Thursday, May 26, 2016
The health care system: What's in a name?
The trail that led me to a career in health promotion is relatively more or less selfish, depending on where we begin it.
The rather more selfish version began at age 13. On little more than a whim, I tried out for the junior high school wrestling team, which, not being a co-ed enterprise, failed to enthrall me. I was there long enough, however, to hear from the coach how many sit-ups and push-ups the worthy among us should have been able to do. Let's just say I was unworthy, and by rather a wide margin.
I had never thought much about exercise before then, despite my father's (a cardiologist) obvious devotion to it. But the margin of my unworthiness grated, so while I did not stick with wrestling, I did go home and do as many sit-ups (not many) and push-ups (even fewer) as I could.
The rest, as they say, is history. I became increasingly fanatical about ever more exercise, and it wasn't long before I began thinking about the fuel, too. So began an early devotion to high nutrition standards that influenced first my family, then my career. I have eaten unusually well, and exercised with great devotion, nearly every day for roughly 40 years.
That's 1 trail. The other, ostensibly less selfish version began around age 27, in the middle of my residency in internal medicine. Residency is that period of medical training that is the stuff of legend and notoriety, and rightly so. Things have improved somewhat since, but in my day, it often meant more than 100 hours of work in the hospital each week, some of it coming in continuous stints of up to almost 40 hours.
Much of the focus was, naturally, on something akin to one's own survival, conjoined to a desperate, continuous effort to avoid killing one's patients through omission, commission, or just general ineptitude. Those were the days!
Despite all that, and through a haze of sleep deprivation, I did what I seem naturally inclined to do: I saw the forest through the trees. Roughly 8 out of 10 hospital beds were clearly filled by miserably sick people that never needed to be so sick in the first place, and that our best efforts, in common with the king's horses and men, would never again make truly whole. Hospitals battled the ravages of disease; we were not in the business of making health. That was beyond our mandate, above our pay grade.
But that didn't seem entirely right, even then. Hospitals were, after all, part of what we have long called our “health care” system. I couldn't swat away the irritating idea that somewhere, among all the catheters and cannulae, and between the raucous resuscitations (successful and otherwise), there was something more to do about actual health. I went on, accordingly, to a second residency in preventive medicine, and have done all I can ever since to keep people out of hospital beds in the first place.
The reality, though, is that a lot of people do wind up in hospital beds; I have been there myself. And along with all of those who are there supine, there are the upright in their diverse multitudes: nurses, doctors, and PAs; technicians, dietitians, and therapists; social workers, chefs, and administrators. There are nearly 6,000 hospitals in the United States, employing more than 5 million of the health care sector's total workforce of some 12.2 million. These are sizable chunks of the U.S. workforce, population, and economy and in a sector that is growing.
As the most visible castles on the most prominent hills of what we call, rightly or wrongly, our “health care” system, hospitals are ineluctably caught up in our notions of what both health and care should mean, and do. There is opportunity here, certainly, but also cause for grave concern, especially if the past portends the future.
Historically, hospitals have been conceived, from their very construction to their by-laws, for the accommodation of providers, not patients. Your medical record, home to all manner of intimacy, has belonged to staff — and not to you. The final hours of potential communion with a loved one in the ICU were subordinate to visiting hour rules often little better than arbitrary.
Not that staff were on a picnic, either. The hours are long; the stress is high; the amenities, questionable. The smells are noxious, the sounds mostly dissonant, and the food generally dubious at best.
So it is these fortresses in the disease wars have done far less than they might to propagate health, and maybe even conspired against it for patients and providers alike. But that can change.
One can imagine kinder, gentler hospitals. One can imagine a lobby like that of a hotel, scented with flowers, not formaldehyde. One can imagine the soothing tones of piano, or guitar. One can imagine an ICU designed with a wrap-around, outer corridor providing families private access to a loved-one's bed, while preserving the unobstructed line of sight and clutter-free workspace the nurses need, thus allowing for visitation any time, day or night.
One can imagine the eviction of fast-food franchises, and junk food vending. One can imagine that these repositories of all the devastation tobacco wreaks would establish smoke-free campuses; sponsor smoking prevention programming; and offer state-of-the are smoking cessation programming as a matter of routine. Tobacco belongs entirely in history's ash tray of dreadful ideas, and hospitals might help speed it on its way.
One can imagine a devotion to actual culinary excellence, so that food, too, is medicine for patients and staff alike. Better still, the hospital cafeteria might showcase family-friendly meals of high nutritional standards, and hand out laminated recipe cards along with encouragement to, by all means, try this at home. Perhaps those cafeterias might extend as well to a take-out service, so that weary staff at the end of a long day or night have recourse to something fresh, and wholesome, and nurturing.
One can imagine, in other words, health promoting hospitals, and ideally, as prominences in a cultural landscape of health promotion. In principle, this is nothing but obvious. In practice, though, and historical context, putting hospitals and health promotion in a common sentence flirts with oxymoron.
There are exceptions, and I am privileged to work in one. Griffin Hospital, in Derby, Connecticut, headquarters for Planetree and the patient-centered care movement, demonstrates much of what's possible. Even here, though, more can be done.
The International Network of Health Promoting Hospitals and Health Services is devoted to narrowing the gap between principle and practice, and to converting the luminous examples of possibility into the industry standards that prevail. They are not new to the fray; they convene their 24th annual conference this June on the Yale University campus. I am honored to be a participant.
Though the most visible landmarks in our health care system, hospitals have historically had little to do with the promotion of health. Deeply caring people around the world are collaborating to change that. There is a bounty of years to add to lives, and a bounty of life to add to years, if we can establish health, and not just the treatment of disease, as the priority of a system that bears the name.
David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
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Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.
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Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Suneel Dhand, MD, ACP Member
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