Saturday, January 27, 2007

Health Courts

I recently became aware of a proposal by Common Good to reform the medical practice system with “health courts.” Common Good Chair Philip Howard explains in a recent Wall Street Journal op-ed: “Fear of erratic jury decisions in medical malpractice cases has spawned a culture of fear, causing inefficiencies that infect every level of medicine.” It’s not just the $28 billion in direct malpractice system costs. It’s the billions in defensive medicine and the inefficiency in care when doctors have to document every action to "build a record" in case there's a lawsuit over a bad outcome. We need a reliable medical justice system in which providers don’t need to constantly look over their shoulders and instead do what they think is right. “The only way to overcome this distrust, and all its debilitating errors and waste, is to create a special health court that is trustworthy,” says Howard.

Their proposal is gaining strong momentum.

There’s still many details to be worked out, as well as challenges such as how to evaluate the appropriateness of care delivered in light of the knowledge gap, practice variation problem, and limitations of today’s practice guidelines.

Nevertheless, these folks are on the cutting edge and it’s worthwhile to read what they have to say.

Also, you may be interested in a live webcast on November 5th in Washington, DC entitled “Health Courts, Administrative Compensation & Patient Safety: Research, Policy & Practice,” which is available at

Motivating people to change

How is one motivated to change one's behaviors … especially if the change requires physical and/or emotional discomfort or inconvenience; if it is expensive or difficult to achieve; if the person has no desire to change or doubts s/he has the ability to do what’s necessary; if there are incentives or other competing forces not to change; etc.? When it comes to one's health, this question is relevant to any preventive measures and plans of care because it affects patient adherence/compliance, engagement, and activation.

Information alone is typically not enough. Sure, people must know how to change and that requires good, understandable, readily available information. They also need ongoing feedback, i.e., information that enables them to know how well they’re doing and what adjustments they can make to promote their progress.

But all the information in the world won’t foster change unless people are motivated to make the changes, which includes having:
  • Confidence in themselves and their healthcare providers/caregivers
  • Resilience to persist when things get tough, frustration, disappointing
  • Positive/adaptive emotions, such as love, joy, satisfaction, peace of mind, etc.
  • Ability to manage negative/maladaptive emotions, such as high levels of anxiety/fear, disgust, sadness/depression, shame, guilt, etc. 
So, when people feel good about changing certain behaviors and feel badly when not making those changes, motivation is maximized and change is most likely to occur.

Well, what has to happen for someone to have (or not to have) such motivating characteristics? I suggest that our beliefs and values about ourselves, others, the world, the future, life-purpose, etc. are the primary triggers of these emotions. These beliefs are affected by our experiences, social surroundings, culture, religions, formal education, economic status, life opportunities, etc. Emotions are also influence by our physical condition and stress, and can be affected by certain medications, what we eat, and environmental factors.

As such, this is a very complex question, whose answer lies in a lifetime of complex mind-body-environment interactions.

It may be that comprehensive biopsychosocial assessments can help us to understand what's affecting a person’s motivation to change and to help us address these influences through some type of focused counseling and personalized social (peer/family) support. Rewards and punishments, may also be useful, as long as the negative underlying psychological/emotional issues are addressed and resolved. And finally, making the change process as simple, safe and affordable as possible would help.

But we have to accept that there's no way to motivate everyone to change, nor does everyone have the physical ability to make certain changes. It may be, for example, that the bodily mechanisms (e.g., metabolism) of some people may make behavioral change (e.g., dieting) largely ineffective even if the person is motivated. Should we expect these people to undergo gastric bypass surgery?

Thursday, January 04, 2007

Alternative therapies – Beyond the myths

A special report in the Jan 2007 Consumer Reports on Health, titled “Alternative therapies – Beyond the myths,” had this to say about such therapies (note that herbs and supplements we not included in this report):
  • Some people are resistant to hypnosis
  • Acupuncture doesn’t hurt
  • Most alternative techniques have very little risk because they rarely cause adverse effects when performed properly
  • Tai chi can help joints damaged by rheumatoid arthritis
  • Unconventional cancer treatment methods, such as mind-body methods, massage therapy, and acupuncture, are generally safe to use in conjunction with standard cancer care treatments
  • Cognitive therapy can help prevent relapse of depression
    Spinal manipulation is no better than acupuncture, yoga, mind-body methods, and message for low-back pain
  • Mind-body therapies are useful for chronic illness and for reducing the pain and recovery time of surgery
  • If a patient’s doctor persistently disparages alternative treatment despite the patient’s efforts to discuss them and despite providing supporting evidence, the patient should consider seeking a different doctor.

See the PBS documentary “The New Medicine” for more about the value of complementary and alternative medicines (CAM).

Being trained as a clinical psychologist specializing in cognitive therapy, and having studied the mind-body connection for many years, I’ve been aware of the value of certain types of CAM therapies. Around 10 years ago, I attempted to promote the idea of “biopsychosocial healthcare” with little success, and I confronted extreme resistance from my mental health colleagues.

Have things changed enough in the past ten years to make CAM and well-care more accepted by mainstream medicine?