Chat and Challenge vs. Test and Treat

As the Supreme Court begins their debate on PPACA (aka health reform) today, I thought I would challenge us to think about how our healthcare system can be different. The health reform legislation doesn't go far enough to transition our disease-care system into a system which takes care of people's health. We need a self-care system which uses our health and medical professionals to help each person learn how to take the best possible care of their own health.

Our current "disease focused" system is all about treating the ill. When most of us visit our doctors, we do so to share a complaint and seek relief. Pain in the knee. Digestion issues. Trouble sleeping. For many of these issues, the standard operating procedure is to run a few tests and then write a prescription. In 2010, Americans spent over $300 billion on prescription drugs. I call this the "Test and Treat" system and it won't help us get healthy.

I am not blaming the doctors here. In order to cover the costs associated with complying with the rules of the disease-care system, doctors must see as many patients as possible each day. Most doctors did not go into medicine to become a manufacturing plant (see my earlier blog on the factory of medicine), they went into medicine to take care of people. But in our "test and treat" world, the patients want quick relief (without changing their habits) and the doctor needs to get onto the next patient.

There is another way. I call it the "Chat and Challenge" approach to health. As we all know, most of what ails us stems from lifestyle choices. Poor food choices and lack of exercise top the list and this isn't the focus of most of our doctor visits. We need to redesign the system so each person belongs to a wellness community. The wellness community includes personalized coaching, implementable plans for getting more exercise and eating well, classes to fill the gaps in personal health knowledge and medical professional (doctors, nurses, etc.) to take care of medical issues. During a visit, each person engages in a conversation with the members of their wellness team. The wellness team chats with the person and then challenges them to make small, specific, personalized and positive changes in their health (ala Tiny Habits by Dr. BJ Fogg).

Everyone's life is different and people, by and large, want to feel great. Let's have a chat and challenge ourselves, and each other, to imagine a different world.

Wellness for Road Warriors

I've been a road warrior for over 20 years. Some months I'm on the road every week and for some glorious months, I rarely travel. For those who also travel you understand the glamour lasts about 2 days... on your very first trip. After that brief honeymoon period is over you realize how difficult travel can be, particularly on your health. Let's face it - when we travel most of us don't get much exercise, we are forced to eat out and our sleep usually suffers. Since I'm on a mission to save the healthcare system by helping people get healthy, I thought I'd share some of the things I do while traveling to help me stay healthy.

Before Your Trip

1. Packing. I take workout clothes on every trip. I don't use them 100% of the time, but having them along is an excellent start. The invention of the Vibram five finger running shoes has made this so much easier. These little gems are great for shorter runs and barely take up any room in your bag (I never check luggage so space and weight is crucial). If you buy a pair, give your body time to adjust to them. If you're a regular runner, I would start with an easy mile or two run on the treadmill and build up from there. If you're not a runner, hop on the treadmill and walk in them. Start slow and soon you'll wonder what you did without them. 
2. Snacks. My go-to travel snack is unsalted, roasted, organic almonds. Akin to the phone charger for my body, these go into a ziploc bag and go along. Choose the travel snack that works for you but the idea is to choose something nourishing and healthy. Nuts and seeds are a great idea. For early morning flights I also may take a peeled hard-boiled egg in a little plastic container. Avocados travel well, as do apples. Whole, real, natural food is your best choice. While a few health bars are actually healthy, I still like to stick with real food while I have access at home. 

At the Airport

1. Water. I think the water bottling companies are in cahoots with the TSA since you can't carry even sealed bottles of water through security. Water, once through your strip, pat, and scan down, is very important. I drink at least 12 ounces on the way to the airport (and am sure to leave some in my car for the return trip) and I buy at least 20 ounces while at the airport. I also have a Vapur which is stashed in my bag and I'll sometimes fill that up at the water fountain. Do not rely on the airline to give you water. Period. Take some onboard. 
2. Walk. Once through security, I head to my gate (stopping for water along the way). Once at my gate, I confirm all looks well (flight on time, gate hasn't changed, either an airplane there or people who look like they expect one) and then I walk. Sitting and waiting for a plane so you can sit during your flight always seemed a bit silly to me. Use your waiting time for walking and get a little exercise. 

On the Plane

1. Drink water. You carried on board, now drink it. Your goal is to finish your last sip of water when the airplane door opens at arrival. 
2. Skip the Airline Snacks. You have also carried on your go-to snack of choice, so enjoy it. This will help you avoid whatever food-like items the airline is either giving away (not common any longer) or selling from the back of the in-flight magazine. For longer flights, I sometimes pack a little picnic. Yes, I get some strange looks from the people around me but I like to think I'm setting a good example for others by munching on my salad with quinoa. 

In Route

1. Find food. For my longer trips and if I have a rental car, I find a grocery store. iPhone is my friend and I do a quick search for a grocery store on my route from airport to office or hotel. My first choice is Trader Joe's. Once there, I buy non-perishable real food such as fruits and vegetables. If I have access to a refrigerator (or feel like getting ice at my hotel to keep things cool), I may expand my purchases. The idea is to have something for breakfast and snacks to help you avoid making bad choices in other places. Also, buy some water - likely cheaper here than anywhere else you'll be. If you have a water bottle along, buy a gallon jug. Cheap and good for the planet.

At the Hotel

1. Find the gym. Most hotels now have a fitness room. After check-in and on the way to my room, I do a little walk by the hotel gym so I know where it is and I know what kind of equipment they have, how much room, etc. This information helps me better plan my workout. If it is a small gym and I have flexibility in my schedule, I'll go there during off peak hours so I don't have to wait. 
2. Get more water (if you haven't stocked up in route). Yes, the in-room water might be outrageously expensive, but if your choice is nothing or that, spend the $5 and be hydrated. Your body will thank you. Better yet, find a convenience store nearby and buy several bottles and keep them handy. Drink water frequently - even more so than your healthy habits dictate at home. Flying is dehydrating. Hotels are dehydrating. Your body needs extra water while you travel. 
3. Workout. My schedule is different in each city so I have to plan my workouts. Sometimes the night I arrive, sometimes the next morning, if I'm lucky after work. The point being, look at your schedule and make an appointment with yourself to workout. Say you have another conference call if you have to protect the time from well-meaning invitations. Make the time. If you're a member, Cybercise.¹

At the Office

1. Skip the Breakfast. The universal office breakfast is donuts, bagels and other sugar-laden "food-like" items. You've had your fruit, nuts and water. You do not need the sticky bun. Just say no. 
2. Walking Meeting. If you're brave, suggest a walking meeting. This is a great way to have a chat with one to two people. If gets you all outside and you may find the act of exercising your body helps your mind get more creative. 
3. Lunch carefully. Lunch brought to you by the same people who tried to poison you during breakfast. Lunch is typically riskier as many companies have lunch brought in so you can have a working lunch (travesty of justice, I think). Most of these lunches are sandwiches and chips or worse yet, pizza (a big dose of thanks to my long-term clients who know I prefer salads for lunch and are sure to have something there for me). I'm sure your Grandma told you to eat what people make for you, so you may have little choice other than eating whatever is presented to you. Whatever it is, eat half of what you normally would. If you're doing the no-bread thing, split a sandwich with a vegetarian (you get the meat, he gets the bread). Skip the chips. Drink more water. And whatever you do, don't drink the soda. If you have your Vapur with you, find the water cooler. Every office has one. Or make a cup of hot tea. 

After Work

1. One Drink. The compulsory "let's go out and have a drink" post-meeting routine. I happen to enjoy a workout after work, but seldom have the chance. The "leave the office and head to the bar routine" is common so you may have to make the best of it. When I arrive at the bar, I'll order a sparkling water while I "think about what I want to drink." That gets a water in my system and takes some of the have a drink pressure off. When round 2 comes by, I'll usually have a glass of wine. If there are more rounds, I transition back to sparkling water. Sometimes people say something. If you're brave and know the people well tell them you have a one drink rule while traveling. If they'll think you're weird, make something up. As I said at the beginning, traveling isn't always glamourous and sometimes we have to lie to protect our own health. 
2. Sleep. Getting enough sleep is crucial. Particularly if you've traveled time zones. Get to bed early and get up early so you can exercise. The great thing about being in a hotel is there aren't any household chores nagging at you to finish before bed. Take 10 or 15 minutes and stretch or do a little yoga. I usually turn the AC fan on to make a little white noise. Have a drink of water, read something you enjoy, and get a good night of sleep. 

Hopefully, this list will help. I welcome other ideas from my fellow road warriors. And, if you see me on a plane eating a salad, please say hello (but please don't try to talk my ear off during the whole flight - I cherish my quiet airplane time). Remember, every moment you can make a choice that betters your health. Be strong with me - I'm cheering for you. Happy traveling!

¹My traveling life was, in large part, the inspiration for Cybercise. I created the company so I could workout anywhere - even if there wasn't a hotel gym or if I only had 15 minutes to grab a quick workout. Not a commercial - just part of my story!

P.S. I've started a group on LinkedIn called "Wellness for Road Warriors." If you're on LinkedIn, join us, won't you? 

A Dog Day Morning

This is Loki, our 7-year old lab. Most every one of his days starts the same and as I watched him this morning, I became more convinced he is the smart one in the family. I think we can learn many things from the animals in our lives if we only take the time to listen. Recently, I've been on a re-training regime, courtesy of Loki. He's teaching me to trust that he will listen when I call him to return to my side while off-leash walking. While conventional wisdom might say he is being trained since we are now living in the city and he no longer has his giant fenced in yard, I'm wise enough to say it is really me that needed the retraining. He is a patient teacher and reminds me to stay present when we're out walking together. If I pay attention to what is going on around us during our walk (and ignore what every silly thoughts are running through my head), he listens perfectly. When I get lost replaying previous conversations, rehearsing new ones or am plotting and mulling the to-do list, he is more likely to wander away. Lost in my head and a lost dog? Irony or truth?

As for the mornings, I think Loki sets a great example for exactly what humans should do to start the day. This is what Loki recommends:

1. Don't get up until you're ready. Granted, Loki doesn't have a job he must rush off to, but I've noticed if his humans are forced to get up early he keeps sleeping. He might rouse himself enough to leave the dog bed for the warm spot in the human bed but he'll quite happily snooze along until asked to get up, or until the time seems right. 
2. Stretch. Yawn. Repeat. Loki's first order of business when finally rising is to do a lovely looking downward dog. Then he gives a big yawn, as if to greet the day. Then he does another downward dog stretch, butt high in the air. 
3. Drink. Next a few slurps of water. He quenches any nightly thirst by enjoying his morning water. 
4. Shake. Yes, I've tried and I think it is impossible for humans to shake like dogs. You know the shake I'm talking about - from the tip of the nose in a wave to the tip of the tail. It looks like a great way to wake the body up, but I can't quite figure out how to do it (advice welcome!).
5. Walk. Next on Loki's agenda is a morning walk. In his previous house with a fenced in yard, he would go out and spend 10 or 15 minutes walking, sniffing and doing his business. In our new city life, it is a family affair. We leash up and head into the park for a morning walk where we all walk and sniff the morning air (he is still the only one doing his business outdoors). The morning walk truly sets the stage for the rest of our day. 
6. Breakfast. After the walk, breakfast is served. A wholesome combination of holistic dog food with a bit of pumpkin mixed in for extra vitamins.

The next step in Loki's day is a morning nap and while us humans might enjoy a morning nap, we really must get on with making the world a better place. Nonetheless, following Loki's six steps for a successful morning will help you start each day more centered, balanced and ready to face the day. If you have any questions, feel free to comment. Loki is almost always at my side so I'll consult him for the answers you seek. 

Factory Life

My better half, son and some friends attended a screening last night at The Creative Alliance in East Baltimore's Highlandtown neighborhood. The screening sponsored by the Johns Hopkins Center for a Livable Future included two films about food and a discussion about sustainable agriculture and Baltimore. The films were thought provoking and provided a good background of the local food economy. Kudos to all who made the event possible.

During the question and answer session a local teacher asked a great question about how to become a farmer today and while doing so related industrial farming to the current state of our school system. He didn't elaborate too much, for reasons which are clear, but the comment stuck with me. His question was are we churning our kids through the school system with little regard for their overall health, wellbeing and growth with our only objective being to spit them out on the other end and send them off to work? If I were to write an SAT question...

ANIMALS : SLAUGHTER :: Students : Graduation

My son received a respectable education in the Howard County school system but the idea of his time there being analogous to an animal in a factory farm struck a chord. At one point in middle school he lamented, "School is sucking the creativity right out of me." At the time, I responded like many parents might and said something akin to, "It doesn't matter. Get good grades so you can get into a good college and get a good job." It is something I look back on now and regret. First of all, I wasn't listening to him and second of all, what if I was wrong? 

If you want to see a great piece about creativity and the school system, see this video created by RSA based on a TED talk by Sir Ken Robinson. Watching it makes me also regret not pulling my son out of school that very day and figuring out something else to save his creativity. Alas. Have we industrialized our schools with the primary objective being graduation rates and forgotten the idea of learning and creating life-long learners? 

I will take the analogy one step further and relate it to my life's work - the healthcare system. In yesterday's WSJ there was an article about how some physician practices are struggling to survive. The managed care era brought with it a huge administrative burden to many doctors' offices. The staff and infrastructure required to comply with each insurance plans' rules and regulations is significant. And while EMRs have promised to make it better, the WSJ article made me wonder... Are we also industrializing the practice of medicine? 

Most doctors I've talked to want their patients to feel great. That is why they became doctors. Instead many of the doctors are lost in a morass of paperwork, rules, pre-authorizations, referrals, formularies, practice management systems and now EMRs. Combined with the glut of television advertisements which "sell" the latest drug to unsuspecting patients, I'm beginning to wonder if our healthcare system is beginning to look like "Doctors : Tests and Drugs"

I, for one, long for a simpler way. Walking through my grandfather's pastures collecting the cows for the evening milking. Building lego towns with my son and watching him draw his fancy future sports car designs while learning in the process. And, taking care of my own health in partnership with my doctor serving as a trusted advisor and resource in tune with holistic well-being, not the computer.

What have we done? 

Farmer to You

Farmer's Market season is about to ramp up across most of the country. Visiting a farmer's market each week is a great way to support your local economy while enjoying fresh, real foods. We're lucky enough to be in Baltimore where there are several farmer's markets each week. The food simply tastes better and we get to know the people who are growing and raising our food. Plus, our weekly market trip becomes a fun event to look forward to each weekend - and over time we have become better in tune with seasonal foods.

While reading "The Prince's Speech: On The Future of Food" I was struck by the many ways industrial farming negatively impacts many things. I understand industrial farming is some people's answer to feeding more and more people, but at what cost?

Each of us can make a difference and begin to ween ourselves off of the industrial farming industry by making a lifestyle change to do more shopping at farmer's markets this year. To help us remember, consider the following:

For a directory of farmer's markets near you, see this directory. Happy eating!

Over the Counter Drugs: Good v. Evil

Yesterday morning @shelleypetersen tweeted an article in the WSJ about the FDA considering to make more drugs available over the counter (OTC) [If you're not following Shelley on Twitter,  you're missing some good stuff - head over and follow her].

After the initial tweet, Shelley and I went back in forth in 140 characters and had a mini-conversation about the impact. I had to leave the tweet-fest for a meeting but wanted to finish the conversation and thought I'd do so here (and break free of the 140-character bind).  There are many stakeholders in such an idea. To take a balanced look at the issue, I'll declare a winner and loser for each perspective. All of this my humble opinion, of course, and I welcome other points of view.

Also, keep in mind, the specific drugs the FDA decides to make available OTC will have significant impact on the outcomes of doing so. While I don't think Oxycontin would ever be on the OTC list it would most certainly result in a vast increase in sales. Winner? Pharma

Other Winners and Losers

1. Most prescription drug plans do not cover OTC medications unless they are deemed medically necessary by a physician (typically via a prescription). By increasing the kinds of drugs available OTC, fewer people would be likely to buy them because they would have to pay out-of-pocket. It may also increase the demand on our already overburdened primary care system as people seek prescriptions for these drugs so they are able to pay a co-pay vs. cash (see likely increase in demand #4). The total benefit dollars paid from prescriptions plans would decrease. Some patients simply wouldn't take the drugs any longer.

Winner: The people who pay for prescription drug plans (Medicare, some Medicaid, employers)
Loser: The consumer (particularly those with less discretionary income) and PCMs

2. The reduction in the total spent in prescription plans could make the overall healthcare system look less expensive (in the short term). The headline might read, "Health Reform Saves Billions in Prescription Drug Benefits." The article is not likely to go on to say how many people aren't taking the medication their doctors think they need. 

Winner: Budget people and the supporters of Health Reform

Loser: The consumer (particularly those without a "medical home" and an established relationship with a physician who they know and trust)

3. The costs of people skipping their medication won't hit the healthcare spend line (at least not enough to be noticeable) for a few years. When people stop taking their high blood pressure medicine because they can no longer afford it (or, possibly, they simply refuse to use their discretionary dollars on something that provides little instant gratification), they won't start dropping dead in the streets. It would take a few years before we'd see the likely increase in strokes and heart attacks. By then, revisionist history will take over and people won't relate A to B. 

Winner: Budget people and supporters of Health Reform

Loser: The consumer

4. When current prescription drugs become available OTC, sometimes, the manufacturer makes a less potent version available that is "safe" for unsupervised use. A patient taking a prescription at 150mg may only be able to get a 75mg OTC. This would have two results: More sales as patients would have to buy more pills and more sales as there would be more product on the market. And, of course the drug manufacturers would have to let Americans know about the health issues (some they don't know they have) while showing photos of people really, really happy because they are taking drug X or Y.

Winner: Pharma
Loser: Everyone who watches television -- can you imagine the volume of commercials? PCMs who will be flooded with patients requesting specific drugs because they have suddenly developed the latest Pharma-invented syndrome.

5. There are several Federal agencies with a role in the health of Americans. A quick overview: USDA deals with meat, dairy, agriculture and the food policy, FDA handles drugs and other foods, DHHS oversees health insurance programs, DoEd teaches our kids about health, DOI handles parks and outdoor space, DOT oversees transportation. The point being we don't have a way to budget for, or even understand, the true costs of health. If the FDA approves an increase in OTC drugs which negatively impact the cost of healthcare programs like Medicare and Medicaid, the FDA doesn't really need to worry about it. The FDA and DHHS don't share a budget, or accountability, for the health of Americans.

Winner: The agency accounting for "saving" money
Loser: The agency accounting for increased costs

6. One of the concepts behind additional OTC drugs is to increase access to the drugs which claim to combat epidemics like diabetes (first of all, one has to believe drugs are the best way to combat lifestyle diseases... I happen to think lifestyle changes are better and cheaper). The "improved access" could be done by kiosk-like devices to help patients self-diagnose to determine if they need a drug. What an opportunity here! I have many questions about the kiosk implementation: Who will write the questions? Will there be drug advertisements on the kiosk or as a commercial spot before the questionnaire? What reading level will written for? Are we going to track outcome (i.e., how many people who go through the kiosk would end up with a drug vs. those who visited their doctor)? Tricky policy and implementation here. And, forgive me, but too many interesting ideas get completely ruined in implementation. What is certain? More drug sales.

Winner: Pharma
Loser: Physicians (whose professional judgement will be replaced by a kiosk). Consumers (who will be even less likely to make lifestyle changes when all they have to do is go to the ADM (automatic drug machine)).

As I wrap this up, I have to admit feeling a bit discouraged. Is our system really as bad as this? I'll leave that up to you and would love your thoughts. In the meantime, I think I'll switch on the television to see what ails me and what magic cure might be available from my pharmacy.