]
If you’ve never heard my thoughts on the current healthcare system (lucky you), one of my main gripes as a healthcare provider is the above, exactly. The huge dependence on reactive medicine (and the financial reward for this, but that’s a whole other topic for another time). Reactive medicine is necessary, yes (there are traumas and things in this world that no amount of prevention can prevent) – but largely the burden on our healthcare system is due to mostly preventable chronic diseases that could probably be avoided in the first place, or could be managed in such a way that expensive and frequent complications do not occur. So then, why is preventative medicine not our focus? So much of our research time, dollars and energy are spent on fixing something that’s already broken – don’t get me wrong, I do think we should certainly invest in reactive medicine –but why isn’t our focus on preventing/minimizing the potential for these big, pricey problems such that the need for reactive medicine (which by nature is often too late and too expensive) LESS?
The second development is our deepening understanding of behavioral economics and the reality that although most people want better health and typically know what it would take to achieve it, the desires, distractions, and urgencies of the moment often get in the way of pursuing what’s in their own long-term self-interest.
–via Automated Hovering in Health Care — Watching Over the 5000 Hours — NEJM. [emphasis mine]
And there you have it – the trouble with prevention. The difficulty with a paradigm shift to preventative medicine is many-fold: for one, prevention does not have the sex-appeal of “a cure” – it is not exciting and dramatic – it takes patience and diligence and putting aside immediate gratification for the big picture benefit. Whereas reactive medicine is so much easier to wrap our heads around (I got hurt/sick – now I have surgery/medicine to fix it). For another, with preventative medicine a majority of the burden of change falls on us as patients – we are responsible and accountable for our own well-being, and this would require a mindset change (not to mention real effort) from our largely “magic-bullet/take a pill/ cure” loving society.
In the recent years this idea of prevention is gaining hold in both business and healthcare in the US – smoking bans, incentives for gym memberships, home-based methods of monitoring compliance… etc. And, really, it should – not only is better for us as the people who are ill less often and less seriously, but I would imagine it’s much better for our financial bottom line and would greatly free up time, money and resources in the healthcare system.
The increasing attention being paid to those 5000 hours takes various forms. Employers are focusing more on employees’ wellness — how they eat, whether they smoke, and how much they exercise. Medication adherence has become a more important goal, thanks to growing recognition that many people with chronic conditions fail to take their medications regularly and therefore do not get the benefits that health care can provide. Home-based biometric assessments of indicators such as glucose level, blood pressure, and weight are emerging as part of longitudinal clinical care. Transitional care models are being touted as a way of coordinating care beyond hospitalization. And hospitals and health plans are developing “hot-spotter” approaches, deploying tailored and intensive attention to managing the care of their most challenging patients. All these activities occur outside the conventional, billable, clinical encounter — and all reflect some sort of hovering over people in their daily lives.
-via Automated Hovering in Health Care — Watching Over the 5000 Hours — NEJM.
Enter Traditional Chinese Medicine (TCM). One of the many reasons I love this medicine (and yes, as a practitioner of it I have inherent bias) is it’s root in preventative rather than reactive medicine. Indeed, the original model of this medicine as practiced thousands of years ago was the acupuncturist as village doctor whose job was TO KEEP PEOPLE WELL. Sorry for the shouting, but, what’s being proposed as ‘revolutionary’ in the field of healthcare these days (you know: preventative, patient-centered care) is absolutely nothing new – we’ve just managed to get caught up in reductionistic, glamourous, immediate gratification technology. Our healthcare system is currently set-up to reward diagnosis and procedures, not outcomes. And to take a rather cynical approach to it all: a healthcare provider’s best financial interests are not for you to be well. This creates some cognitive dissonance doesn’t it? I don’t doubt that many if not most physicians and healthcare providers do in fact want you to be well – I know I do – but the system we find ourselves in is reinforcing the exact opposite. It’s a hard place to be as a provider, to be constantly fighting against the flow to do what is best for your patients. Preventative medicine is such a beautiful answer to this dilemma.
Keeping people well. It’s not really that radical is it? Taking action before a problem arises to keep it from occurring – why is this so hard to wrap our heads around (believe me, I fall prey to it all the time: “I feel fine, why do I need spend time/money to take vitamins/get a check-up/change my diet…etc”)? The auto industry has figured it out. We all (or most of us, anyway) maintain our cars even when nothing is wrong; we get oil changes every 3000 miles because if we don’t we risk a much bigger problem of serious engine damage – a costly prospect for something we’ve already invested a lot in. And who doesn’t want to avoid the expense, time and potential injury associated with engine failure if we don’t? It makes sense, doesn’t it- the every few month preventative maintenance ends up saving us a lot of money, time and trouble down the road. My question is: if we do this for our cars, why aren’t we willing to do it for ourselves? Arguably, our healthy bodies are infinitely more valuable than our cars.
/rant. On a personal note: I do truly embrace preventative medicine, not only logically and philosophically, but I like the idea of it karmically, too! I want you to be well. I want you to be out doing the things that keep you sane, make you happy, bring you and others joy. I am also truly hopeful that the paradigm of medicine in this country will shift more toward the preventative, but we have to demand that to make it happen. While I absolutely enjoy the time getting to know you when you’re in my office, if I do my job right and give you the resources to be well during those 5000 waking hours a year, you shouldn’t have to see me that often. And maintenance is key to not having to come in often. Semi-regular care is an oil-change for the body, keeps everything running cleanly and smoothly; and I think TCM in particular is well-suited to making it happen. Even if nothing is “wrong” (and I LOVE hearing that from patients) acupuncture treatment every so often, for instance at the change of the seasons, is a great way to keep you moving.