Dr. Phillip M. Stephens

The traditional models of medicine are changing.  One patient, one problem, one at a time was always the norm.  But it was also the norm that your family clinician took care of every bump and bruise.  It was a time when you could depend on the same family clinician to be there when you were young with a sore throat or older with arthritis.

Today we have conflicted paradigms.  The norm of "one patient, one problem, one at a time", has more value when there is consistent care from the same clinician who knows each patient, each problem and will see you every time.  But today care is changing.  In many ways the change was inevitable and the trend is both good and bad.

Rarely is your family clinician the same medical professional that admits you to the hospital.  Someone else will take care of you in the hospital these days then turn you back over to your family clinician upon discharge.  That family clinician may also change over time or even visit to visit.  You will see new clinicians as practices grow or community hospitals become large academic centers.  You will see new clinicians in communities unable to retain consistent medical professionals or as training centers rotate new trainees in and out of a region.  It is simply the sign of the times. 

While the one patient, one problem, one at a time model is evolving on its own, the sick model should evolve as well.  We simply don't know how to evolve it at the same speed.  The reason it is important for the sick model to evolve is disease and treatments have evolved.

The sick model is treating people when they get sick.  A well model is keeping people well before they get sick.  The reason we need to move from a sick model to a well model is because the diseases that are now prevalent are influenced mostly by prevention.  This requires ongoing care from clinicians with whom the patient can build a relationship over time.  The well model runs counter to our evolving systems.

For hundreds of years diseases like pneumonia, meningitis and diphtheria were leading causes of death.  Antibiotics and vaccines began to mitigate the impact of these diseases.  Today, heart disease, cancer and stroke are heavily influenced by genetics we can't fully control but are best addressed with prevention before they occur in terms of what we can control.  Preventative care is now more effective than reactionary care.

Controlling blood pressure, blood sugar and proper medical screenings for potential disease has the most value today.  That's a well model.  Treating someone before they get sick rather than just waiting until they develop one of these diseases is how to optimize care.  The problem is, we haven't figured out how to reimburse medical professionals for keeping people well.  We only know how to pay them for doing things after someone is sick.  Medicine pays for doing things, not preventing things.  It's simply easier to measure reaction than prevention.  We also are evolving away from the family clinician model who knows the patients' needs best.  Everyone is now a specialist.

There is value in a population health model that finds ways to address broad health disparities in a community.  It is natural that the one patient, one problem, one at a time approach is evolving as disease has evolved.  We now find populations sharing common health risks.  The approach has become many patients, complex problems and many focused specialties designed to address emerging disease.  But something seems lost in this evolution.

  Many patients feel medical care has become too impersonal. We need to find ways to get the best of both worlds within these models.  Finding ways to deliver preventative care to a population while maintaining personal attention to individual needs is a challenge.  But it is the real model that best serves individual patient needs.

Finding a healthcare home helps.  We need a lot of sub-specialists who can provide advanced care for specific problems.  But the need for a consistent clinician who knows the patient and understands individual long-term needs is vital to ongoing care. 

The evolution of big box healthcare isn't going away.  Large corporations consuming community hospitals and smaller practices is inevitable. So, while funding healthcare is always a challenge, maintaining individual relationships and personalized medicine will be a growing challenge as well.
 
Phillip Stephens, DHSc, PA-C is affiliated with Carolina Acute Care & Wellness Center, P.A.  

www.CarolinaAcuteCare.com
 

Announcement - Wolters Kluwer has announced that our Emegency Medicine reference text, "Emergency Medicine: The Inside Edge," has been selected for translation into Spanish.

 

Wolters Kluwer is the largest medical textbook publisher in the world & only translates less than 10% of their titles.

 

We are humbled at the success of this medical reference.

Losing weight is probably the number one New Year's resolution.  Unfortunately, one size does not fit all when it comes to losing weight.  Many experts blame diet.  Others blame lack of exercise.  But the research reveals the issue is a bit more complex. 

The medical definition of obesity now applies when describing the "average" American.  But despite over half the population experiencing some level of overweight issues according to the National Institutes of Health, few clinicians are willing to tackle the challenge.  Clinicians tend to offer simplistic solutions to a problem where solutions are varied and often require personalized attention.

You would never tell someone with high blood sugar to just eat less and exercise more.  Instead, you'd determine individual needs to treat the disease. Obesity needs the same focused approach as any other health challenge.  Diet and exercise are still core solutions to losing weight.  But research has shown that it is not always the patient's fault if weight loss solutions fail. There are many options to explore to address the challenge in such failures.

Surgical solutions are at one end of the scale.  These solutions are reserved for serious weight loss challenges that may result in serious health problems if obesity is not reversed.  The downside is patients undergoing surgical solutions still face a lifetime of follow up, diet and nutrient control.

On the other end of the scale are new drugs.  At least half a dozen oral medications designed to combat obesity will soon hit the market. Progress has also been made on injectable drugs this past year.  But none of these injectables are free of side effects.  Risks include certain thyroid cancers, low blood sugar and kidney problems to name a few. Fortunately, the tumors often cited appeared in early rodent studies and the drugs involve naturally occurring hormones so they appear to have a reasonably good safety profile despite the early findings.  The oral equivalents of these new drugs are still being studied.   The upside is considerably positive as the medical community gains experience using these new drugs.  The current barriers are cost and experience with long term outcomes.

In between are various exercise and diet plans.  These plans range from fad diets that come and go to well-studied diets that have strong track records.  There are also medically monitored diets where patients are followed under the care of a clinician.  Lab work is followed as caloric intake is adjusted and nutrients are supplemented.  The application of diet is just as varied as the diets that are available.

Patients who attempt these diet and exercise plans on their own have varying degrees of success.  It is individual dependent.  Medically monitored plans have a higher success rate and should have the goal of not only losing weight but to manage the patient's overall health during the process.  Self-administered diets have lower success rates but are certainly more convenient.

Medically monitored weight loss programs also have many options even within this solution ranging from low calorie diets to very low calorie diets.  The cost of medically supervised programs is generally offset by meal replacements being provided by the medically supervised program.  So, the cost in the end is generally no more than the cost of food the patient would have paid anyway for each week with diagnostic testing included as well.

Biologists are beginning to understand that weight loss success is more than simply diet and exercise.  Genetics and metabolism play a huge role.  Co-morbidities must also be considered when designing a plan.  There has even been research into genetic markers that predict the success of weight loss programs within given individuals. 

The bottom line is that there is no such thing as the perfect diet or the perfect plan.  It is also wrong to simply blame the patient for failures to lose weight.  It not only is counter-productive but is scientifically unsound to dismiss failures without considering a multitude of factors like DNA, metabolism and co-morbid conditions that directly influence diet and exercise modalities.

The science on what to eat is even changing.  Remember when all fatty foods were bad, then some fats were actually good?  At one time the focus was on what we ate.  Then it evolved to how much we ate.  Then went back to what we ate again.  Today we are moving from the idea of needing certain food groups to the evolving focus on certain individual nutrients that are needed instead.

If your diet is socially isolating, you're on the wrong diet.  If you are simply told to eat less and exercise more, you're getting inadequate advice.  If you have co-morbidities, a family history of obesity or struggle with success, you should ensure these factors are included in any plan to lose weight.

One size does not fit all when it comes to weight loss.  Everyone responds differently. While there is no perfect plan, there is a perfect approach.  And that approach is understanding individual biology.
 
Phillip Stephens, DHSc, PA-C is affiliated with Carolina Acute Care & Wellness Center, P.A. – www.CarolinaAcuteCare.com