Doctors Should Prescribe Lifestyle Medicine

Okay, there are no medicines to prescribe, just prescribed advice, but for some this may be a bitter pill for some patients to swallow. Healthy lifestyle should be the first advice received, regardless of the illness you are seeing the doctor for. The doctor presently will always take care of the illness first, but seldom looks at any of the underlying causes from a lifestyle side of things.

With obesity on the rise and diabetes going up at an increasing rate, doctors must start changing their priorities. Yes, treat the illness, but also set up treatment for the other causes that my be there – like obesity and obesity-related causes, diabetes, and other potential problems.

Why is there so much resistance on the part of physicians to prescribing lifestyle changes. The reasons are many and vary from one physician to another. Some but all of the following may apply: clinician lack of confidence, skills, and training; inadequate payment; insufficient time during patient visits; and lack of integrated office flow and documentation processes to emphasize healthy behaviors and lifestyle interventions. One of the large barriers is healthcare providers' perceptions of lack of effectiveness of office interventions, biases about patient motivation, lack of awareness of community resources, and resistance to change.

Are doctors going to be required to do lifestyle prescribing? Yes, if, and this is a big if, the current healthcare law remains the law. Doctors will be required to preform effective prevention services as a part of medical practice. The longer the doctors delay making prevention practices, the more difficult it will become to provide for these prevention practices and those that are part of ACOs will either be squeezed out or will need to find other places to practice medicine.

Surprisingly, the Leaders in lifestyle medicine, such as the American College of Preventive Medicine (ACPM) and the American College of Lifestyle Medicine (ACLM), is encouraging this and published a list if 15 core competencies as Lifestyle Medicine Core Competencies which is included in this article.

They recognize that lifestyle medicine begins outside the clinical setting by having healthcare providers lend their expertise and authority in the community by serving as advocates on behalf of health promotion policies. Next the clinicians need to bring lifestyle medicine into the office. To be successful healthcare providers need to lead and perform a full assessment of the patient and order screening and diagnostic testing according to national guidelines. They need to realize the importance of their role in promoting health behavior as first-line prevention and treatment.

Lifestyle medicine is a recently defined field and has the15 core competencies for this practice. This should give healthcare providers a plan to help reverse the chronic disease epidemic in our country. There are three key areas – reframing the clinical practice to prioritize healthy lifestyles for patients, the providers adhering to healthy lifestyles themselves, and leading change in the medical system and in the community to support healthy lifestyles.

This may be a tall order for some healthcare providers, but will be a necessary component under the current healthcare law. Next, how will we as patients adapt? Hopefully it will be in a positive manner and that we will be able to meet the challenge and for those that are physically able, we will succeed.

A Excellent Discussion About Hypoglycemia

Hypoglycemia – this word may put fear in your heart especially if you are a person with type 1 diabetes or are a parent with a child with type 1 diabetes. Rightfully so. Even those of us with type 2 need to be more aware of this than many are. Those of us with type 2 and on insulin need to be as aware as people with type 1.

Then we come to those with type 2 on oral medications and they think they are immune to this serious complication – wrong. It does depend on the medication or combination of medications that you are taking, but if your doctor has not given you any information about having hypoglycemia, take time to look up your medications on WebMD. Please look carefully and read all the information and especially if you are taking more than one oral diabetes medication. Look for effects of one medication when taken with another medication. Since I am on insulin, I have little knowledge here, but I do know that some oral medications can and do cause blood glucose lows – hypoglycemia.

Joslin has posted a blog on August 30, 2011 which is good reading for all types of diabetes. Please read it carefully as it does contain a lot of good information especially about blood glucose awareness training (BGAT) for those of you that may not feel the symptoms of hypoglycemia anymore. Be sure to follow their links to further information.

My blog on BGAT is here.

Insurers Still Skirting Mental Health Parity Law

Hopefully this problem will come to an end. It is disturbing that our medical insurance industry continues to sidestep the law and continues to discriminate against patients with mental illnesses. Some companies will cover some conditions with no problems, but for the majority of mental health illnesses, they will drop the coverage as soon as they can and many drop all coverage after a patient is diagnosed with a mental illness.

I am not saying this is the case, but it may go a long ways to explain why doctors are prescribing antidepressants without a diagnosis. I had not considered this when I wrote my blog here. The Mental Health Parity and Addiction Equity Act passed into law in 2008, but not taking effect until 2010 requires insurance to cover mental health illnesses.

Unfortunately, the guidance from parity regulators has so far not been specific or clear enough, allowing some insurers to hide behind a level of vagueness. Until enforcement of the parity law, and until there is an effective definition of what parity protections there are, it's possible that even under Medicaid insurers are free to delete some of these essential treatment services.

Many in the American Psychiatric Association say that there is too much not spelled out in the law and until the APA and Parity regulators determine a clear definition, some insurance groups will continue to interpret the law to their benefit. Are they right? Yes, as there are legitimate differences of opinion even among the APA and parity regulators that need to be resolved.

Until the federal agencies responsible for regulations of the parity law finalize clear definitions for the scope of services, insurance groups will continue down the path of their choice. At present there is no one that can definitively say that an issue in your health plan is clearly out of compliance, and that another issue may be in compliance. At present there is confusion at all levels.

So at present, the medical insurance companies will continue doing their thing and patients may suffer the consequences. Read the article here. There are some real problems to be resolved.

Types of Patients – Part 2

I have covered patient, passive patient, and proactive patient in the previous blog. Now I will cover empowered patient, e-patient, and patient advocate.

Empowered patients are those patients that have done extensive learning and are more than a little knowledgeable about the disease or illness they have and often about related diseases. They communicate with other patients and constantly add and upgrade the knowledge they have. They sometimes do controlled experiments from the knowledge they have received and do determine what works for them. They communicate with their doctors and often teach their doctors about their disease. Doctors are generally not intimidated (but not always) by these patients because they communicate freely and have much valuable information.

Read this blog by Trisha Torrey about being an empowered patient. Then learn the eight steps you need to know to be an empowered patient. These are necessary for many, because this separates you from other patients. After reading these, many will think they are part of this patient group. This can be very good, but read carefully.

Some will say that empowered patients and e-patients are the same. I disagree because of some differences. Some follow a different set of eight points that need to be learned, and most e-patients are even more diligent in their learning. While all patients can and do participate in online communities about their disease, it is generally the empowered and e-patients that are able to teach more information to other patients. Read this blog for another eight steps that some participatory e-patients use. Yes, both eight step guides can be used by either an empowered or e-patient.

Now to really set the e-patient apart, go to this link and look at the very top of the page. There are three sections - the center is e-patients.net blog which is where you are. The right section is Journal of Participatory Medicine which is probably new to most of us, but is a valuable resource. While most of the participants are not people with diabetes, much can be learned from them. Now investigate the left section - the Society for Participatory Medicine. This is patient participation beyond anything I have considered previously and I keep learning more.

Now that we have looked at the types of patients, yes, each person can be involved in parts of proactive, empowered, and as an e-patient. The similarities are there, but there are also some important differences in what each patient does and accomplishes. Unless you have desires to become a person of the last patient type, be proud of any accomplishment in being a proactive, empowered, or e-patient.

Patient advocates can be patients, but that is not their purpose. They have taken classes and often passed exams to become qualified as a patient advocate. Most, but not all, have received a diploma or certificate showing that they have been trained and have the knowledge to be an advocate. Most doctors and hospitals will recognize them, but a few do not like the fact that they are now between them and the patient. A few will reject patients that have hired a patient advocate. More states are beginning to realize the necessity of setting up standards.

if you are a person that is going to be unable to communicate because of an operation or increased problems because of an illness or disease, a patient advocate is an excellent person to have one your side. Most are knowledgeable about medical costs and billing, legal and hospital assistance and many other services. This can be especially helpful if you live alone and have no close relatives to give any assistance. Read this blog by Trisha Torrey and if interested follow several of the links to other blogs.

If you have followed all the links, I think you will have learned a lot. This can help you decide at what level you wish to participate as a patient, or if you are comfortable where you are. Hopefully, some of you will see the opportunity to expand your horizons as a patient.

Types of Patients – Part 1

In my research for another blog, I came across several terms I think need to be discussed. This is not a definitive list, but I think includes the bulk of patient types.

Patient
Passive patient
Proactive patient
     Above are covered in this blog
Empowered patient
E-patient
Patient advocate
     The last three will be in the next blog

Looks simple enough on the surface, but when compared to each other, I have listed them in order of knowledge and sometimes education. That does not mean necessarily formal schooling as I have seen people without college degrees in each category. Many have more common sense knowledge and life experience knowledge than some medical professionals.

All of us have been patients. Everyone has to have been one at some time in their life, whether as a child or an adult. Another way of viewing patients is covered in my blog here, but I will let you read it later. This blog from May 10, 2011 on patient literacy and who is responsible for improving this shows that many in the medical community are ready for patients to step up. It is a shame that some physicians are taking a pass on what their associations are advocating.

Once you are a patient, then you normally decide what type of patient you want to be. Many people chose to listen and be led by their doctors and office staff and follow these people lock-step. As such they are making themselves passive patients. They seldom ask questions or disagree with what their doctor tells them. They seem to be disinterested in learning more about the disease or illness that brought them to their doctor.  If the doctor prescribes a pill or cure that heals them, that is all they are concerned about. If there is not a pill or cure, then they are at a loss and often seek out herbal medicine or quasi-medicine people promising a cure.

Proactive patients are people that attempt to learn all that they can about an illness or disease they have or are suffering from. They educate themselves by what ever method they can. Some utilize their local library, some get access to a medical library, and today, most use the internet to research and learn. Proactive patients attempt to ask knowledgeable questions of their doctors and other healthcare providers. They want to engage the doctors in their care, but may be ignored. These patients then may seek other doctors because they want knowledge and not being patronized or having fear thrown at them.

If they have doctors that answer questions and that talk with them to help them learn, they will try to expand their knowledge and work with this doctor to get the best care possible. Not that this will always be possible because of unforeseen circumstances, but they at least feel they have had the opportunity and are often more satisfied in the outcomes received. These patients are good people, but often overload their doctors with information that they are looking for help in deciphering some of the information.

Proactive patients often look to the next levels for aid and assistance for information they do not understand and to help sort out the relevant and helpful information. Where do I fit in this listing - I am not sure. I am a very proactive patient and am striving to become a more empowered patient, but I don't think I have fully reached this level yet.

I will continue the discussion of the last 3 patient types in part 2.

Buyers of Herbal Medicines – BEWARE! - P4

Then the final piece of the puzzle is governmental actions that make the picture grim for all concerned. And this is also the most puzzling part of the mistake picture. Government legislation is often passed to correct mistakes, but the agencies do not enforce what they have on the books and ignore some of the powers already granted to them. The FDA, USDA, and several other governmental agencies have neglected to due their due diligence in the area of herbal medicines.

The majority of herbal medicines and supplements are classified under the category of food and unless they advertise that it treats a disease or something that it does not, generally they are left alone until AMA decides they want to rattle cages and get the support of a few members of congress that decide to see if there is anything to actually be concerned about. Sometimes there is, but most of the time there is much posturing and nothing more. That is politics.

Occasionally an manufacturer will add something that is not permitted and not added to the list of ingredients, over add an ingredient and not change the percentage, or will get brave and decide to advertise something they should not and then the FDA steps in and does an investigation and often orders a recall, and assesses a fine. The only time FDA orders an herbal medication banned is when it is doing harm and has damaging health effects.

Most of the time everything works like it should and when this happens, the AMA is sure to step in to stir the pot and attempt to get congress to take some action.

While I do not always agree with the attempts by the AMA to shut the herbal manufacturers down and put them out of business, this is part of the checks and balances that have become part of our regulatory system. It just needs to be recognized for what it is.

Another mistake made by government is not testing random samples. The FDA does have this authority, but seldom uses it unless there is evidence of prohibited substances in a product.

Another area which may or may not be a mistake has to do with studies that could be done to determine when and if herbal supplements or medicines have any value for the average consumer and to what limit and at what dosage for different health problems. This could settle many arguments and be helpful to consumers.

Buyers of Herbal Medicines – BEWARE! - P3

This blog is about the errors committed by manufacturers of herbal medicines. Unless the manufacturers make major mistakes and get caught in the government web, you seldom hear about their mistakes. Getting caught by the government is often for serious mistakes and making advertising claims that brings them under scrutiny. Or they committed an error that has the American Medical Association up in arms. Some of these mistakes are unintentional and not serious, but the AMA feels it is in their best interest to put them on the hot seat.

Manufacturers make all kinds of stupid mistakes and some could be sabotage caused, greed, or putting ingredients into a supplement and not on the label. The last cause is their most common mistake and often the most serious. They want to have something that will do what it is not supposed to do and generally they get caught.

Herbal manufacturers are a different breed of manufacturers that often are looking for the one item that will make them have something that no one else has thought of and make them rich.

The one mistake that I believe all herbal medicine manufacturers make is not doing due diligence in guaranteeing the consistent formula manufacturing, guaranteeing consistent quality of product, and meeting some of the manufacturing standards they proclaim to follow.

They are constantly under attack by the AMA and a few other groups for the wrong reasons, but they have not consistently raised their manufacturing standards to follow a guide set forth by the Federal Drug Administration called the “Good Manufacturing Practices” standard. Even though many of the herbal manufacturing associations claim they are, consistently it is found that there are rogue manufacturers that violate these standards.

In this article by Jon Barron, he does make some valid points, but you need to get past a lot of rhetoric and almost hysteria to understand what he is saying. His mantra against the AMA is well based and valid, but he needs to leave the rhetoric out to be more convincing.

In the final blog in this series, I will look at the mistakes on the government side.

Buyers of Herbal Medicines – BEWARE! - P2

In this blog I will pull together some of the errors made by doctors in dealing with herbal medicines. Be aware that the American Medical Association has a public position against herbal medications and supplements and most doctors do follow this position.

This section is not meant as a diatribe against doctors, but to just list some of the reactions I have seen and had people tell me about how their doctors have reacted to their list of herbal medications or supplements. Doctors are aware of herbal medicines and supplements. It is their actions that determine how successful they are in dealing with these.

The first reaction I saw was total disinterest and a comment that I should not be taking any of them. When he got to vitamin D, I was told that I got enough of that from the sun and enriched foods. I was not aware that he had requested a test for this and when he showed me that the reading was 25 and more than enough to stop taking vitamin D, I almost believed him. I was fortunate to have been reading several medical blogs that felt that a reading of 25 was the lowest anyone should have and if they are that low they should be taking vitamin D supplements.

Another doctor just pooh-poohed the necessity of herbal supplements, or minerals and said that if I was eating the right foods they were totally unnecessary. In fact he basically warned me to stop. This reinforces what other people have told me about reactions their doctors have had to herbal medicines and supplements.

This comprises the largest mistake by doctors – totally ignoring or advocating against taking them at all. Most people do take some and many people take a lot of herbal supplements. Doctors need to recognize this if they want cooperation in the future from patients, they should just make note of these and if necessary ask about others that are not listed. Their reactions to patients taking herbal supplements will determine future problems that the patients may face. The patient may need to take precautions since the doctor is not willing consider or discuss anything herbal or berates the patient for using them. In these circumstances, I would suggest locating a different doctor.

One comment I have had from others points out a second mistake by doctors. This is just writing a prescription without reviewing the list or asking the patient if they were taking any of the herbal medicines that would react unfavorably with the prescription. In this case the patient had an excellent pharmacist that did ask and advised the patient correctly to stop taking the herbal supplement while on the prescription and explained what could happen if the patient did not stop.

Another mistake a friend had the doctor make was prescribing a supplement that was about 15 times more expensive than could be purchased over the counter in most stores and pharmacies. Again a pharmacist saved the day. These types of mistakes are commonly made by doctors that do not recognize herbal supplements and medicines.

My next blog will cover mistakes of manufacturers.