An apple a day keeps the doctor away, or so the saying goes. One day, that preventative mentality may become the norm--if physicians at the Medical Center have anything to do with it.
Over the next three to four years, several researchers will begin the Duke University Health System's push toward preventative medicine through a study aimed at creating a system in which prevention--not treatment--is emphasized.
"Ultimately, it will improve health and lower cost per any given individual," said Dr. Ralph Snyderman, chancellor for health affairs and president and CEO of the Health System.
"It's a much more rational way of delivering health care," he added.
The proposed shift, presented to the Board of Trustees at its October meeting, would redefine the patient-doctor relationship and the traditional national view of health care. Going to the doctor would become an interactive rather than passive process; proposed changes range from more regular communication via the Internet with doctors to more frequent visits to clinics. And patients would be treated by a set of health practitioners, not just one doctor.
"We've known for years that people need to exercise, lose weight, not smoke," said Dr. Tracy Gaudet, director of the Center for Integrative Medicine. "The thing that's shifting here is, how do we embrace a whole person philosophy and offer different [mechanisms] to support that?"
Such a shift would represent a major change in the practice of medicine, and researchers admit there are several obstacles, financial and psychological. Most notably, they point to the current method of health care reimbursement; in fact, the most recent grant for the study was granted by the Centers for Medicare and Medicaid Services.
"A lot of care these days is based on acute care of a specific illness when a disaster happens," said lead researcher Dr. Gary Stiles, chief medical officer and vice president of the Health System. "So somebody has diabetes that's out of control and gets admitted to the hospital. Somebody has congestive heart failure and is out of control and goes to the hospital. That's how medicine has been practiced for quite some time now, so methodologies for reimbursement have been aligned that way."
Researchers agree that, in the long run, preventative health care would lower costs by decreasing hospital visits for acute care. But they also caution that when life span increases, costs rise as well.
"The simplistic argument is, OLet's prevent disease because it will save money,'" said Dr. Robert Califf, associate vice chancellor for clinical research. "Unfortunately, if you take the long-term perspective and look at the national budget, that's not the case. The reason is, because [now], eventually people get sick and die, so if you prevent disease at age 50 and age 60, people are living longer, but they don't live forever."
Califf said even short-term financial savings may be disadvantageous, citing that money from in-patient care often supplants funds in divisions that lose money, such as neo-natal intensive care.
"If I could give a pill today that would wipe out heart attacks, it would be a disaster for a lot of other areas in the Medical Center," Califf said.
Furthermore, Califf and others note that they must develop a method that spurs patients to be more proactive. This may be particularly difficult in younger patients, despite growing reliability of medical predictions.
"Young people feel they are immortal," said Stiles, also chief of the division of cardiology. "They won't believe smoking is bad for them or being overweight [is unhealthy].... Part of this project is interacting with patients to understand what it is that would make them want to change."
Due to this obstacle, Snyderman said researchers will concentrate first on more severe and immediate diseases. For example, one part of the study, led by Stiles, will examine prevention specifically in patients who have suffered congestive heart failure.
Stiles pointed to preliminary research already completed by Dr. Christopher O'Connor, associate professor of cardiology. Although he did not cite numbers, Stiles said the research, conducted on about 100 to 150 patients, proved that with a preventative mindset and process, patient admission to the hospital does decrease. Still, Stiles emphasized the long road ahead and, above all, cited teamwork as a must, given the complexity of medicine today.
With a preventative approach must come changes in physician training, something the School of Medicine has already begun to take into account.
"We can figure out how we need to deliver health care differently, but if we're not training people that embrace that philosophy... it's not going to work," said Gaudet, Trinity '84 and Medicine '91.
Gaudet will be involved in phases one and two of the study. In phase one, researchers will examine data that may already demonstrate the success of preventative care; in phase two, they will design the health intervention process and test it on Duke employees. Phase three consists of the study on congestive heart failure patients.
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