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Another's Point of View

10/25/2016

Whenever I'm late for a meeting, I tend to stammer. "I'm so sorry," I mumble. "There was a lot of traffic." According to a social-psychological theory called the 'attribution effect', I probably won't blame myself for not leaving early enough; but everyone else in the room probably will.

This 'actor-observer asymmetry' involves the tendency for other people to place an undue emphasis on internal characteristics in explaining the actions of another person (e.g., their temperament or intentions) while that person is more likely to explain her own behavior by describing the situation. Thus, I am less likely to look inward and focus attention on my time-planning deficiencies or blame my own personality. Instead, I am more likely to think about the traffic that I just slogged through. It's not that I am trying to avoid responsibility for my actions, or to offer excuses; it's just that my situation is pretty salient to me. Other people don't tend to think of traffic; what they see is somebody who showed up late.

I have oversimplified this attribution effect, of course. Social psychologists have labored for decades to understand the complexities of this phenomenon, which is more or less likely to occur in various contexts (e.g., whether the attribution is negative vs. positive or about ethical behavior vs. trivial action; whether the people are from the same or different cultural backgrounds, etc.). Generally, however, research shows that 'actors' and 'observers' have a tendency to use different explanations for the causes of an agent's actions. It takes some effort to overcome our tendency to minimize the situations that other people are dealing with.

This challenge is all too clear in the care of what we call "vulnerable populations" (...as if being ill does not make one vulnerable enough). These are the millions of poor, and those with limited education and low or marginal health literacy. They are patients with perceptual and/or cognitive challenges (such as, though not limited to, the elderly) and those with mental illness. They are patients whose language and culture are not accommodated effectively by the healthcare institutions they access. In many cases, they might be most of our patients.

Empathy is something that we, as health professionals (and simply as humans), strive to have with other people. We think of empathy as the capacity to place ourselves in another's position and see the world through their eyes. In doing so, we could see the constraints they face and hopefully offer some help in overcoming their challenges. Empathy could help us to listen to the reasons (and not view them as excuses) that prevent our patients from adhering to their treatments. We could help them, instead of judging their commitment or their resolve. And in truly understanding the situations faced by our patients, we often realize that they may be doing the best that they can under the circumstances. For example, we might be surprised to learn that despite having health insurance, many low-income workers delay or avoid getting needed medical care or purchasing prescription medications because the co-payments and deductibles remain financially prohibitive. Or, a patient may delay filling a prescription in order to repair the car and get to work and feed an entire family. It might be natural (...the attribution effect, again) to view a patient who delays care as intentionally non-adherent, but a closer look can reveal the daily challenges faced by that patient. Perhaps we can offer assistance in the form of more affordable medications, or community resources, or encouragement and supportive ideas for coping. At the very least, we can avoid judging another for their actions in a situation we barely understand.

We can best appreciate the situational context of others by offering them a chance to tell their story and truly listening without judgment. We can also learn more about vulnerable populations. The book Scarcity: Why Having Too Little Means So Much examines scientific evidence for the ways in which insufficient resources (e.g., money, food, time, the emotional support of others) can affect how people think and make choices. Written by a behavioral economist and a cognitive psychologist, this informative book offers us the opportunity to empathize with the struggles of those less fortunate than we are.

Empathy can help us to find the commonalities we share with all of our patients including the most vulnerable. We can support our patients' goals to care for their loved ones and to persist despite challenges-- medical and otherwise. And we can better emphasize our partnership with our patients in caring for them.

For health professionals: Please check out my latest QuantiaMD.com program entitled Vulnerable Populations: Communication and Effective Care. I offer some insights into building partnership and engagement, as well as improving adherence and outcomes, in the clinical care of vulnerable populations. This presentation appears on QuantiaMD, a free web and mobile community for healthcare professionals. QuantiaMD is a division of Aptus Health.

Motivate Me

7/30/2016

In the next few weeks, as we watch the Olympics on TV, many of us will likely feel increased motivation to exercise. Olympic athletes inspire us and offer us strong cues to action. This is great; exercise is the best thing we can do for our health short of not-smoking. I will be watching the swimming events and getting motivated to work harder in the pool to improve my lap times. Many of us, myself included, will likely also think about our general health goals -- moving more, eating better, managing our stress, drinking more water, taking our vitamins or medications, meditating regularly. We really want to achieve these; we just need the motivation!

I think we need to have a good understanding of motivation if we are to achieve our health goals. Motivation is generally defined as the desire or willingness to do something, but it is one of those popular concepts that is hard to pin down. I did a simple web search for "motivation" and found there is no shortage of motivation language: "Yes you can!" "Make things happen!" "Believe in yourself!" This language is on posters and in books, and it dominates video presentations of all sorts. This language often comes with offers to make you, or your employees, richer, stronger, happier, faster, harder-working, and better-looking.

Psychologists have long studied motivation and agree that helping someone, or ourselves, to be motivated is a complex process. Clinical psychologists William Miller and Stephen Rollnick wrote the classic book about that process (Motivational Interviewing: Helping People Change) and their companion book (Motivational Interviewing in Health Care) offers strategies for healthcare providers to motivate change. While inspiration is important in kick-starting motivation, research shows that we also need step-by-step plans; changing what we do day-to-day and sustaining that change requires knowledge of ourselves and of what we really feel. Motivation is generally defined as the desire or willingness to do something, but as psychologists have found, the desire to do something is often paired in our minds with a true desire to not do it. Take exercise, for example. On the pro side of the equation we can list more energy, better health, getting in shape, being healthier, and maybe even looking better. But on the con side, we feel deep down that we really don't like the gym, or that exercise makes us sore or takes too much time. Further, even when desire and willingness are high, we tend not to change our behavior right away. We usually do so in stages. Psychologists are on that one too, with the "Stages of Change Model."

Let's start with an example. We begin by stating a concrete goal, a specific target behavior like "walking for a half-hour, four evenings a week after work or dinner." Being specific allows for clarity in examining what to do and how we feel about doing it. Being specific also helps us track whether we actually did the behavior or not (compared with "getting more exercise" which is hard to pin down). It is unlikely that we will change all at once, begin our new walking habit, and continue it without fail. Instead we are likely to go through the following stages.
     Stage 1 is called Pre-contemplation. In this stage, I can easily list all the reasons not to walk (I'm tired after work; I prefer to watch the news; I don't have the right shoes.). If encouraged to do so I can probably come up with a reason to walk (I'll make my dog happy), but it's not easy. The goal behavior seems far off.
     Stage 2 is Contemplation. I intend to start walking, maybe sometime this summer and I am becoming more aware of the potential positive effects of walking (e.g., getting stronger, having more energy) but I remain ambivalent because the arguments against walking are still strong (e.g., too many things to do in the evening, like laundry and cleaning up from supper). At this stage, though, I am open to being inspired by others who walk (e.g., several neighbors who walk their dogs in the evening). I might still think about the negatives and I put off the action, but I am moving slightly closer to taking the steps.
     Stage 3 is Preparation and is just what it sounds like. I might get a new pair of walking shoes and find a later news show to watch while folding laundry after a walk. I have not started yet, but I'm getting close.
     Stage 4 is Action. It took a while to get here (perhaps days; perhaps months), but my first evening of walking after dinner arrives. It is important at this stage to pay attention to the natural rewards of the action --to notice the coolness of the evening, or the friendliness of the neighbors, or how I feel better the next day. It is important to have a sense of pride in having taken action. If family members are supportive of the health behavior, it is important for them to say so and to acknowledge the success!
     Stage 5 is Maintenance. We cannot emphasize enough the importance of reinforcement at this stage. Going for a walk four evenings a week does not have to win a person a new wardrobe or any large reward; in fact, small rewards are much better. For example, after a month of adhering to the plan, a movie night might be enjoyed.
     Relapse-- a lapse in behavior and return to the previous state-- is bound to occur at some point. Bad weather or a cold can cause us to stop walking for a while and it is difficult to get started again. How we deal with relapse is crucial. We need to remember the strategies used in the past to get started walking. We should examine the impediments to walking (e.g., need a place indoors to walk in bad weather--like the mall). Perhaps it is time to switch to walking on a treadmill or riding a stationary bike at home (used fitness equipment can be inexpensive). We can benefit greatly from the support and encouragement of others at this stage. It is important for us to remember what has been accomplished and can be accomplished again with encouragement and support.

A very important concept in Motivational Interviewing is the "readiness to change." It's an overall feeling of (you guessed it) one's readiness to take action. Health professionals can ask their patients a simple question: On a scale from 0 to 10, where 0 means you are not at all ready to start (...walking, taking the medication regularly, meditating etc) and 10 means you are ready to start right now, where are you at this time?
"Oh, a 2 you say...okay, what would it take for you to be at 5 or 6?"
or "Great, you say 7. So can you elaborate on your choice of a 7?"
The individual who said 2 can be encouraged to express the reasons for their resistance; the person who chose 7 can begin to solidify the choice by expressing the reasons for their readiness.

There are four very important principles of Motivational Interviewing that can be used by clinicians working with patients, and by those of us developing and maintaining our own motivations for behavior change. The first principle is empathy, which involves understanding another person's perspective. Empathy can also involve integrating different parts of ourselves, our different perspectives. The reluctant, cautious, lazier parts of us need to be accepted and understood more patiently by the parts that are more impatient and critical. Understanding our situational constraints (time limitations, fears, aches and pains) can help us to find solutions. The second principle is rolling with resistance. Generally this means not punishing ourselves for not being perfect, not arguing or pushing, but rather being patient with our challenges and limitations. Even if we feel too lazy to walk some evening, we might start out and if it doesn't feel right, just return home. Many times we will feel fine once we get outside, and will enjoy our walk after all. The third principle is developing discrepancy: "Here is where I am; here is where I want to be (need to be). If I do this, I will get closer to my goal. Step by step. Not perfect but trying." The final principle is self efficacy: "I can do this, It's my choice and I can do it. I'm doing it. I've come so far. I can keep going." Maybe this is the point when the motivational cards and posters finally come in! (I have one on my desk that reminds me: "Most people don't know there are angels whose only job is to make sure you don't get too comfortable & fall asleep & miss your life." Amen to that.)

In his valuable book, The Power of Habit, Charles Duhig tells us that by understanding and enacting certain principles, we can recognize the cues in the environment that trigger our actions and the things that reinforce them. We can build or change any habit we put our minds to. Our challenge, I think, is to first analyze and understand our own process of "" putting our minds to" a behavior. We need to understand, develop, and sustain our motivation to put our minds to the multiple tasks of behavior change.

Some things are clear. The more we know about motivation, the more we can use it to help others, and even ourselves, to adopt health behaviors and maintain them for life. We need to be patient with ourselves as we specify our behavioral goals, think about their pros and cons, gather the necessary resources, take action, maintain that action over time, and restart the whole process if we relapse. Desire and willingness are essential to behavior change, of course, and so is a deep understanding of each of the steps, in our minds and in our actions, that we need to take in order to change our behavior. We need to plan out what we want to do, be clear and specific, do the necessary thinking and planning, be honest with ourselves, be kind to ourselves, and maybe also get a poster.... maybe one with an Olympic athlete on it.

**Health professionals: For more about Motivational Interviewing in Healthcare, I invite you to listen to Motivational Interviewing (MI): Strategies for Behavior Change. This presentation appears on QuantiaMD, a free web and mobile community for healthcare professionals. QuantiaMD is a division of Aptus Health. In this program, I examine strategies for building effective partnerships between clinicians and their patients and for applying the well-researched and supported techniques of Motivational Interviewing. I suggest ways to enhance effective communication with your patients toward the goals of greater patient engagement, adherence, and commitment to treatment.

Not Perfect

5/31/2016

Recently I read Less Medicine, More Health by Dr. Gilbert Welch and Watch Your Back by Dr. Richard Deyo. My 18-year-old car reached 250k miles last week, and I worked out at my gym in mid-day instead of at prime time. These occurrences got me thinking about the wisdom of striving to attain perfection -- even without much hope of ever doing so.

Let's start with the gym. Over the years, I've belonged to many different gyms, and it has almost always been the case that mid-day provided a break from the prime-time workout crowds. Early afternoon was generally a time when the staff took it easy; the cardio-machines were almost all available, and the few dedicated souls who were working out appeared to be there because they worked swing-shift or they had the day off. This is not the case at the gym I joined recently. Not at all. Mid-day is workout time for the folks I lovingly call the "Gym-rats in Retirement". (I've always been a "gym-rat" and aspire always to be one, so despite how it sounds, this is, indeed, a term of respect and endearment.) At mid-day, my gym is hopping! Starting at around 11 am and continuing until 4 pm, there are weight-lifting and kettle bell workshops, and balance classes, TRX training, and exercise classes for chronic disease management and cancer recovery. Throughout the day, there are older folks working with personal trainers, or following their own written (or online) workout schedules. There are senior citizens on eliptical machines, treadmills, stationery bikes, and rowing machines, some taking dance or Zumba class, and there are lots of people swimming laps solo or in masters' swim programs. Classes in Tai Chi, QiGong, Yoga, Pilates, Core Strength and Balance are going on, and folks in their seventies, eighties, and even nineties are enjoying each others' company as they workout--many of them EVERY DAY!

There is a great deal of good data on the importance of moving throughout the life-span, and especially into older age. In fact, many of the symptoms associated with older age (weakness, stiffness, loss of balance, joint pain) are actually symptoms of inactivity and not of aging. Many elders are afraid to exercise for fear of increasing their joint pain when in fact studies show a significant decrease in osteo-arthritis pain with movement. In the ADAPT study, combining a healthy diet and weight loss with exercise brought about noteworthy improvements in walking velocity and reductions in pain. Modest weight loss combined with moderate exercise produced significant improvements in self-reported functioning and pain and greater measured mobility, allowing people to avoid medications and surgical interventions. Exercise and weight loss are now considered "cornerstones" for the treatment of Knee Osteoarthritis in overweight older adults. Exercise has many additional benefits including preventing bone loss, elevating mood, reducing the chances of falling by improving strength, balance, and coordination, and preventing or managing cardiovascular disease.

Only about 25% of those 65 to 74 get regular exercise, however. Even when people have the time in retirement, they assume they are too old or out-of-shape to do even the simplest and potentially most beneficial exercise such as taking regular walks. Some worry about the cost, but moving does not have to cost anything. Most senior centers have fitness classes and many TV channels offer exercise demonstrations. Those who want to improve their strength at home can use soup cans or milk jugs filled with sand, and even do exercises sitting in a chair if necessary. Many elders with chronic medical conditions are eligible for sessions with a physical or occupational therapist and many health insurers cover all or part of the cost of gym membership for those over 65. Working out at a gym can be intimidating to many older people, however, depending upon the atmosphere and the degree of respect shown to elders. Mine is a modest gym with a very broad age range, from young singles and families to folks using walkers and wheel-chairs, some in their 90's. Some members have been working out with each other for 30 years! It works well because it is an environment with strong social connections; it functions a lot like a community center, with organizing activities like March Madness, time together watching the game, barbecue dinners, fundraisers for local animal shelters, and arts and crafts shows. The trainers and staff are quick to offer help and advice for exercises and any modifications that might be needed; all are supportive and encouraging. Offering a fitness center with respect and social support for all is an excellent business decision--the U.S. population is aging, and the benefits of exercise are being recognized more and more by those who pay the medical bills, like insurance companies, medical plans, and patients themselves.

So how are my car and the books by Drs. Deyo and Welch relevant here? They offer the message that we can keep going in older age, even with limitations, even in the midst of chronic conditions, living lives that are meaningful and worthwhile to us. My old car has quirks (a passenger side door lock that only works manually, a driver's window that works only intermittently, and the need for a quart of oil every thousand miles) but with regular maintenance my car gets me where I want to go.
Basic regular maintenance (moving more, moving correctly with good posture (e.g., using the Gokhale method), sitting less, eating well) can buy us humans some quality time too. As Drs. Welch and Deyo note, it is not always the case that it's better to fix a problem, even one like back pain. [Dr. Jerome Groopman, Professor of Medicine at Harvard Medical School, offers his own analysis of this issue from personal experience.] Sometimes it is better to live with imperfections as one strives to maintain functioning. For example, despite having MRI reports that detail litanies of 'fixable problems', some people can function, exercise, and live happy, productive, creative lives as long as they just keep moving. Combined with managing one's emotions and motivation, movement as a daily "treatment" can have far better functional outcomes than back or knee surgeries that "fix" the problems.

Trying to make a body (or even a car) function perfectly, without limitations or quirks, can introduce greater risk than benefit. As Dr. Welch notes, Americans get far too much medical care (too many drugs, too much surgery), much of it not particularly beneficial and some of it downright dangerous, because many believe that every problem needs to, and can be, fixed. A new study identifies medical treatment errors as the third leading cause of death in the United States today. The costs of medical care are climbing for the entire population, even those with "good" insurance.

Living with “quirks” and limitations is part of getting older; modern medicine might be able to help with some of those limitations, but for many of the challenges of aging, it's the day to day habits, like moving, that matter. Perfection may not be possible, but striving to become incrementally stronger, happier, and more resilient may be-- and that might be just good enough.

On Adherence and Kicking the Risk Down the Road

4/28/2016

I'm not sure if this comes as a surprise to readers, but many people with chronic disease don't do a very good job of following their treatment recommendations. Between 15 and 30% of new prescriptions written are never filled, and after 6 months of treatment have passed, more than half of people with a chronic condition have stopped their therapy. In some diseases that percentage is even higher. And it's not just because people don't think their treatment is helpful; a quarter of those who stop long-term treatment for autoimmune diseases, for example, do so because the treatment has been working and it is making them feel better!

If there existed a blockbuster drug that would save the U.S. healthcare system 300 billion dollars a year and improve healthcare outcomes, I think that everybody (including those who "own the risk" ...see more about this odd concept below) would jump at the chance to use it! With many diseases, the costs of care over the long term can be very high. If HIV patients fail to take medication regularly and correctly, they can end up experiencing many expensive hospitalizations. If diabetics do not properly test their glucose levels, use insulin, and follow appropriate diet and exercise regimens, the costs of care can increase dramatically; heart disease, amputations, and kidney failure can (as they say) "complicate the clinical picture" not to mention make life pretty miserable for the patient.

Adherence to treatment is that blockbuster drug, the magic bullet, the path to better health and financial savings --but achieving it seems to be above everybody's pay grade. It's tempting to think that people would always follow their treatments correctly if only their medicines were not so expensive, or if only those medicines didn't cause unwanted side effects, or if only their health professionals just gave them more information and advice. While these factors (and many more) do matter, no one factor matters a great deal. In other words, no simple set of explanations works for everyone.

For every person with an adherence challenge, there's a unique set of reasons causing it. For example, Patient A might simply not understand the reason for her prescription in the first place. And she might remember incorrectly what her doctor told her. Indeed, 40 to 80 percent of the information that doctors give their patients during the office visit is forgotten or remembered incorrectly by the time the person gets to the waiting room! Perhaps Patient A goes home and tells a family member what she recalls from the visit, and that family member looks up treatments and medications on the internet (where a large proportion of health advice is actually incorrect). The family member might hint at his concerns about the regimen and so the medication remains unused. At the patient's follow-up appointment a few months later, she tries to get through the ten minute medical visit without having to admit that she didn't understand, didn't believe in, and consequently didn't follow the prescription. The physician thinks all is well, or (worse) increases the dosage because the lower dose (which was never taken) appears not to have worked. Patient B might genuinely plan to adhere to treatment. But he doesn't have anyone to help with food shopping and preparation, emotional support for exercise, or reminders to take medication. He might also be moderately depressed and feeling pessimistic and hopeless, withdrawing from others, and having difficulty thinking and planning. Treatment adherence ends up on the back burner most days.

The most effective and least costly way to manage chronic disease involves helping patients adhere to the treatment prescribed for them, and supporting providers to focus on treatment adherence. Those who "own the risk" for patient outcomes would do well to invest in ways to help with adherence. "Owning the risk" seems like an odd concept, but it's a simple one. Although a patient must ultimately deal with the daily consequences of any health challenge, it is the financial risk of care that we are referring to here. If an employer offers health insurance, the rising costs of that insurance must be borne across the "risk pool" of employees, and when health costs go up, so do premiums. There is incentive to control costs and insure optimal care. One ideal situation for the reduction of financial risk is in an Accountable Care Organization (ACO) that maintains a focus on insuring that chronically ill patients receive correct, coordinated care as well as necessary support to maintain their commitment to treatment. More problematic are situations in which chronically ill individuals (often for financial reasons) switch insurance companies and providers year after year, and receive uncoordinated and episodic care. The danger here is that few patients will find a healthcare provider who helps them improve their adherence and manage their chronic diseases successfully over the long term. Healthcare costs keep climbing partly because there is an incentive to "kick the risk down the road"-- to the next health plan, or the next employer.

An example of the disastrous results of kicking the risk down the road is the creation of opioid addiction from the poor management of low back pain, which I wrote about in February 2016. Imagine that a patient with low back pain really needs and (as research shows) would likely benefit greatly from physical therapy, exercise, and some Cognitive Behavior Modification. These approaches require a coordinated effort by health professionals as well as payment coverage by insurance; they are far less expensive and more likely to work than surgery. With support to adhere to back exercises and behavior change (such as losing weight and keeping it off, and lifelong attention to body mechanics while moving, lifting, and carrying things), patients with low back pain have a very good chance of effectively managing their pain throughout their lives. Additional complementary medicine treatments like massage and acupuncture are also likely to be helpful in the earlier stages to help manage pain and get the patient moving. But limits on physical therapy, acupuncture, and psychotherapy coverage in most health plans, as well as a general absence of focus on helping patients adhere to behavioral change, can push the patient's treatment toward the quickest and least expensive short-term solution --a prescription for opioid painkillers.

Medical care is going to get more expensive. By 2020, it is expected that 157 million people in the U.S. will be living with at least one chronic disease and 81 million will have multiple chronic illnesses like diabetes, heart disease, hypertension, stroke, back pain, depression, and cancer to name a few. The best and the most effective treatments for these conditions will only work if people adhere to them, and in order to achieve optimal outcomes and manage costs, all patients, providers, and health systems need to be engaged in promoting adherence to treatment.

For more information on adherence, please check out the tab above entitled "PDFs of Published Work" where you will find a number of my written articles about treatment adherence.

Also, the link below will take you to my recent presentation for health professionals offered by QuantiaMD: Improving Your Patients’ Adherence to Treatment Recommendations
In order to view/listen to the entire slide presentation-- and many more --you will be asked to register. The service is free and filled with great information about many topics in healthcare.

https://my.quantiamd.com/player/ycirjiztx This presentation appears on QuantiMD, a free web and mobile community for healthcare professionals. QuantiaMD is a division of Aptus Health

On Puppies and Health Insurance

3/18/2016

I believe that it is better to think about health insurance before becoming a patient. A befuddling market is easier to deal with while relatively well, instead of when ill or injured. Health insurance can be staggeringly confusing, even for the most motivated and knowledgeable consumers. For those who have high deductible insurance (such as being offered by many employers and exchanges), it is essential to be engaged in making good decisions. One should access care in the most efficient way, follow cost-effective treatments, and even make sure to decline services that are unnecessary. Healthcare consumers are being asked, more and more these days, to be involved in choosing their treatment options; they are supposed to be engaged and ask questions.

This can be difficult for anyone, especially those with low health literacy. Health literacy involves a patient’s ability to comprehend medical directives, such as how to take medication correctly (e.g., 3x/day, roughly every 8 hours--not at 9am, noon, and 3pm). While studies show that literacy within the health care context tends to be lower among the less educated and those of lower income, poor health literacy can cut across all levels of education and income. Someone with an advanced degree can have difficulty managing decisions about the risks versus the benefits of medical interventions, especially when anxiety and pain come into play. When patients have a limited framework for understanding and using health information, they tend to generate higher healthcare costs, achieve worse health outcomes, and have lower adherence to treatment.

Literacy regarding healthcare benefits (sometimes called Health Benefits Literacy) is a related phenomenon; it is focused on the degree to which an individual understands the health insurance options available and how to use those options effectively. Some interesting survey results are offered by the nonprofit International Foundation of Employee Benefit Plans (IFEBP), which has over 33 thousand members representing public and private sector employers that insure over 25 million people. Only 19% of respondents believe that their employees' understanding of health benefits is at least somewhat high; 23% believe that their employees have low understanding of their health insurance. Human resource managers and benefits counselors in companies across the country report spending more than half of their time answering employees' questions about healthcare benefits. And yet a lot of motivated, capable people remain confused.

Learning about your healthcare plan involves issues that can be intimidating: premiums, deductibles, in-network versus out-of-network providers, percentage coverage, visit limits, and preventive services, just to name a few. Most employers, health insurance exchanges, and health plan providers (insurance companies) offer large amounts of information. But studies show that most employees and subscribers (that is, the people who buy health insurance for themselves and their families) don't fully understand what they have or how to use it. Informal employer surveys show that less than half of employees even read all the materials they receive about their health plan benefits. (Quality research on this topic is sparse, though, and more is needed). Many people who buy health insurance don't even know that they have certain preventive visits and tests available to them at no cost. Of course, simply deluging people with information does not work very well; being told a lot of confusing facts can be overwhelming and not very helpful.

I once had a high deductible plan that was supposed to save me money if I chose the right providers and asked the right questions. But I had the same feeling as my friend who had some construction work done on her house. She was dissatisfied with the results, and in response the contractor told her that she should have, up front, asked more questions! "If I knew what questions to ask," she said, "I would have asked them!" The same is true in health care, where we want people to be astute consumers of medical care when the information available can be confusing, anxiety-provoking, and sometimes even inconsistent. I have had years of experience in the healthcare field, working with health plans, employer groups, integrated systems, and patients; I don't think I have low health (or benefits) literacy. But last year I was pretty confused by my own health plan. I had moved to a new area, and tried to "front load" decisions and care plans for myself and my family before becoming ill or having a crisis. (I am the one in my family who is responsible for knowing the steps necessary to access care and clarify medical choices; most families have a member who does that, whether they enjoy it or not.) This kind of exercise is something that all health plan subscribers and employees should do in order for them to make the right choices, insofar as those are possible, if and when the time comes to do so. One scenario I 'walked out' in my mind was being ill on a Saturday night. Which urgent care establishment is within a reasonable distance and open on a Saturday after 6pm and in our network? (answer: none) There's always the emergency room, of course, and the closest (much admired) hospital is "in network." (smile). However, many of its doctors are not. In planning this out, I checked the website which was confusing enough to prompt a call to my plan to clarify. The names of in-network doctors and hospitals, according to the website and according to the person on the phone, were different. These experiences are not unusual.

Health plan information is not just difficult to understand and negotiate when one is ill; it can be copious, complicated, and anxiety-provoking at best, and unclear or inaccurate at worst. Yes, there may be a lot of information for people to read, but even if they read it, can they translate it into their own lives? Will they take the right steps when they are ill on a weekend? Do they understand the potential consequences of being unprepared? Do they have an extra few thousand dollars sitting around in case they make a suboptimal decision, or get the wrong information?

Not all of my family's healthcare is frustrating; veterinary care is a dream. I just got another new puppy (photos available upon request), and I considered, again, the issue of whether I should buy him health insurance. Today's options include "wellness plans" which cover only preventive services, and "canine veterinary medical plans" which cover illnesses and accidents, excluding pre-existing conditions. I read the policies offered and the "pre-existing condition exclusion" is quite broad. After calculating monthly premiums and deductibles for various possible unsettling future scenarios, I decided instead to open a 'personal health savings account' for my puppy (i.e., just some money put aside to ease the sting of a big vet bill.). This is the same conclusion I came to for his older brother and many dogs before him. And although the world of veterinary healthcare is not a space in which I have great expertise, I did figure it out because it is not nearly as complicated as human insurance. In my efforts to make a decision, I considered this veterinary scenario: It's Saturday night, and the puppy needs care--now. We pile into the car, drive to the animal emergency hospital a few miles away. After diagnostic tests and discussion with the kind veterinarian about risks, benefits, and costs of various courses of action we make a decision. (I like to make these scenarios end happily.) We eventually head home with medicine, having paid the bill with said puppy's personal health savings account. I did all the thinking ahead of time and made the financial decisions, and now I can just focus on my family and getting our puppy well again. I was able to do this for pet insurance because pet insurance is easy, veterinary care is much cheaper than human medical care, and the number of insurance options is fairly limited. It took some time, but it was manageable. I don't feel that way about medical insurance.

How can these challenges be managed? Maybe we should start by helping people, when they are healthy, to ask the right questions of their doctors, and plan hypothetical courses of action for themselves and their loved ones. Maybe experts on health insurance could offer some more support for this. We ask people to be good consumers, but it's frustrating and difficult unless they get help asking the right questions and dealing with the answers, making plans, and front-loading decisions whenever possible. The motivations to plan ahead are clear (save money, plan out-of-pocket costs ahead of time, get the best care). But that support is rarely available; as consumers we have to figure it out on our own.

Nearly every year, with new health insurance options and costs, I had to plan out potential scenarios in my mind --what to do under various emergency situations or chronic disease diagnoses, what general questions to ask, what pathways to take, how much to spend in premiums for what benefit -- knowing that I could not know what the future would hold. Certainly these thought-exercises can cause existential anxiety for all of us; thinking about future health challenges can be upsetting. But medical plan information should help to reduce that anxiety, not increase it, or consumers will never want to plan ahead. As a psychologist, I considered the possibility that stress about my health insurance might someday make me sick. So, I finally threw in the towel and joined an Accountable Care Organization (ACO), one that prides itself, as many do, on its safety and effectiveness metrics. In a medical crisis, I know exactly whom to call and where to go, and I know exactly what's covered. I don't even have to remember my health history because it is available in a detailed electronic health record. Also, I trust that this ACO's focus on safety and effectiveness makes it unlikely that I will be offered unnecessary, expensive procedures that have questionable benefit. I can concentrate instead on asking about treatment options and considering how they fit with my own values and expectations. And I can spend more time playing with my puppy.

The Pain is the Problem

2/29/2016

As the 2016 primary elections and caucuses take place in various states, certain local problems are being highlighted and, temporarily at least, they capture political attention. One of these problems is the widespread addiction to opioid medication that is ravaging a number of states and growing at an alarming rate nationwide.

Current figures suggest that more than 2 million people in the United States suffer from substance use disorders related to prescription opioid pain relievers, including medications like hydrocodone and oxycodone. Addiction is very expensive in terms of both financial losses and human suffering. The total monetary cost to our society of prescription opioid abuse is estimated to be over 55 billion dollars, with close to half resulting from lost earnings and lost productivity in the workplace and another half due to excess medical costs including emergency room visits. Deaths from prescription pain reliever overdoses more than tripled from 1990 to 2010; there were 18,893 such deaths in 2014 alone.

The year 2012 saw 259 million prescriptions written for opioid painkillers; this is roughly the number of adults in the US population. These medications are almost miraculous in their ability to relieve acute pain from tissue damage due to surgery, injury, or terminal cancer. The use of these medications for chronic pain, such as low back pain and headaches, however, can lead patients to addiction and even put people at risk for heroin use. In the U.S. today, 29 million people still do not have any health insurance despite the Affordable Care Act; many who do have insurance cannot afford the copayments to keep seeing a doctor. Providers are also subject to legal limits on offering such prescriptions; in some communities, the only option available to a patient in chronic pain may be illegal and potentially dangerous substances like heroin that mimic the effects of the pain-killing opioids.

I am going to go out on a limb here and say this: I don't think many people get into abusing prescription opioids, or switching to heroin (with all its attendant risks of criminal prosecution, procurement dangers, and uncertain ingredients and dosages) just to have a good time. They risk losing their jobs, families, and social networks to their addiction, not to mention their health and peace of mind. I do think that many people have fallen down a rabbit hole of pain, and they can't get out alone, and they can't get appropriate help because it is not available to them. Serious socioeconomic inequities are at play here, of course, and these need to be addressed in our society. But here I just want to focus on one part, likely the first, in this complex and terrible cascade --pain.

"Pain is soul destroying," Marcia Angell, M.D. wrote in 1982. Having to experience pain every day can focus a person's life on that and that alone. It's difficult enough for many to keep going, working several jobs, or being unemployed, caring for children and elderly parents, dealing with economic uncertainties. Many adults in the United States try to do all that is required of them even while they are in severe chronic pain. At some point in their lives, over 80 percent of people in the U.S. population experience an episode of debilitating low back pain, and for about 5% the pain persists past three months and becomes chronic; up to 85% of those who have one bout will have a recurrence. About 16% of people in the US have chronic migraines or other severe headaches. Knee osteoarthritis, which brings substantial pain, joint stiffness, and difficulty getting around, affects millions of U.S. adults. Chronic pain is relatively common.

For many people, however, chronic pain is mismanaged, leaving them at risk for addiction. For example, opioid medications are prescribed for chronic low back pain without ever having tried other modalities (see some described below); this can begin a cascade of problems. I think it is fair to say that, generally, medicine does not fully understand chronic pain (i.e., pain that lasts for months after tissue damage has healed). People vary widely in how much chronic pain they feel. The degree to which pain limits them depends upon a host of factors, including the meaning of the pain to them, how much stress they are under, and their expectations for relief. Because the complexity of chronic pain has been in large part ignored in U.S. healthcare, I think we have gotten our approach to chronic pain all wrong. In the U.S., medical care for chronic pain tends to focus almost exclusively on trying to 'banish' it with (mostly narcotic) drugs. Writing prescriptions, however time-efficient, can end up being very costly and it does not work. Opioid medications introduce side effects and a significant risk of addiction, and can even increase a person's sensitivity to pain (a phenomenon called opioid-induced hyperalgesia).

Chronic pain is far too complicated to approach simplistically. For one thing, pain is all in the mind. Where else could it be? Our pain "signals" are always interpreted by our minds in the context of everything from our past experiences to how we are feeling about our lives at the moment. Studies show, for example, that if we expect a treatment to relieve our pain, it likely will, even if it is an inert substance like a sugar pill. Studies also show that if we are depressed or anxious or under stress, we feel more pain. This doesn't mean that our pain is not real; it means that the experience of pain is a complex process in our minds, and the relief of our pain is also.

One of the best books I have read on the role of the mind in the management of pain and other symptoms is the newly released Cure: A Journey into the Science of Mind Over Body. It is a well-written and well-researched investigation into the role of the mind in health and healing by science writer Jo Marchant, who explores how our responses to pain and other symptoms depend on our expectations and beliefs, and levels of relaxation, stress, sadness, and attention. Marchant and many others who have looked deeply into this phenomenon have concluded that if we accept the power of our minds in the interpretation of our bodily experience, we can open up a world of effective ways to be healthier.

There are many safe approaches to treating chronic pain that really work and do not use drugs at all. The National Center for Complementary and Integrative Health (part of the National Institutes of Health) today has a budget of over $100 million to support research and offer information and training on treatments such as Mindfulness Based Stress Reduction (MBSR) Meditation and Traditional Chinese Medicine (TCM) (including acupuncture and Chinese herbal formulas). These and other approaches show impressive effectiveness in managing chronic pain. There are many more avenues to chronic pain management. In his book, Watch Your Back, Dr. Richard Deyo (see 12/2014) offers convincing evidence for exercise/movement and Cognitive Behavior Therapy in treating chronic low back pain. Weight loss and exercise can help immensely in the management of chronic knee pain from osteoarthritis. Yoga is very effective in chronic pain management. In her book, Cure, Jo Marchant describes the successful use of Clinical Hypnotherapy among burn patients (who must endure treatments which inflict possibly the worst pain imaginable). Other modalities such as Chiropractic, therapeutic massage, and Active Release Therapy are used by millions. In fact, recent research shows that today in the United States, about 4 in 10 adults (and 1 in 9 children) are using some form of Complementary and Alternative Medicine (CAM). Latest statistics show that Americans pay almost 34 billion dollars per year out-of-pocket for alternative treatments because their health insurance, if they have it, offers them limited options, if any. I think it is fair to suggest that perhaps so many people are paying out so much money because these therapies help them feel better.

In 1982 Dr. Angell wrote: "No patient should have to endure pain unnecessarily....Few things a doctor does are more important than relieving pain." The epidemics of opioid abuse and chronic pain need to be addressed with better management that includes harnessing the mental and behavioral abilities of patients to eliminate or reduce their pain. Physicians in training and in current practice need a commitment to, and in-depth training in, the effective management of chronic pain using multimodal approaches. If opioid medications do make sense for a particular patient with chronic pain, their use must be part of an overall strategy including behavioral change (weight loss, exercise, movement), as well as approaches such as TCM, yoga, meditation, and the identification and management of anxiety, stress, and/or depression (all of which make pain even worse). We need to go well beyond a reliance on powerful pain-relieving medications. We need to develop better approaches to caring for the whole person who is in pain.

Keeping Track of Everything I Do

1/21/2016

Happy 2016 Everyone!

I haven't posted for a while. Recently, I completed my service at U.C. Riverside and became a University of California Emeritus Professor; I am now focusing on speaking and consulting, and moved my home and business to the San Francisco Bay area. Changing my environment and routines offered me all the ingredients I needed to develop "a habit of not doing" (see April 2015), and I let my blog fall completely out of my daily equation; my discipline for diet and exercise took a hit as well. But I'm back, with hopes for a fresh start in a New Year.

I've been thinking more about behavior change these days, trying to figure out how we can all do things we want to do --indeed, intend to do -- but never seem to get around to: drinking enough water, taking yoga classes, meditating, eating mindfully, exercising regularly. I have finally decided that I might benefit from a "smart phone app" which I can use to keep track of all that I eat and its nutritional count, and everything I do for exercise, including specific exercises. Since the basis of cognitive behavior modification (CBT: a very powerful behavior change modality, see December 2014) includes a component of detailed self-monitoring, I decided to try it.

Many of us have New Year's resolutions; the most common are to lose weight and get in shape. Weight loss requires a change in eating behavior; getting into shape requires the initiation and maintenance of movement patterns. Our daily lives are composed of a series of behavioral patterns, each of which can become a habit (for good or bad) if it is cued, then occurs, and then is reinforced-- over and over again.

I have always been very skeptical of smart phone fitness apps, and related methods for detailed self-monitoring (aka, keeping track of everything I do). In the past, I have used charts with check marks for medication reminders or for physical therapy exercises, but the detail available with electronic methods seemed excessive. Further, I was convinced that if I wanted to change, all I had to do was make the decision --and do it. Compulsively entering into some list every morsel of food and every action taken seemed like an unnecessary distraction. But curiously, I have come to see great value in keeping track of what I am doing whether I use a notebook, a smart phone app, or a list on the refrigerator. As research shows, monitoring our behavior can help to change it simply through the process of self-awareness. The form or level of detail doesn't matter, just as long as the recording is consistent.

I recently joined the millions who rely on a smart phone app to track their health behaviors. The app I chose is a simple one, and it appears on my smart phone's home screen, so I can't ignore it. When I want to eat crunchy corn chips, and I am committed to being honest with my app, I count out a serving for myself and record the number of calories--feeling both virtuous (for controlling myself) and slightly deprived (because I used to love unconsciously eating chips right out of the bag). After some time, I am told, paying attention to what I am eating (i.e., mindful eating) will become a habit; after three weeks, it has just started to become one.

The same is true for exercise. I do some exercise every day partly because I need to enter something in my app. I might not feel much like jogging or swimming laps, but I feel a sense of accomplishment entering my exercise intensity and minutes into the app. On some days, my app entry is the reinforcement, and it feels better than the exercise itself. On days when I don't feel like exercising, a 'habit of not doing' could start--but it doesn't because my app holds me accountable.

Do fitness apps work? Can they help people who want to change their behavior actually change it? The answer to the latter question is yes! This is because people who want to change have already solved one of the greatest challenges to health behavior management --motivation. Without motivation, there is no app in the world that can get us going. But something beyond motivation is needed and that is where they can help. Fitness apps and all forms of self-monitoring can offer information to us, such as the calorie and fat content of our food choices. They can serve as reminders of what we should be doing. They can help us to be more mindful of our behavior and more accountable for it. They give us an outlet for our desire and motivation to change, and offer us strategies to do so. Some of them even offer explicit reinforcements for good choices; mine congratulated me for choosing almonds for a snack. I liked that.

I used to think apps like this were unnecessary at best, and annoying at worst. But as diet and exercise have become more of a challenge and the apps have gotten better, I am at the sweet spot where the technology I need is the technology I have--right there in my smart phone.

Eggs and Coffee

5/28/2015

This essay is not about breakfast, although breakfast is, I am told by the morning news anchors, the most important meal of the day. Instead of accepting that "there is research evidence" for the importance of breakfast, however, I usually just have a very large cup of coffee. I know there are studies saying that I should eat a balanced breakfast --eggs perhaps -- but there are also studies that say it does not make any difference at all.

Most health research is like that, actually. Collect up studies on the value of most health interventions (whether they involve medications, procedures, or meals) and you will find that some studies show positive effects, some show negative effects, and some show effects that are close to zero. For a long time, I have believed that I cannot trust any one study because most individual health research studies are probably false. That is, their findings do not reveal what, in nature, is true.

This was not originally my idea. Dr. John Ioannidis, Professor of Medicine, Health Research and Policy at Stanford University, and their director of the Meta-Research Innovation Center has published some interesting papers on this topic. They have catchy titles like: "Why Most Published Research Findings Are False" and "How to Make More Published Research True." The problem with research studies is that they are subject to all kinds of limitations and biases; there are many factors that affect whether a given research finding is true. These factors range from the way the study is designed (a researcher can make the most miniscule effect "significant" by using enough subjects) to the degree to which the researcher has a vested interest (financial, professional, etc.) in the results.

When news reporters tell us about the "latest research study," the single study results they report are bound to be wrong. Days later we might even be told about a new finding without mention of what was reported a few days earlier although this is the nature of news. The fact that individual studies often disagree with each other and tend to range widely in their results might not concern news reporters at all, but should be something that consumers of health information take seriously.

A few decades ago, we were told, unequivocally, that eggs were bad for you because they are high in cholesterol. After a few years, however, a number of studies found that eggs are not so bad after all, as long as we don't eat too many of them (how many was unclear). Later studies found that eggs are really good for people. Again, the studies varied. Some studies had many subjects; others had few. Different kinds of eggs were used in the different studies. Some studies examined the effects of egg consumption on cholesterol (the good, the bad, and the total), which may or may not matter, and on heart attacks, which probably do.

When clinical recommendations are made based on the results of the most recent study (or the largest, or the one done by professors from the most elite universities) the pendulum swings (good for you, bad for you, good for you) depending upon the results of a single investigation.

One way to approach the truth is to instead examine the entire collection of studies done on a particular topic. This is a very time-intensive method; it is a major statistical review called meta-analysis. Meta-analyses of egg consumption have found no danger, and perhaps even some benefit, to eating eggs. The same thing has recently happened with coffee. Drinking a lot of coffee was once considered a "vice," but now coffee is considered clearly healthy, and coffee drinking has benefits in a variety of medical conditions. It is associated with a decreased risk for type II diabetes, gallstones, Parkinson's disease, heart disease, and stroke; it even seems to protect the liver. Coffee drinking is associated with decreased mortality from all causes.

For both eggs and coffee, researchers and clinicians have used meta-analysis to examine all the research that has been done to date, and they combine the results statistically. The need for this approach is particularly acute in public health and medicine, which are disciplines that generate too much information to manage easily. And, the consequences of not finding the truth are fairly high. In medicine, over two million articles are published every year! When medical researchers do more than one study (which they should do), the results are bound to differ from one study to the next, making it difficult to summarize a body of research and offer a correct clinical recommendation (like what to have for breakfast). A broader and more objective view of research is available from meta-analysis because the “landscape” (or distribution of results) can be examined in detail. Meta analysis can answer some important questions like these: Are certain findings more likely with certain study characteristics? Are results different for different populations? Do some researchers find positive effects while others do not?

News reporters tend not to distinguish between individual studies and meta-analyses, but consumers of health information should make it a point to understand the differences. Headlines might capture our attention, but as consumers of health information, we need to distinguish between headlines worth listening to and those that are a just lot of noise. Whether a reported finding comes from a meta-analysis study or from an individual study is a good place to start. Meta-analysis results are not perfect, but they do move us closer to the truth.

I just Googled "meta-analysis breakfast" and found that there is not yet a clear direction in the research. Some studies are showing that weight is managed better with a healthy breakfast; others suggest that the calories from breakfast simply raise the total of daily intake. There has not been enough research to effectively meta-analyze. Health research is sometimes like that, of course. When there is not enough evidence to make a decision, and the issue is critical (like which medications are safest or whether a surgery tends to have good outcomes), we hope that meta-analysts like Dr. Ioannidis and his team are working hard at major statistical reviews for the benefit of all of us. If the issue is not so urgent we can decide on our own and hope for the best until meta-analyses tell us otherwise. Our own decisions are probably as good as the advice of any one study. So, tomorrow's breakfast, for me, will likely be a very large coffee --and if I am hungry, probably an egg.

A Habit of Not Doing

4/30/2015

Last Fall, when I decided to write a blog, I didn't really understand what I was doing. I have been a "writer" for decades and I've published books and articles (many of which are uploaded on this website). That amounts to a lot of words, and I thought these many words would give me the confidence that I would need to do this blogging-thing. I found it harder than I expected, though, partly because there is a big difference between writing essays and writing about data results or "reviews of the evidence." Creative work, to me, feels like it is done without a net; essays don't allow me to nail down every corner of everything I write with research citations. It's just me and the blank page.

So, you can imagine how easy it has been to avoid doing what I set my mind to do. I wanted to post one analytic essay a month. But this year, I got to the end of February with no essay, and although I had planned to post twice in March, it's now the end of April. What I have done during this time has been to essentially reinforce myself, nearly every day, to avoid writing something creative for my blog. I developed a habit of not-doing.

I have been doing other things that are far easier for me such as writing more scientific articles and editing students' papers. Also, because I am mid-way through the process of moving 500 miles away, I have had the pleasant distraction of packing. This happens a lot, for all of us, when we try to manage our health habits. We decide one day to not take prescribed medication; we pass up a trip to the gym. We sit down in front of the TV and skip the evening walk (although I have a Schnauzer who usually does not allow this). We "fail to enact our goal behavior" and if we keep doing that it starts to become a habit.

This morning, as I was trying to avoid writing, I turned to a perceptive book by Charles Duhigg called "The Power of Habit." I decided to be my own lab rat and try to understand how I developed my habit of not-doing my blog. In his book, Duhigg summarizes the basic behavioral psychology principles of classical and operant conditioning and, with lots of compelling examples, he offers a simple framework for understanding how habits form and ideas for how to change them. He is careful to point out that some habits are complex and require considerable analysis to understand and change. For me right now, though, and for many of us trying to change our behavior, some elements are pretty straightforward.

My behavioral goal is to sit down and do focused writing for my blog for 30 minutes. (This could just as easily be 30 minutes of meditation, back exercises. or preparing fresh veggies to keep in the fridge so I am less likely to grab a cookie when I'm hungry.) Often, instead, I do something else --something easier. I check email and pack some boxes (... easier than writing, believe me). Duhigg calls this the ROUTINE. As a result, another box of books gets packed and I get to look at a home decorating website link that my daughter sent me by email. This is the REWARD. According to Duhigg, I got this whole process started in the first place because of a CUE, and I need to identify that cue in order to change my pattern. This morning, I did what I often do; I attended to cues unrelated to the target activity of writing for 30 minutes, I looked at a section of the room and imagined packing it up. I allowed my hands (!) to type in my email password. That started the CUE-ROUTINE-REWARD progression, and the rest is history.

If I were developing the habit of NOT taking medication, the process would be similar: see the pill bottle, think "later", and instead turn attention to other things (CUE); do some activity other than take the medication (ROUTINE), derive some benefit from that other activity (REWARD). Note that since we usually choose that "other activity," it is likely to be pretty rewarding to us.

Are there deeper reasons for not taking medication, and for not writing? Sure...People often worry about medicine; they are concerned it might do more harm than good. Or they feel that they are people who "do not take medication." The medication might be expensive, cause distressing side effects, or threaten long-term consequences. So, it's pretty easy to "forget" to take it, and to be "distracted" by other things. Are there deeper reasons for not writing? You bet. (I wish I had a dollar for every essay I have read by a writer who discusses how hard it is to write and why.) Deeper reasons definitely drive our behavior; but conditioned responses and habits do too.

One of my favorite authors, Dani Shapiro, has inspired me yet again to keep trying to write. Her book: "Still Writing: The Perils and Pleasures of a Creative Life" and her blog danishapiro.com are filled with honest, solid advice. Writing requires us to put out something we are thinking, pulled up from within and begging for structure; we need to connect that something to the experiences, emotions, thoughts of our readers. As Shapiro points out, it is often the case that others nod in recognition ("Been there..."), but we don't know that when we are writing. It's just us and the page (or the gym, or the pill bottle). We have to structure our own goals and focus our behavior toward them.

I remember reading a newspaper headline once: "Father loses 103 pounds to Donate Kidney to Young Daughter." A man who once struggled, unsuccessfully, to lose weight was finally able to do so because he had a very good reason. His habit of not-doing got turned around and he steadily changed his diet and exercised regularly until he achieved his goal. Sometimes we get shaken up to change because of our child's needs, or a health scare, or a friend's diagnosis. The old cue-routine-reward gets shaken up too, because the cues, and the routines, and the rewards suddenly look very different.

Most often, however, our lives are simply filled with small habit patterns that persist day after day, just as they are. Unless we do something to shake them up, the days and the weeks and the months pass by, and we strengthen our habits of not-doing, and we look back on lost opportunities to achieve something we have our heart set on achieving.

Autonomy, more or less

1/29/2015

People talk a lot about autonomy in medicine--the patient's freedom to choose how much, and what kind of, medical care he or she will receive. Autonomy is a fundamental principle of medical ethics, and philosophers and legal scholars write about the central premises of choice and informed consent. The recognition of patient autonomy means that the "power of the physician" should not dominate patients' decisions about their treatment, and information should be freely provided to patients. Fully informed patients are free to choose.

Often, though, the right choices are not clear; the information is complicated and can be interpreted differently depending upon one's values and point of view. People often face complicated medical decisions when they grow older and when they face chronic illnesses like diabetes, heart disease, arthritis, and a host of other conditions. In older age, and with chronic illness, things are not "fixable." Chronic conditions are just that --chronic. The unfixable won't ever go away and requires daily management.

Choice can become even more difficult when immediately life-threatening and unfixable conditions like some cancers strike. How aggressive should treatment be? How should one choose from an array of options for treatment? How does one manage the likely tradeoffs between time and quality of life?

"One has to decide whether one's fears or one's hopes are what should matter most." This is one of the many issues to ponder in a superb new book by Atul Gawande: Being Mortal: Medicine and What Matters in the End. Dr. Gawande examines the role of the physician in helping patients to make decisions about their care. He surveys the many medical care choices that often must be made by older and more seriously ill patients, and the critical importance of preserving each individual's right to make their own autonomous choices. "This is what it means to have autonomy--you may not control life's circumstances, but getting to be the author of your life means getting to control what you do with them."

What role should health professionals play in this process of choosing? In the "old days," physicians were taught to follow the authoritarian model, and tell their patients: "Take these medications and this treatment, because I know best." Even now (although usually more subtly) some clinicians urge their patients with cancer or other life-threatening conditions to submit to extraordinary treatments long past the point of usefulness and any hope of offering an acceptable quality of life. "...the only mistake physicians seem to fear is doing too little. " Gawande notes, "Many have no appreciation that equally terrible mistakes are possible in the other direction." A few decades ago, perhaps spurred by a patient-as-consumer movement, physicians responded to patient demands for more information, greater autonomy, and self-direction. Physicians were trained to give patients information-- a lot of it, sometimes unfiltered: You can try Medication A, or B, or C (pick one). And here are the things you could do to manage your diabetes. Testing your blood glucose level is best done four times a day; following a good diet and getting some exercise can be helpful, and here are some pamphlets.

In this informative approach, there is little direction or support. In the management of chronic disease, and in the treatment of very serious conditions, the "informative" approach becomes a bit like sending the patient off to fly a small airplane, mostly on their own: Here's a flying lesson, and the tower will ask you for your location once in a while, and here's a manual on flying ... good luck!

But as Dr. Edward Wagner (developer of the 'Chronic Care Model' who suggested the above analogy) notes, chronic disease requires both biological and behavioral management. His Chronic Care Model (CCM) is an organizing framework for improving chronic illness care--and it consists of several components of healthcare delivery, some of which are system-focused and others of which are implemented at the level of direct patient care. Among those that directly benefit patients: (1) helping people make decisions about their treatment in conjunction with their physicians and the rest of the healthcare team; (2) helping people with self-management of their chronic conditions, including dietary management, exercise, and adherence to medications; and (3) connecting people to community resources that can help provide both practical and emotional support. There is much strong evidence that this approach to chronic disease care works: it keeps people out of the hospital and the emergency department by preventing medical crises and intervening early --when problems are brewing. It improves quality of life, and helps people avoid depression. It saves a lot in medical care costs.

As Dr. Gawande notes, we appreciate doctors who push us to avoid shortsighted choices: to follow a treatment that has a good, and documented, chance of helping; to commit to adhering to our medications, our diets, and our exercise plans. As patients, we all want, and need, better than one-size-fits-all recommendations for choosing and managing our complex care. We need doctors (indeed the whole medical team, including nurses and psychologists) to deliberate with us about our goals for the life we have remaining, and to see our health not simply as an end in itself, but as a stepping-stone to our life goals.

According to Dr. Gawande, sometimes the best medical treatment requires each of us to "contemplate the unfixables in our life." Often, medical care cannot "fix" things. Whether it is chronic disease or a condition that likely will shorten our life, we need a team of health professionals who will communicate with us, coordinate our care, and collaborate to help us live, each day, in the best possible way.

"What Have We Got On That Spacecraft That's Good?"

12/30/2014

Apollo 13 is the 1995 film directed by Ron Howard, which dramatizes the NASA space mission that tried to send three astronauts to land on the moon. The lunar landing was aborted, however, and the mission, commanded by astronaut Jim Lovell, had to focus on returning the astronauts safely to earth. The film is based on Lovell's book "Lost Moon: The Perilous Voyage of Apollo 13," and it is one of my favorites, mostly because the story involves persisting despite really bad odds. Among the many inspiring scenes in the film, one involves Gene Krantz, then NASA flight director of the Apollo 13 mission (played by actor Ed Harris). Krantz is overseeing a team that is highly stressed as they tally up the many system failures on the Apollo 13 spacecraft. It is becoming very clear that the astronauts are in deep danger.

"Can we review our status here, Sy," says Krantz, "let's look at these things from a... from a standpoint of status. What have we got on that spacecraft that's good?"

I just finished reading a really interesting book called Watch Your Back by Dr. Richard Deyo. It's an impeccably referenced and highly readable book, for both patients and health professionals, about the problem of chronic low back pain and the many ways that people try to treat it. One of the most salient points that Dr. Deyo makes is that few people make it through life without ever having back pain; it is one of the most common complaints brought up in primary care medical visits. Among US adults, 60-80% have back pain at least sometimes, and many have it often, with accompanying limitations. As do many academics, I "dance" with back pain a lot, so I very much appreciate Dr. Deyo's review of the evidence. He supports something that has always been a solution for me: to learn the right physical therapy exercises and do them, and to try to modify my cognitions to avoid hopelessness ("What's the point? It's too hard to exercise every day"), impulsive thinking ("I want it fixed now"), and catastrophic thinking ("If it hurts this much today, imagine how bad it will be in the future!"). Exercising and keeping a positive attitude sound cliché, but they actually work. When my attention is riveted on pain, and everything seems to be going wrong, I find that it is wise to pull together a status review: What have I got that is working? What have I got a handle on? What's good?

Dr. Deyo offers a great deal of evidence that exercise and cognitive-behavior therapy (CBT) together are highly effective treatments for chronic low back pain. CBT is a problem-focused and action-oriented psychological approach in which the individual learns to develop and reinforce target behaviors, such as appropriate pacing of activity and rest, that help the pain. In CBT, the individual also learns to control thoughts in order to stay positive and solution-focused. Exercise and CBT together surpass many medical and surgical interventions, hands down, in both their efficacy and their safety. They help people both feel better and function better; they give people with chronic low back pain a sense of control over their lives. Increased self-efficacy --the belief in one's own ability to reach one's goals --helps to avoid the anxiety and depression that can often accompany chronic low back pain and contribute to making it even worse.

Exercise and CBT do require commitment and effort, and while this effort does pay off, it must be maintained for a lifetime. Some people are happy to develop and maintain new habits, such as exercise and CBT, that will serve them lifelong. They understand that chronic low back pain is chronic, just like many other medical conditions such as diabetes, heart disease, COPD, asthma, HIV/AIDS, and even some cancers. By definition, chronic conditions persist over the lifetime; nearly one in two Americans has at least one chronic medical condition, and chronic disease care accounts for over 75% of healthcare spending in the US today. But with chronic low back pain, many people tend to hope for a cure. Data show, however, that surgical interventions and many pain medications can sometimes have poor outcomes and can cause a lot of problems (including increased pain, movement limitations, and pain medicine addiction). Bed rest has been shown, in much research, to be among the worst possible choices. Exercise, on the other hand, does work. It is important to get moving and keep moving in ways that include aerobic exercise, and strengthening, flexibility, and balance-type activities; it is critical to continue to stay positive and engaged in valued life activities.

But Americans don't move nearly enough. We spend up to 60% of our waking time (i.e., nine or more hours/day) sitting or lying still. According to the CDC, only about 20% of US adults 18 and older meet recommended minimum levels of aerobic activity and muscle strengthening guidelines; for middle aged and older adults, that drops to below 15%. For individuals with pain, that percentage is even lower. Mostly, we say we don't have time to exercise, or we don't like or cannot afford a gym, or the weather is too bad, or we are tired, and/or our backs hurt. But Americans watch television 5 hours per day on average, and the older we get, the more TV we watch. We spend several more hours each day on personal email and social media.... all sitting or lying down. In the realm of activity, a status review can focus on what we can do as opposed to what we cannot. We may not be able to join a gym, or run anymore; but walking in the neighborhood, or at the mall, can be great. Stretching and core strengthening exercises can be done while watching TV. Taking the stairs instead of the elevator, and parking farther from the building at work, may be possible most days. We have heard it all before, of course; moving is essential.

And sometimes, even after we have evidence that some activity makes us feel better, and stronger, and happier, we stop doing it. Studies even show that among the many patients who stop caring for their chronic conditions, 25% do so because they "feel better". The fact is, it's hard to continue to manage chronic conditions for the rest of one's life --taking medication, exercising every day, changing one's diet. We stop because we hope we are cured, a word that does not even belong in the vocabulary of chronic disease.

Every day, we need to assess what we can do to actively take control of our chronic conditions. We need to figure out what works and keep on dancing with our limitations, whatever they may be. Perfect health might not be achievable, but we may be able to live our lives doing things that we value. We might not be pain-free, but if we are honest with ourselves, we often find that we can do a lot of what we enjoy and also care for ourselves. In the realm of health, we can ask ourselves (and perhaps our health professionals can help us to ask): What do I have that works? What activities can I engage in to the fullest extent possible? What goals, that challenge and push me, are within reason? Will I commit myself to be actively involved in exercise and managing my thoughts pretty much every day, for the rest of my life? A status review of what is working can help us commit our thoughts and our activities to living our lives as fully as we can, and figuring out what we can accomplish. Often, it's a lot.

“All or Nothing” Invariably Leads to Nothing

11/12/2014

I woke up this morning, as I do most mornings, with thoughts about achieving my goals…I need to write. And stretch, and do some yoga. And meditate, and work out. And most of all, write.
So, I write a little, but it’s not good enough, of course. So, I skip over to yoga and meditation, where my monkey-mind does a full gymnastics routine. I meditate for less than five minutes before I get lost in thoughts about an upcoming lecture, and about the writing I’m supposed to be doing. I go back to the computer and check my email. I am, again, failing. I always tell my students to just get to it: meditate, or write, or exercise, or whatever. Just take the first steps, and keep stepping. But I encourage and forgive myself much less. I must meditate for a long time with complete serenity, stretch and strengthen efficiently, and write really good stuff and a lot of it. That is, all or nothing.

In her book Devotion, Dani Shapiro writes: “This was the way it had always been for me: all or nothing, I realized, invariably led to nothing.” I’ve been re-reading two nonfiction books by Shapiro, who is one of my favorite novelists; her kind heart and wise counsel continue to reach out and inspire me. One of her nonfiction books is Devotion, in which she shares a great deal of wisdom about acceptance, and living in the present, and spiritual practice. The other book is Still Writing: the Perils and Pleasures of a Creative Life, and her counsel is the same as that of another of my favorite novelists, Ann Patchett, who advises in her essays on the process of writing. You need to sit yourself down in the chair and write, every day. Develop and nurture the habit. Invariably you will disappoint yourself because what you end up with won’t be perfect, and you will probably experience some feelings more acutely than you would like to, but accept that and keep writing.

Did I mention that one of the things I’m writing about is developing and maintaining habits? Health habits to be exact, but a habit is a habit. So I’m reading books about how to stick to the habit of writing so that I can write about developing and sticking to health habits. This reminds me that once when my daughter was in junior high school, she saw me reading a book about how to overcome procrastination. She pointed out the obvious in a way that only a junior high school student can --that this was an ingenious way to procrastinate.

But when I learn from Shapiro and Patchett about the habit of writing, I also learn more than I ever have about changing oneself, with all the depth that implies. I am trying to learn to focus, to write more about what I love and am passionate about (health and healthcare), and in the process learn to just “be” -- to calm down, accept, strive with joy, get stronger, create something of value, become more flexible, and stop scanning for stuff to worry about. My own struggle to do all of it right, and right away, offers me ample opportunity to generate some empathy for anyone who has tried to develop and maintain a habit.

Medical patients, for example, are told by their physicians to lose weight, exercise regularly, never go in the sun without sunscreen, and manage their stress. And this is for the basically healthy ones. People who have diabetes are also supposed to test their blood sugar levels (finger pricks for blood, anyone?) four times a day, measure out and self-inject various types of insulin in doses that can change depending upon eating and exercise. Patients who also have high blood pressure and heart disease (commonly co-occurring conditions) must also remember to take several different medications per day. [Take Drug A three times a day with food, Drug B twice a day on an empty stomach, Drug C once a day but not with the others….] Oh, and give up most sweets and starches, walk 30 minutes most days (before or after work?), and even on terrible-traffic-jam days, don’t forget to meditate!

People feel overwhelmed striving to get it “just right” and they just give up. Six months after diagnosis, more than 50% of patients with serious chronic diseases have given up trying and become “nonadherent.” Nonadherence to high blood pressure medicine leads to 89 thousand premature deaths a year in the United States. Nonadherence costs the U.S. healthcare system more than 300 billion dollars annually in preventable hospitalizations and emergency room visits, poor outcomes, and avoidable complications. Diabetics lose limbs and their eyesight. Roughly 600 thousand people die of heart disease in the United States every year; rough calculations suggest that perhaps 300 thousand of them die sooner than they might have if health behavior change were not so daunting. All or nothing, invariably leads to nothing.

There’s a wonderful classic book on habits by Karen Pryor; the catchy title is Don’t Shoot the Dog. In it, she describes in great detail the essential elements of training and maintaining behavior; the principles apply to a dolphin, the family dog, one’s spouse or children, and even oneself. A complex behavior is built upon the acquisition of individual smaller behaviors, each of which is reinforced. Meditate for five minutes, give yourself an “atta girl,” then work towards ten. Show up at the gym or walk around the block, put a gold star in your exercise diary, and the next day try for a 15 minute workout or a walk around two blocks. Test blood sugar levels once a day, feel good about accomplishing that, then try for twice and then for more. Reinforcement doesn’t have to be a big reward; a kind nod to oneself every day for moving in the right direction can work wonders. Something, reinforced, can lead, incrementally, to something more.

“It’s not what I want, but it’s what I’ve got”

10/15/2014

My favorite Buddhist writer and teacher, Sylvia Boorstein, offers a thought on the way to acceptance: “It’s not what I want, but it’s what I’ve got.” I’ve been thinking about the role of acceptance in the management of chronic disease, and how it can be so difficult for many patients to make the necessary changes in their behavior in order to avoid some bad consequences. Change is not easy, and it’s not what they want. After all, who really wants to spend energy, time, and attention changing health behavior to solve a problem you never asked for in the first place? It’s one thing to decide to get into shape, lose weight, and look better. It’s another thing to be told you had better give up your favorite foods, exercise when your body hurts, and take a medicine that sends you constantly in search of a restroom. The diagnosis of a chronic disease such as diabetes, hypertension, or CHD (among many others) changes a person’s perspective. This disease condition is not going away; it is here for life.

Years ago, I had a beloved dog who went completely blind. This was, apparently, not unusual for his breed, and he seemed to do quite well. His senses of hearing and smell were keen, and he lost little of his skill at stealing food when no humans were looking. Still, whenever I give a lecture about the challenges that people face in managing chronic conditions, I think of my dog. His blindness triggered, for me, strong feelings of sadness and loss and grieving because he would never again be the same; he would never again see. I understand why the data show that at least 30% of people who are diagnosed with a chronic disease (which by definition, will never be cured) develop depression.

Depression in medical patients is not surprising; many chronic diseases come with a loss of functioning, or a change in appearance, or the need to alter future goals. Daily life might change a lot. Medication needs to be remembered, often many times per day. Dietary habits need to be altered, and familiar, personal comfort foods may need to be avoided. Old habits need to be broken; new habits need to be formed. And life will never again be the same. Health can never be taken for granted, and more losses might follow.

Depression has a serious and detrimental effect on patients’ adherence to their chronic disease treatments. Research using meta-analysis has shown that adherence is diminished by as much as 27 percent when medical patients have untreated depression. Why? Depression fosters pessimism about the future and it interrupts effective thinking and planning, which are essential for setting and achieving health goals. When people are depressed, they tend to withdraw from the very folks –family members, friends—who might help them to follow their treatment regimens.

And yet, few providers even assess whether their chronically ill patients might be depressed. Certainly, if a patient appears to be having poor treatment outcomes, depression might be the culprit, but research suggests that among medical patients who actually are depressed (as assessed with questionnaires), only about 6 percent of their physicians take the time to ask.

Providers, practicing in an already stressed healthcare system, wonder what they can do with the little time they have with their patients. My first response is “pay attention.” If your patient seems sad, he probably is. Ask about what the patient enjoys doing. An unenthusiastic response might be a clue. Providers can make a huge difference in recognizing depression, and ideally they will have a psychologist or other behavioral professional available in their practice and on the medical team. The cost-effectiveness of clinical health psychologists is becoming more evident, and many healthcare teams benefit greatly from their inclusion (more on this topic soon).

But failing that, talk with your patient. The chronic disease is real, and it must be accepted. The sense of loss and grieving in response to a chronic disease diagnosis are real too, and the patient should not have to bear them alone. Understanding this might be the first step in helping the patient toward acceptance and effective chronic disease management.

Press OK

9/27/2014

In my future blog posts, I hope to offer some serious ideas about medical care, based in part upon my 40 years of experience studying healthcare communication and the many factors that influence patient engagement in their health behaviors. I plan to share some thoughts about ways that the medical system might save some of the billions of healthcare dollars wasted annually, and also improve the lives of patients and their health professionals. Getting started is sometimes a challenge for all of us, and in my writing I am no exception.

So I want to start with a brief story that is too good to pass up. It speaks to me about the importance, and sometimes the simplicity, of getting started.

The other day, I struggled to set up my new printer; the incomprehensible instruction booklet didn’t help, and I couldn’t get my computer to recognize the printer. So I called my favorite computer consultant at my university’s tech support help line. He guided me through the many steps of driver installation, all of which I had taken, to no avail, the night before. He had me check that the printer was plugged in and turned on, and that all the connectors were nice and tight. The printer display said “ready” but the printer remained stubbornly hidden from the computer’s view.

“There’s a button that says OK, “ I noted.
“Go ahead and press it,” he said. “It can’t hurt”

Success! My computer shook hands with my printer!

Lessons:

Get started.

Take the next step.

When you see a button that says OK, go ahead and press it.

There are so many ways that healthcare can be improved, and I hope to share some thoughts about them. Some of the necessary steps are extensive and require changing whole systems of care.

But some steps are simple: Listen for two minutes (really listen, without distraction) to a patient’s concerns about having diabetes. Problem-solve with a patient who is confused by having to take six different medications, all with different dosing schedules. Recognize that a patient is depressed and at risk for nonadherence.

These are small steps in patient care; they are opportunities that present themselves every day and can make a huge difference in chronic disease management. Multiplied by millions of medical interactions, they can save billions of dollars in preventable emergency room visits, hospitalizations, and complications. They can prevent a lot of human suffering and a lot of provider frustration.

Some of the steps are simple. Just get started. Press OK.

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