September 15, 2014

By Dr. Virender Sodhi, ND, MD(Ayurved) and Dr. Anuprao Mulakaluri, ND

The Hippocratic Oath is taken by all medical students that graduate from Western medical schools as part of their initiation into the profession and as an affirmation of their responsibility to their patients. The original oath was penned by Greek physician, Hippocrates, in the 5th century BC. This ancient covenant is still used because it is the truth. In the modern scientific era, where the logic and practices of the past are questioned and easily dismissed as quack medicine, it is interesting that we depend on this oath to guide our modernized practice of medicine.

An excerpt from the Modern Hippocratic Oath

“I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon's knife or the chemist's drug.

I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being, whose illness may affect the person's family and economic stability. My responsibility includes these related problems, if I am to care adequately for the sick.

I will prevent disease whenever I can, for prevention is preferable to cure.”

—Written in 1964 by Louis Lasagna, Academic Dean of the School of Medicine at Tufts University, and used in many medical schools today.[1]

In this ancient oath, we see the emphasis on the humanity aspect of the relationship between the doctor and patient. This relationship is based on sincere desire for promoting optimal health in the human seeking the doctor’s services. Often, this level of attention to individuality is compromised in favor of efficiency. This type of compromise is a great contributor to the healthcare crisis of our nation. Every year, the U.S. Preventive Services Task Force (USPSTF) comes forward with new guidelines for preventive care. These guidelines are presented as the most efficient ways to practice preventive care in conventional medicine.[2] They are outlined as evidence-based recommendations for screening exams, as well as guidelines for questioning patients regarding their health, daily activity, and functionality. The “evidence-based” nature of these guidelines is used to create a recommendation that is essentially, “one size fits all”. The problem of using these guidelines is that many conventional doctors neither have the time to develop a relationship with patients, nor are they able to investigate the cause of the disease in these individuals.[3] As a result, a doctor’s decision making and practice is based on an impersonal model of care, contrary to the promise of the Hippocratic oath.

Dr. Sandeep Jauhar, author of the book “Doctored” and the creator and director of the Heart Failure Program at Long Island Jewish Medical Center, a teaching hospital, describes the problems as follows:[4]

“There's no question that there's a lot of unnecessary testing in American medicine today and the reasons for it are manifold. Part of it is … a lack of time. You have a patient come into your office and you have eight minutes with them and they have lower back pain and you don't want to miss something because one of the major causes of dissatisfaction among doctors today is malpractice liability; there's that fear.

A lot of doctors are practicing defensive medicine. There have been various estimates that defensive medicine costs up to $100 billion a year out of the roughly $3 trillion we spend on health care, so it's a huge, huge waste. … It takes time to evaluate the patient, get a good history, examine the patient, and it's just so much easier to order a test— especially when the financial incentives of the system are to reward for more and more testing.”

Two studies looked at the quality of healthcare visits for patients with depression in U.S. and U.K.[5,6] In the UK, the average time of doctor visit is about 5-8 minutes.[5] Patients with depression, who need longer interview time and counseling, were seen for relatively longer periods. Constraints in visit times caused anxiety among patients about expressing their needs and their suffering adequately so the doctor could understand. However, when they received longer visits of 20-30 minutes, satisfaction among these patients was greatly improved. The data from the US study found that average visit time was about 22 minutes. Patient satisfaction was correlated with length of visit time with the doctor, as much as quality of care provided.[6] Study also found that the average doctor was seeing up to 12 or more patients in one half-day shift. Additionally, the average doctor was doing 9 half-day shifts each week. This adds up to an average of 108 patients each week. Do you wonder why medical doctors can be impersonal and are burning out?

While time is an important data point to measure, what happens in that time is the key for better health care. Studies have found that time is a necessary pre-condition for promoting a strong doctor-patient relationship.[6] This relationship is instrumental for “enhancing patient satisfaction, improving adherence to treatment regimens, and fostering better health outcomes.” Good medicine is not just about accurate diagnosis and giving good medical advice; it is also making sure that patient can receive the advice, understand it, and apply it for their benefit.

Yet another problem with our healthcare system is the over-specialization of care. Each specialist tends to look at the area of their expertise, often losing sight of the whole person. Dr. Jauhar explains his view on the problem:[4]

“One patient who came in with shortness of breath — his primary care physician called 15 specialists onto the case. … He underwent 12 procedures in the hospital, and when he was sent home he had follow-up visits with seven different specialists. … We actually never figured it out. This is so common. …”

When you have a symptom like shortness of breath that has multiple inputs from different organ systems, probably the best doctor to diagnose that and treat that is a good general family physician. But, when you call in these various specialists, they are apt to view the problem through their own organ expertise. And they make recommendations based on their own expertise and these recommendations are frequently not coordinated and so you get a whole host of recommendations and suggestions for care.”

Modern medicine is an extremely broad field of work. Having specialists makes sense because not everyone can be an expert in every organ system. However, lack of coordination among these experts causes overlap of treatment, excess use of diagnostic procedures, as well as over-prescription of medications. Patients are often left to deal with conflicting and confusing explanations of their treatment plan and health status. Confusion about their health status and lack of understanding their treatment plan leads to patient disengagement. Patient disinterest is the greatest failure of modern healthcare. Recognizing these failures of the healthcare system, solution-oriented practitioners are turning toward patient-centered care. The solution is coordination of care by a primary-care provider or general practitioner.

Primary care and primary prevention:

At our clinic, primary care and prevention are the main focus of practice. We recognize that this is only achievable through holistic approach to diagnosis, coordination of care with specialists, and an egalitarian doctor-patient relationship. This model of practice has greatly contributed to the success and popularity of services provided at the clinic.

One of the main foundations of effective preventive care is regular contact with patients. When one is healthy, the thought of visiting their doctor is the least of their concerns. No one wants to visit the doctor unless they are sick. However, prevention is more difficult to practice after the illness has already taken hold. Effective preventive care is only attainable when patients voluntarily come in for a regular annual examination.

The annual exam is a key component of healthcare because it gives the doctor an opportunity to take a broader look at all factors of health, without the distractions of acute or chronic problems. Annual examination encompasses the following components:

  1. Gathering of complete interval history and all relevant family history.
    1. Discussion of the patient’s health concerns, symptoms, discomforts, challenges, etc.
    2. It involves questioning the patient regarding various components of their health.
      1. Assessment of the physical, mental, emotional, and spiritual components of health.
      2. Past medical history, Social history, family history, etc.
  2. Complete physical examination
    1. Includes examination of all organ systems and the nervous system.
    2. Psychological screening for age-related decline or behavior and mood disorders.
    3. Assessment of the physical, mental, and emotional state of the patient.
  3. Review of comprehensive laboratory examination
    1. Review of essential lab results that pertain to the patient’s health history or concerns.
  4. Recommendations of risk-related screening exams
    1. Special lab reports are obtained to assess for risk of cardiovascular disease, diabetes, inflammatory disease, hormone imbalances, etc.
    2. Special exams are also done to assess male and female sexual health.
  5. Recommendations for age-related screening exams
    1. USPSTF provides guidelines for various age-related screening exams – to assess risk of cancer, chronic disease, neurological disease, etc.
    2. Recommendations can be individualized based on the patient’s needs and history.

Each component of the annual physical examination provides a different perspective of the individual’s health. The true art of medicine is exemplified by the gathering of all this information, synthesizing it, and developing a comprehensive care plan for the patient. For this reason, the annual exam is an essential part of preventive medicine.

Periodical preventive visits have been shown helpful in performing important preventive physical and laboratory exams that may be missed on a regular visit.[7] The research on the benefits of annual physical exams is limited. Many studies are old, but show that regular physicals improved compliance and satisfaction among patients.[7] Authors of a review of all studies on annual exams concluded that these visits are an important preventive tool for clinical practice.

The model of care used at our clinic is a patient-centered model. Research by the Picker Institute has delineated 8 dimensions of patient-centered care, including:[8]

  1. Respect for the patient's values, preferences, and expressed needs
  2. Information and education
  3. Access to care
  4. Emotional support to relieve fear and anxiety
  5. Involvement of family and friends
  6. Continuity and secure transition between health care settings
  7. Physical comfort and
  8. Coordination of care

This model of care serves two very powerful functions.

  • First, it places responsibility on the doctor to engage the patient, educate the patient, coordinate care with other practitioners that are involved in the patient’s health-care team.
  • Second, it empowers the patient with knowledge and autonomy to make their own health-care decisions.

The call for transforming the whole healthcare system in the United States towards a more patient-centered system have been on-going for the past few decades. There have many been research papers published on the subject. Researchers and medical doctors have endorsed proposals for a “2020 vision” for establishing a patient-centered model of care in US.[9,10] Unfortunately, changes on a large-scale happen slowly and the transition progress can be a frustrating.

During this time of transition, clinics like the Ayurvedic and Naturopathic Medical clinic are leading the way in adopting the 8-dimensional model of care described above. Though we are not always perfect, the intention for excellence keeps us on the path of progressive improvement and transformation. Patient-centered model of care is the main reason for our great relationship with our clients, second only to the power and effectiveness of natural medicines that we practice and promote.

Over the 30 year history of our clinic, we have successfully detected numerous cases of pre-diabetes, pre-hypertension, pre-cardiovascular disease, etc. Early detection always provides the opportunity for total prevention. This fact aligns with the guiding principle of natural medicine: Vis Medicatrix Naturae, “The healing power of nature”. This principle teaches us that when we remove the obstacles, the body and mind naturally begin to heal. In my experience, I have noticed that diabetes can be detected 10 years before it happens. At the first sign of this disorder, I begin implementing preventive measures – this has led to many cases of prevention or delayed the disease. Cardiovascular disease can be recognized a long time before it can become a threat to you. The latest lab tests look at special lipid profiles, proteins related to heart function, blood vessel function, etc. to provide a thorough assessment of cardiovascular imbalances before symptoms of disease appear. Here are some example cases from the clinic: A fifty-seven year old female with a pre-diabetic condition came to our clinic 20 years ago, her A1C ( long term blood sugar measure) and microalbumin ( a measurement for kidney function) tests are all normal even twenty years later. She has a strong history of diabetes in her family. Her mother, father and brother all are diabetic.

A fifty-five year old male patient who has strong h/o of heart disease, wants to prevent heart disease. His treadmill test was normal, his cholesterol was slightly elevated. He was put on statin drugs by his cardiologist. His parents were on statin drugs and did not benefit from statin therapy and still had heart attacks and lots of side effects. He refused to use statins. We performed special testing like C-reactive protein, homocysteine, CAT scan of the heart to check the amount of calcium deposits in his blood vessels, and special lipid profile to check the particle size of cholesterol. He has extensive build up in his blood vessels supplying his heart, which is called atherosclerosis. After all the evaluations were done, he was put on special diet, herbs and a cleansing program. In nine months, all of his lab parameters improved. Now, 15 years later, he is a living fuller and healthier life.

Similarly, we are following many patients with cancer and some of them have been in remission for the last 16+ years.

Despite great advances in high-tech tests like mammograms[11], colonoscopies[12], or PSA testing[13] we are not cutting down the numbers of various cancers. This is because these procedures are designed to detect cancer after it has occurred – by that time it is already too late for prevention. The latest research on epigenetics shows that cancer is a product of the internal environment of the individual. Healthy diet and lifestyle are the foundation of a healthy internal environment. Therefore, we have an opportunity to prevent cancer and other deadly diseases if we catch the unhealthy patterns early. We encourage everyone to see their doctor at least annually for a thorough examination. Prevention is the best medicine and you can live disease-free by following natural and Ayurvedic lifestyle modifications.

References

  • [1] Tyson P. The Hippocratic Oath Today. PBS: NOVA, March, 27, 2001; online article
  • [2] U.S. Preventive Services Task Force: USPSTF A-Z Topic Guide; http://www.uspreventiveservicestaskforce.org/uspstopics.htm
  • [3] Braddock C and Snyder Lois. The Doctor Will See You Shortly The Ethical Significance of Time for the Patient-Physician Relationship. Journal of General Internal Medicine, Nov. 2005; Volume 20, Issue 11, pages 1057–1062.
  • [4] Jauhar S and Gross T. Cardiologist Speaks From The Heart About America's Medical System. National Public Radio, Aug, 2014; Online article
  • [5] Pollock K and Grimes J. Patients’ perceptions of entitlement to time in general practice consultations for depression: qualitative study. bmj.com 2002; Vol. 325, Pg. 687.
  • [6] Geraghty EM, et al. Primary Care Visit Length, Quality, and Satisfaction for Standardized Patients with Depression. J Gen Intern Med, 2007; Vol. 22(12), Pg. 1641–7.
  • [7] Boulware E, et al. Value of the Periodic Health Evaluation. Agency for Healthcare Research and Quality — Evidence Report/Technology Assessment, April 2006; number 136.
  • [8] Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL. Through the Patient's Eyes: Understanding and Promoting Patient-Centered Care. San Francisco, Calif: Jossey-Bass; 1993.
  • [9] Davis K, et al. A 2020 Vision of Patient-Centered Primary Care. Journal of General Internal Medicine, Oct. 2005; Vol. 20(10), pages 953–957.
  • [10] Davis K, Schoen C, Schoenbaum SC. A 2020 vision of American health care. Arch Intern Med. 2000; Vol. 160, Pg. 3357–62.
  • [11] Anderson WS, et al. Assessing the impact of screening mammography: breast cancer incidence and mortality rates in Connecticut (1943–2002). Breast Cancer Research and Treatment October 2006; Vol 99(3), pp 333-340.
  • [12] Thiis-Evensen E, et al. Population-Based Surveillance by Colonoscopy: Effect on the Incidence of Colorectal Cancer: Telemark Polyp Study I. Scandinavian Journal of Gastroenterology, 1999; Vol. 34, No. 4 , Pages 414-420
  • [13] Etzioni R, et al. Overdiagnosis Due to Prostate-Specific Antigen Screening: Lessons From U.S. Prostate Cancer Incidence Trends. J Natl Cancer Inst (2002); Vol. 94 (13), Pg. 981-990.
  • [14] Bissell MJ and Hines WC. “Why don't we get more cancer? A proposed role of the microenvironment in restraining cancer progression.” Nature Medicine, 2011; Vol. 17, Pg. 320–329.
  • [15] Hu M and Polyak K. Microenvironment regulation of cancer development. Curr Opin Genet Dev. 2008 Feb;Vol. 18(1), Pg. 27-34.