While walking this morning, I was listening to a podcast from NYC radio.  The discussion was about bringing about behavioral changes and stopping smoking was one of the examples.  One woman after many, many years and numerous failed attempts to stop smoking finally decided to do something more compelling that all her prior attempts.  She swore to a friend that she would give $5,000 to the KKK (her most detested organization) if she ever smoked another cigarette and with that pressure, she immediately stopped.  The discussion about that example and others was quite interesting.  How do you get a commitment?  How do deal with a decision today which is difficult to keep in the future when temptation keeps getting in the way.  They discussed the thought that there are 2 parts to each of us and on any given day, one or the other may take charge.  If you could find a way to make them co-exist temporally, you could get the favored one to prevail.  The woman whose good havlf gave up smoking and put the onus of a very undesirable option upon the bad half by announcing a donation to the KKK succeeded.

Perhaps without thinking about it in this way, I have been counseling smokers for many years with great success apparently using a similar approach.

#1  I present convincing  evidence that smoking is not an addiction; indeed it is quite easy to stop without significant withdrawal which takes away the biggest excuse leading to failure.

#2  The likelihood of premature death from vascular disease is very high in smokers and is totally reversible. I spell this out with convincing medical data.

#3  The emphysema, coughing, social ostracism, disappointment from the children, cost et al are already known by all, but it doesn’t hurt to remind smokers.  

#4  I insist they go public telling everyone that as of this date, I am stopping smoking.  This puts positive pressure (like the KKK donation) on yourself to succeed.

#5  There are a bunch of small specific steps which enhance the likelihood of success which I will not spell out here, but know that  the likelihood of success with this approach exceeds 90%.

#6  I tell them they need to have a conversation with themselves in which they tell themselves that “I no longer smoke and I mean it!”  Indeed, if you make that commitment to yourself, you indeed are no longer a smoker.

#7  You must stop “cold turkey” and please don’t take nicotine gum, patches, or drugs.  You must get all the nicotine out of your system and keep it out for a period of 2-3 weeks to be home free.  Weaning or using substitutes keep nicotine in your system during your peak motivation period and will almost certainly negate your good effort.

IF you are currently a smoker, for all of these reasons and more, STOP NOW.  Virtually every smoker I’ve counseled contacts me about 5-6 weeks later and says: “If I’d known how easy this was going to be, I’d have done it years ago.”

Gerald L. Evans, M.D.

A couple recent medically related articles caught my attention. 

The first was a study showing a 20% incidence of hospital errors – a shocking number at best! You can’t get into a clinic or hospital without the registration area putting an ID bracelet on you and triple checking your insurance info lest you accidentally get care without paying.  Everyone then checks your ID before drawing blood, doing an x-ray, giving you a pill or whatever.  If you have surgery, they put signs on where to make the incision.  How can you make an error???  Maybe if everyone didn’t spend so much time double checking, you’d have time to avoid all those errors. I picked up an Rx recently and the charge machine had multiple screens, each requiring a signature.  Was the privacy policy explained? Did the pharmacist explain the medication to me?  Do I have any questions?  Sign for the amount of the charge.  4 signatures in the credit card machine on different screens to get out of the drugstore.  Am I missing something?  Does anyone care about me or only about the regulations?  If we are making a ton of errors, perhaps it is because we spend so much time on un-necessary crap that we have no time for the patient.  And if you think it is going to get better, wait until you see the impact of the computerized medical record and computerized order entry systems.  It takes thousands of hours to convert a hospital to a working system and participation at many levels is essential to do it right.

 The second was the utilization of a robot by a NY hospital pharmacy to fill prescriptions. Intriguingly, it did so in 1/5^th the time of a pharmacist allowing the pharmacist “to spend more time on patient care.”  In my 40 years practicing medicine, I never witnessed a pharmacist offering patient care, but maybe that is coming.  Everyone else seems to practice medicine these days; except the doctor who has trouble getting into the game.  But as I thought about the article, I wondered why the robot did not take care of the patients.  It does its thing 5 times as fast as the pharmacist.

 Where is this impersonal system leading us? How many consent forms must I sign?  What or where is the role for judgment? Will Accountable Care Organizations solve all our problems?  Doubtful as the bigger the behemoth, the more impersonal it becomes.  Medical homes?  Sounds great to me.  A group of dedicated doctors working hard to personalize care and keep it local to the practice and out of the hospital.  Guess what?  Non-physicians are forming them such as nurses and nurse practitioners.  HMOs are sponsoring them as are other insurers.  Hospitals, not wanted to lose money by fewer admissions, are buying medical practices to control the medical homes.

 I trained in the 60s and started practicing medicine in 1970.  In those years, 60% of the money was spent on hospital care, 30% went to physicians, and the rest to pharmacy and other services.  Today, administrative costs of running an insurance company approach 25% of the total and that comes off the top.  Special laboratory testing – CT scans, MRI studies, special cardiologic tests (catheterizations), g-I endoscopies and other special procedures eat up a huge amount of money. Hospitals are losing money and physicians are leaving programs like Medicare because they cannot cover their practice expenses anymore because of the steep discounting.

For those skeptics out there who still believe the health care system will take care of all their needs in the future, I wish you well.  For the rest of you, start living healthier and do everything in your power to reduce you need for complex medical services.

Gerald L. Evans, M.D.

Historically, when indemnity insurance was getting too expensive, HMOs appeared on the scene offering “more” care for less dollars.  Initially, they attracted all the healthy young workers who wanted to save premium and copay money; the sicker people fearful of higher personal costs were willing to pay a higher premium to assure themselves of ready access to high quality (albeit expensive) care.

          Eventually indemnity disappeared and everyone was in HMOs.  Then things like PPOs were formed which were a hybrid between indemnity and HMO.  Over time both those products became very costly.  Consumer driven health plans arose and like their predecessors promised lower costs if you stayed out of the health care system or negotiated lower rates for your own personal care.  If you used the system a lot, it would actually cost you more than the HMO option.  The thinking on the street was that only the “healthy” young will join the new option and the “unhealthy” older would stay with the HMO or PPO.

          Well, I listened to a presentation last week by a human resources vice president who introduced a high deductible health plan in addition to the HMO plan.  He also pushed hard on healthy lifestyles for all the workers.  What was interesting was that the individuals who were changing their lifestyles to make them healthier were the ones electing the high deductible consumer driven plan whether they were healthy to start with or had diabetes or another chronic illness.  The cost savings in the active healthy group was enormous; much of it remaining in their own pockets as savings.  There were as many high risk in each group demonstrating the cost effective nature of healthy living par excellence!

Gerald L. Evans, M.D.