Chronic Disease Care: New Model

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facetguy

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Good article on where medicine needs to head to become more effective at addressing chronic illness and to remain a sustainable system:
http://www.jeffreybland.com/uploads/Bland Integr Med J 2009 Reforming the US Healthcare System.pdf

Key points:
*Switching from reactive/pathology-based system to proactive/prognostic-based; "prospective" or "functional" medicine

*Uses systems biology approach that "focuses on underlying functional disturbances in physiology at an early stage of development prior to the onset of severe pathology".

*More primary care focus

*Need to develop reimbursement systems to reward earlier interventions, lifestyle counseling, etc.

Clearly, any of the currently proposed healthcare reform that happens through Congress will simply perpetuate the same broken model of chronic disease care, will not make us healthier, and will not save money. More effort needs to go into implementing on a larger scale the functional medicine approach described in the article.

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Good article on where medicine needs to head to become more effective at addressing chronic illness and to remain a sustainable system:
http://www.jeffreybland.com/uploads/Bland%20%20Integr%20Med%20J%202009%20Reforming%20the%20US%20Healthcare%20System.pdf

Key points:
*Switching from reactive/pathology-based system to proactive/prognostic-based; "prospective" or "functional" medicine

*Uses systems biology approach that "focuses on underlying functional disturbances in physiology at an early stage of development prior to the onset of severe pathology".

*More primary care focus

*Need to develop reimbursement systems to reward earlier interventions, lifestyle counseling, etc.

Clearly, any of the currently proposed healthcare reform that happens through Congress will simply perpetuate the same broken model of chronic disease care, will not make us healthier, and will not save money. More effort needs to go into implementing on a larger scale the functional medicine approach described in the article.

The only real prevention/reversal of many of these diseases is lifestyle improvement, and doctors cannot provide that in the clinic. Individuals are solely empowered to change their habits and will seldom do so even with physician encouragement. Those who are willing to commit to a healthy lifestyle don't need doctors to coach them.
 
The only real prevention/reversal of many of these diseases is lifestyle improvement, and doctors cannot provide that in the clinic. Individuals are solely empowered to change their habits and will seldom do so even with physician encouragement. Those who are willing to commit to a healthy lifestyle don't need doctors to coach them.

That's the prevailing wisdom, and to a certain extent it's true. But that mindset needs to change or our disease-care system will continue to spiral out-of-control fiscally.
 
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That's the prevailing wisdom, and to a certain extent it's true. But that mindset needs to change or our disease-care system will continue to spiral out-of-control fiscally.

I think it is actually you that is parroting the prevailing wisdom: that a focus on primary care/prevention will save us money. It's not necessarily true, and unfortunately there are few, if any, interventions that primary care docs can make that have been shown to save us money. True we need to get away from expensive diagnostics and surgical interventions, but that is less a product of mindset and more a product of the litigiousness nature of our system. If you don't give patients the million dollar workup, you're going to give them the million dollar paycheck when you miss a rare diagnosis. What doctor is going to risk that?
 
I'm not arguing against moving toward a more primary care centered approach, just pointing out some issues.

If we were to move toward a more counseling based intervention strategy ("You should quit smoking and lose weight or you'll get sick.") we don't really need doctors for that. We don't even need midlevels. We could pay "life coaches" $10/hr to tell people to live healthier. Would that be better or worse in the long run. Hard to say.

We would likely still need the same number of specialists as people would still needed the same number of CABGs and so on, they'd just need them later in life. The years of quality living could increase, even dramatically, without decreasing the costs and number of intensive interventions.
 
I'm not arguing against moving toward a more primary care centered approach, just pointing out some issues.

If we were to move toward a more counseling based intervention strategy ("You should quit smoking and lose weight or you'll get sick.") we don't really need doctors for that. We don't even need midlevels. We could pay "life coaches" $10/hr to tell people to live healthier. Would that be better or worse in the long run. Hard to say.

We would likely still need the same number of specialists as people would still needed the same number of CABGs and so on, they'd just need them later in life. The years of quality living could increase, even dramatically, without decreasing the costs and number of intensive interventions.

This is an excellent point, and it's the one that most preventative care advocates miss when they suggest that prevention saves money. In the end, we all get sick and die. Pushing that death back by 10 years doesn't save us money, it just pushes back the expense. The only way to save money is to provide less care. Period. The way the current system is set up neither the patients nor the doctors have any incentive to use less.
 
I think it is actually you that is parroting the prevailing wisdom: that a focus on primary care/prevention will save us money. It's not necessarily true, and unfortunately there are few, if any, interventions that primary care docs can make that have been shown to save us money. True we need to get away from expensive diagnostics and surgical interventions, but that is less a product of mindset and more a product of the litigiousness nature of our system. If you don't give patients the million dollar workup, you're going to give them the million dollar paycheck when you miss a rare diagnosis. What doctor is going to risk that?

One obvious example: diabetes. Are you telling me that preventing diabetes won't save billions of dollars? And by prevention, we aren't talking about just ordering tons of tests; the prospective/functional medicine model is a bit more than that. You are right, however, that reforming malpractice regulation would appear to be an important move.
 
I'm not arguing against moving toward a more primary care centered approach, just pointing out some issues.

If we were to move toward a more counseling based intervention strategy ("You should quit smoking and lose weight or you'll get sick.") we don't really need doctors for that. We don't even need midlevels. We could pay "life coaches" $10/hr to tell people to live healthier. Would that be better or worse in the long run. Hard to say.

Practicing functional medicine is more than telling a patient to quit smoking and eat better. The Institute for Functional Medicine published a nice-sized textbook a few years ago to describe many of the principles and approaches and the science behind them.


We would likely still need the same number of specialists as people would still needed the same number of CABGs and so on, they'd just need them later in life. The years of quality living could increase, even dramatically, without decreasing the costs and number of intensive interventions.

Perhaps. I'm not really sure on this one. But even if true, increasing the number and quality of years is a noble goal, compressing all of life's illness into a brief period at the very end of life (this has been written about in the literature and isn't an original idea of mine by any stretch). I would also think that if people are generally healthier longer, they will require less medications, with fewer associated complications, which would offer savings (and make some rather uncomfortable at the thought!). Healthier people require less medical intervention.
 
This is an excellent point, and it's the one that most preventative care advocates miss when they suggest that prevention saves money. In the end, we all get sick and die. Pushing that death back by 10 years doesn't save us money, it just pushes back the expense. The only way to save money is to provide less care. Period. The way the current system is set up neither the patients nor the doctors have any incentive to use less.[/QUOTE]

An important point. And that may be the crux of our healthcare system problems: more testing, more procedures, more costs, less overall health of Americans. Your earlier malpractice litigation point is well taken, and exemplifies that there are many issues involved and there will be no easy fix. But a functional/prospective medicine approach seems to make more sense to me.

And it's not so much pushing death back as it is pushing overall morbidity back. As a simple example, if a patient is going to live to age 80, is it more expensive or less expensive to treat his Alzheimer's disease for fewer years?
 
Thank you for posting up the article. It was interesting to read.
I've been learning about this model and ways to implement and act using it since the year 1 of nursing.
 
Key points:
*Switching from reactive/pathology-based system to proactive/prognostic-based; "prospective" or "functional" medicine

*Uses systems biology approach that "focuses on underlying functional disturbances in physiology at an early stage of development prior to the onset of severe pathology".

*More primary care focus

*Need to develop reimbursement systems to reward earlier interventions, lifestyle counseling, etc.

The heart of the problem is not the system, it is the health care consumer. First of all, if you want any of those suggestions to make a difference, you need to convince the people of the importance of preventative medicine, not the physicians. It is not really the system's fault that we run on a reactive/pathology based system, most people just don't come to the doctor unless they are sick. You can increase primary care docs and reimbursements all you want, if the patients don't come in until they are peeing 25 times a day you are not going to prevent their diabetes. Yes systemic changes will have an effect, but to truly make a difference the mindset of the people needs to change.
 
The heart of the problem is not the system, it is the health care consumer. First of all, if you want any of those suggestions to make a difference, you need to convince the people of the importance of preventative medicine, not the physicians. It is not really the system's fault that we run on a reactive/pathology based system, most people just don't come to the doctor unless they are sick. You can increase primary care docs and reimbursements all you want, if the patients don't come in until they are peeing 25 times a day you are not going to prevent their diabetes. Yes systemic changes will have an effect, but to truly make a difference the mindset of the people needs to change.

Point well taken. If a person doesn't give a crap, then it's hard to help them. However, I think there are plenty of opportunities in most cases to approach these chronic cases differently and to communicate a different message to them.
 
Point well taken. If a person doesn't give a crap, then it's hard to help them. However, I think there are plenty of opportunities in most cases to approach these chronic cases differently and to communicate a different message to them.

Absolutely but it is not solely based on the "system". I, for one, wouldn't mind seeing some sort of marketing campaign similar to the anti-smoking one (albeit a lot less facetious than that) that tells people to go see their primary care doc. Hell I even have a slogan....."It's your life." (patent pending)
 
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Forgive the long post. This is the Executive Summary of a much longer document from the Institute of Functional Medicine entitled "21st Century Medicine: A New Model for Medical Education and Practice". If there is interest, I can try to post the full 142 page pdf file.


Executive Summary
________________________________________
In early 2009, an extraordinary degree of public attention was focused on
healthcare reform. In Washington, DC, two hearings were held before the
Senate Committee on Health, Education, Labor and Pensions, and the Institute
of Medicine of the National Academy of Sciences hosted a


Summit on Integrative
Medicine and the Health of the Public.

In New York City, a major conference on
Integrative Health Care was held. The January/February 2009 issue of

Health
Affairs

was devoted entirely to The Crisis in Chronic Disease. Why?
We know with certainty now that rapidly rising rates of complex, chronic disease
are creating an unsustainable burden on the national economy in both direct (e.g.,
treatment) and indirect (e.g., lost productivity) costs.

7 The $1.3 trillion estimated
to be the cost of chronic disease today may well grow to $4.2 trillion within
15 years.

8 Health professionals struggle every day to cope with the increase in
suffering and disability that accompanies this modern epidemic. At a time when
many other urgent pressures on the national economy command our attention,
we absolutely

must sustain our focus on the system-wide changes in health care
that will be required in the years ahead if the most severe consequences of this
epidemic are to be avoided.
A careful examination of the evidence on both performance and costs in
American health care convincingly demonstrates the urgent need for this
transformation. We have been taught to believe that we have the best health
care in the world, but the facts do not support such an assessment. We spend
about twice as much per capita as other industrialized countries and yet we rank
shockingly low on most parameters of health.

9
Many diverse influences are responsible for the current state of the public’s health
(see Figure 1).


10, 11, 12 It is not enough, however, to demonstrate, as many experts
have done, that the majority of today’s chronic diseases could be prevented or
ameliorated by changes in lifestyle,

13 and then suggest that patient responsibility
and self-care can take care of the problem. We must also ask what contributes
to such unhealthy lifestyles and how can we best equip clinicians to serve the
xii | 21st Century Medicine
21st century medicine:
A New Model for Medical Education and Practice
patients who are living every day under those pressures. It is critical that we understand how great a
proportion of environment and lifestyle is influenced by conditions beyond the control of individual
patients—not only the genetic vulnerability one is born with, but increases in environmental toxicity,
the homogenization and denaturing of the food supply, the influence of sedentary technology on jobs,
education, and entertainment, the powerlessness and despair of poverty, the debility produced by chronic
stress, and the fragmentation of family and community life that leads to isolation and a lessened sense of
purpose and meaning. These are all complex problems that took many decades to create and that will
require a long-term national effort and effective leadership in public policy to alter. We recognize—and
emphasize—that not only must we change healthcare and medical education (the primary focus of this
paper), but over the next decades we must also change the practices and priorities of our political, social,
and economic structures to achieve fundamental change in the public’s health.
Figure 1: Major Influences Contributing to the Epidemic of Chronic Disease
In order to change our future, however, we must thoroughly understand our past. Therefore, after
presenting an overview of the paper (Chapter 1), we focus first on exploring the dominant influences that
have helped to shape the current crisis in health care (Chapter 2). Next, we present and discuss the most
prominent models that have been proposed for the future (Chapter 3). The implications of these issues


EXECUTIVE SUMMARY
21st Century Medicine | xiii
for the practicing clinician are then analyzed (Chapter 4). And last, a preferred model for 21st century
medicine is presented (Chapter 5). It is important to recognize that even if patients do everything it is
possible for individuals to do for their own health (an idealized state that is highly unlikely to be realized),
we still have tens of millions of people with multiple chronic diseases, and well over 100 million with
at least one,


14 and both figures are on the upswing. All of these people need more effective therapeutic
services, and


everyone needs more effective disease prevention and wellness promotion strategies in order
to cope with the pervasive environmental influences that make achieving health such a challenge.
The transformation of 21st century medicine from the prevailing acute-care model to a far more effective
chronic-disease model will succeed only if we attack the underlying drivers of the epidemic—the complex,
lifelong interactions among lifestyle, environment, and genetics—and if we engage the entire healthcare
system in a concerted effort to implement a unified, flexible approach that can readily adapt to shifting
needs and emerging evidence. The central purpose of this paper is to demonstrate that such changes are
urgently needed and achievable.
In order to accomplish such an ambitious goal, several key objectives must be achieved. As discussed in
the succeeding pages, these include:
1.


A shared understanding of the powerful, primary influence of lifestyle and environment upon
genetic vulnerability in the initiation and progression of chronic disease must be matched with a
therapeutic tool kit that reverses the trajectory toward disease and disability, promotes health, and
empowers patients as full partners in the lifelong pursuit of wellness.
2. A more balanced perspective on the appropriate uses of both evidence and insight must be
integrated with broad-based clinical skills to establish the foundation for healing partnerships
between practitioners and patients.
3. A common set of principles, concepts, and practices that can be used by all health professionals
must be taught and applied in clinical practice so that well-trained integrated healthcare teams
can be deployed appropriately.
4. A model that incorporates all these elements must pervade education, clinical practice, and
research in both private and public arenas.
In this paper, we propose that functional medicine exemplifies the systems-oriented, personalized medicine
that is needed to transform clinical practice, education, and research. The functional medicine model of
comprehensive care and primary prevention for complex, chronic illnesses is grounded in both science
(the


Functional Medicine Matrix Model™; evidence about common underlying mechanisms and pathways of
disease; evidence about effective approaches to the environmental and lifestyle sources of disease) and art
(the

healing partnership and the search for insight in the therapeutic encounter). Many years of developing,
writing about, and teaching this model to thousands of clinicians in both private practice and academic
medicine have demonstrated that functional medicine can enable us to reshape health care for the
demands of the 21st century. Using this approach, a healing partnership between doctor and patient can
flourish, new and useful insights can be achieved, and a broad array of assessment and therapeutic tools

can be utilized by integrated healthcare teams.

 
Just provide the link. Thanks.

There are many things to discuss here, but I really don't have the time at the moment. I remain skeptical that "preventative medicine" is the cost saver that many claim. Same for primary care. We are discussing issues of disease burden, largely and specifically those attributed to controllable choices, such as lifestyle. Unless you give the doc the authority to whack kneecaps, it's neither the doctor's right nor plausible for the doc to modify lifestyle. These are personal choices. Further, the doc's role is limited to that of educator and mechanic; there are much, much more efficient ways to serve the role of educator than one on one tutoring...

Technology, devices, and drugs are the line items that could easily -- and rapidly -- benefit from efficiency improvements, leading to lower costs. The same for patient education, much of primary care, including "preventative" medicine and lifestyle modification. Those things that truly require MD level training, and must be performed on a case by case basis such as surgeries and procedures, by their very nature can only realized very limited and finite efficiency improvements.

"Integrated health" is a buzzword currently being bandied about for the promotion of the consolidation and corporatization of medicine. It will relegate physicians to the level of any other employee in an organization -- a line cost item -- to be dealt with as such. Be very careful what you wish for.
 
Just provide the link. Thanks.

There are many things to discuss here, but I really don't have the time at the moment. I remain skeptical that "preventative medicine" is the cost saver that many claim. Same for primary care. We are discussing issues of disease burden, largely and specifically those attributed to controllable choices, such as lifestyle. Unless you give the doc the authority to whack kneecaps, it's neither the doctor's right nor plausible for the doc to modify lifestyle. These are personal choices. Further, the doc's role is limited to that of educator and mechanic; there are much, much more efficient ways to serve the role of educator than one on one tutoring...

Technology, devices, and drugs are the line items that could easily -- and rapidly -- benefit from efficiency improvements, leading to lower costs. The same for patient education, much of primary care, including "preventative" medicine and lifestyle modification. Those things that truly require MD level training, and must be performed on a case by case basis such as surgeries and procedures, by their very nature can only realized very limited and finite efficiency improvements.

"Integrated health" is a buzzword currently being bandied about for the promotion of the consolidation and corporatization of medicine. It will relegate physicians to the level of any other employee in an organization -- a line cost item -- to be dealt with as such. Be very careful what you wish for.

The link would be for a 142 page document, which few if any would have read. Thus the copy/paste of the Executive Summary (albeit a little sloppy on the formatting, but you'll live).

You are correct to be skeptical that "preventative medicine" and primary care medicine in their current form will bring about much change. That's the idea behind the new model.

As to squandering MD-level training on such trivialities as lifestyle modification, how many MDs will whine and complain when non-MDs take a larger role in this aspect of healthcare? These forums are full of paranoid pre-meds and medical students who pound their fists that only MDs/DOs should be permitted to deliver healthcare, and all others are dangerous, quacks, charlatans, etc. Perhaps if more seriousness were placed on such things as diet, nutrition, etc on the part of MDs, perhaps patients would sit up and listen more.

And the functional medicine model goes beyond telling patients to eat fewer donuts. Their training classes are more and more filling with MDs and DOs because these cases are challenging and intellectually stimulating.
 
The link would be for a 142 page document, which few if any would have read. Thus the copy/paste of the Executive Summary (albeit a little sloppy on the formatting, but you'll live).

Never mind, I found it myself. It's here for those interested.

As to squandering MD-level training on such trivialities as lifestyle modification, how many MDs will whine and complain when non-MDs take a larger role in this aspect of healthcare? These forums are full of paranoid pre-meds and medical students who pound their fists that only MDs/DOs should be permitted to deliver healthcare, and all others are dangerous, quacks, charlatans, etc. Perhaps if more seriousness were placed on such things as diet, nutrition, etc on the part of MDs, perhaps patients would sit up and listen more.

Their whining is largely irrelevant. It is utterly ******ed to have an individual with a minimum of 10 years post secondary education doing the job that one with 2 years is perfectly capable of. It is even more asinine to have an individual provide a one-on-one service that can just as easily be accomplished through mass communication. If they want to martyr themselves for these tasks, that's their prerogative; they just won't get compensated at MD level for those services.

I would make participation in these programs mandatory for discounts. Have people maintain certain goals to encourage health and qualify for discounts on their coverage. It's not hard, and there is a good precedent in the auto and liability insurance sectors.

And the functional medicine model goes beyond telling patients to eat fewer donuts. Their training classes are more and more filling with MDs and DOs because these cases are challenging and intellectually stimulating.

Then that is their reward; services will eventually be paid according to the lowest common denominator. The potential role for the physician could be the design of the program, but that's about it. You simply cannot justify high prices for simple goods or services.
 
Why the immediate animosity toward a new look at dealing with the meteoric rise of chronic conditions in this country? You seem awfully negative toward all of this when, and I'm only guessing here, you don't have a whole lot of in-depth knowledge as to its proposals. And they are more than just proposals; practices like this are popping up all over. I'm not questioning anything about your skills, knowledge, dedication, etc. I'm just a bit surprised at the knee-jerk negativity. They hold an annual symposium, along with various other classes throughout the country. Why not sit in on one and speak to those involved. You'll see that they aren't a bunch of whackos, nor are they a bunch of dietitions (not that there's anything wrong with dietitions).
 
Why the immediate animosity toward a new look at dealing with the meteoric rise of chronic conditions in this country? You seem awfully negative toward all of this when, and I'm only guessing here, you don't have a whole lot of in-depth knowledge as to its proposals. And they are more than just proposals; practices like this are popping up all over. I'm not questioning anything about your skills, knowledge, dedication, etc. I'm just a bit surprised at the knee-jerk negativity. They hold an annual symposium, along with various other classes throughout the country. Why not sit in on one and speak to those involved. You'll see that they aren't a bunch of whackos, nor are they a bunch of dietitions (not that there's anything wrong with dietitions).

Friend,

If animosity exists it is because this is the latest in a long line of proposals, trends, "new" directions, etc that is likely destined for the very same failure as those preceding it if for no other reason than they too ignore basic economic truths and the patterns of human behavior. The more time and effort that I expend learning the workings of our current model, with all of its warts, the more I understand that our failures are often the result of a refusal or failure to acknowledge basic human behaviors, its motivating factors, etc.

In any given successful institution these basic patterns are present: never have a $100/hr person performing the tasks that a $10/hr person can equally perform. Efficiencies are to be realized wherever possible. Quality needs to be assured.

This is why I wanted the link to the full article; someone can make any series of proposals sound great when given only the bullet point version. I would like to learn more about this prior to rendering an informed opinion, and hopefully they have truly disruptive ideas.... instead of a rebranded primary care/disease prevention model as I remain skeptical of these. That's all....:)
 
In any given successful institution these basic patterns are present: never have a $100/hr person performing the tasks that a $10/hr person can equally perform. Efficiencies are to be realized wherever possible.

Not to point out the painfully obvious, but if we were to move towards a system where "efficiency" was valued above all else, your specialty would cease to exist.

As you've said yourself, be careful what you wish for.

Incidentally, most skin cancers are also lifestyle-related. Based on your theory, I hope you aren't wasting your time advising your patients to wear sunscreen and avoid excess sun exposure.
 
I knew that it would not be long before you showed up here, Blue.. :D

I do waste my time as it is part of the job... but I multitask and do so as I am performing a more vital, delicate process -- reconstruction or tumor extirpation. I also dispute the claim that dermatology would "cease to exist" -- mostly because no one else really knows how to do what we do... not very well at least. When you throw in the fact that a dermatologist can perform his/her duties more expeditiously than one without the benefit of such training and experience -- at the same cost to payor in a price fixed environment -- your "efficiency" theory really starts to fall apart.

Oh, BTW, "efficiency" has more than one variable component.... cost and efficacy are but two.... and, since you brought it up, there have been some fairly decent studies on the cost effectiveness of the competing treatment modalities for skin cancer. Prior to the loss of the multiple procedure reduction MMS arguably held its own for select tumors. The MMS argument has only been strengthened with the loss of the multiple procedure reduction exemption.

On a practical note, the lag time between carcinogen exposure and malignant transformation is sufficient enough for UV that I can have a long, busy career even if the message were to sink in tomorrow.
 
Friend,

If animosity exists it is because this is the latest in a long line of proposals, trends, "new" directions, etc that is likely destined for the very same failure as those preceding it if for no other reason than they too ignore basic economic truths and the patterns of human behavior. The more time and effort that I expend learning the workings of our current model, with all of its warts, the more I understand that our failures are often the result of a refusal or failure to acknowledge basic human behaviors, its motivating factors, etc.

Fair enough. It's easy for anything new to promise the world.

In any given successful institution these basic patterns are present: never have a $100/hr person performing the tasks that a $10/hr person can equally perform. Efficiencies are to be realized wherever possible. Quality needs to be assured.

Physician extenders can certainly be part of the mix. And I agree that we don't want someone making $10/hr to be in charge of trying to figure out a patient's complex health challenge.

This is why I wanted the link to the full article; someone can make any series of proposals sound great when given only the bullet point version. I would like to learn more about this prior to rendering an informed opinion, and hopefully they have truly disruptive ideas.... instead of a rebranded primary care/disease prevention model as I remain skeptical of these. That's all....:)

From the bit that I know, the 'functional medicine' approach is different, so I wouldn't put it in the rebranding category. It can also be effective.
 
I do waste my time as it is part of the job... but I multitask

So do I, and so do most primary care physicians.

I also dispute the claim that dermatology would "cease to exist"

I was referring specifically to Mohs surgery, not general dermatology. If one chooses not to place any value on cosmesis, wide excision would likely be considered far more "efficient" than Mohs for most lesions.

If you want to talk about cost vs. value, there's no better medical bargain than good primary care, even if you completely disregard the screening/prevention aspects of what we do.

I can have a long, busy career even if the message were to sink in tomorrow.

Sadly, so can we all.
 
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I was referring specifically to Mohs surgery, not general dermatology. If one chooses not to place any value on cosmesis, wide excision would likely be considered far more "efficient" than Mohs for most lesions.

Fortunately, friend, that is untrue as well.

-Reconstruction constitutes the lion's share of the cost incurred.
-Reconstruction is directly related to the size of the defect.
-Wide local excision necessitates larger margins, leading to larger defects, and thus higher reconstruction costs and often limits reconstruction options.
-Assuming similar operative settings (which is clearly NOT a sound assumption), the costs incurred by the payer with MMS vs standard excision is no longer significantly different when the pathology charges are included.
-And, finally, the relative risk reduction benefit of MMS is huge -- a person is 10x as likely to have a recurrence with standard excision and clear margins as they are when treated with the micrographic technique.

For all that I bitch about the loss of the multiple procedure reduction, it absolutely saved the specialty by taking away the only knock against it. Those silly plastic surgeons and ENT's on the RUC thought they were advantaging themselves..........
 
a person is 10x as likely to have a recurrence with standard excision and clear margins as they are when treated with the micrographic technique.

OK, we're digressing now, but you've piqued my curiosity...what's the citation for the "10x" quote? And, what type of lesion are we talking about?
 
Quoted recurrence rates vary significantly, and there has been very poor standardization... but the meta-analyses have been fairly consistent in stating that 5yr or longer recurrence rates for BCC's treated with surgical excision approaches 10%, while for MMS is on the order of 1%. When you look at the actual studies you find that randomization did not occur, aggressive tumors were shifted to the MMS arm, etc -- either they were trying to stack the deck in order to achieve the desired results or they were secretly acknowledging the superiority of MMS. The 92-95% quoted recurrence rates come from studies with either poor follow-up, design flaws, etc -- some flaw significant enough to exclude them from review analyses. The 4mm margin that is bandied about is largely the result of a Zitelli (MMS guru) study that looked at the margin required to clear 95% of the tumors in a series. While I truly respect and admire the man, this study has serious flaws as well (tissue contraction that results from the initial stage, which artificially lowers the required margin, not to mention the assumption that negative margins are "true" negatives, etc). In any event, this is for primary BCC; recurrent tumors skew the benefit even more in the favor of MMS, as does SCC.

If you were to only consider those tumors with a high risk for subclinical spread (aggressive histology, recurrent tumors, tumors arising in "high risk" anatomic locations -- central face, embryonic fusion plane, etc), MMS becomes a clear winner. For appropriately selected tumors, however, standard excision is arguably the most appropriate. Small, well defined tumors of nonaggressive histology, located in areas of significant tissue laxity are good candidates for example. I don't do much MMS off of the head, neck, or hands. Occasionally for a recurrent aggressive tumor or for the random DFSP.
 
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Focus on prevention will do almost nothing until a greater question is resolved. Why do the majority of American refuse to change their habits knowing full well what the consequences are? Simply multiplying the message "You need to eat better", "You need to exercise" , "You need to stop smoking" by factor of 10, 100, or 1000 wont make a difference.

IMO this generation of Americans are beyond help. This will get much much worse before they start to get better. Prevention means nothing without education. The only hope there is for a healthier America is mandatory early childhood education. Just like Math, Science or any other subject that children are exposed to every single year until 12th grade. And by early I mean 1st grade early. Children should be taught about cancer, diabetes, heart disease etc. as early as possible. They should be made aware of the consequences and how those consequences can be avoided by simple lifestyle decisions. Waiting to knock sense into people once they are Adults is futile.
 
Focus on prevention will do almost nothing until a greater question is resolved. Why do the majority of American refuse to change their habits knowing full well what the consequences are? Simply multiplying the message "You need to eat better", "You need to exercise" , "You need to stop smoking" by factor of 10, 100, or 1000 wont make a difference.

IMO this generation of Americans are beyond help. This will get much much worse before they start to get better. Prevention means nothing without education. The only hope there is for a healthier America is mandatory early childhood education. Just like Math, Science or any other subject that children are exposed to every single year until 12th grade. And by early I mean 1st grade early. Children should be taught about cancer, diabetes, heart disease etc. as early as possible. They should be made aware of the consequences and how those consequences can be avoided by simple lifestyle decisions. Waiting to knock sense into people once they are Adults is futile.

Starting early is a good suggestion. As stated earlier, our healthcare crisis is obviously a complex issue requiring attack from multiple fronts.

The model discussed in this thread isn't the same ol' same ol' prevention message. Let's not confuse things.
 
Starting early is a good suggestion. As stated earlier, our healthcare crisis is obviously a complex issue requiring attack from multiple fronts.

The model discussed in this thread isn't the same ol' same ol' prevention message. Let's not confuse things.[/QUOTE]

Really? It seems like that model is pretty light on guidelines and pretty heavy on philosophy. I read the executive summary you posted, and what I got out of it was "Focus on prevention" wrapped in a lot of mumbo jumbo and buzzwords.
 
Starting early is a good suggestion. As stated earlier, our healthcare crisis is obviously a complex issue requiring attack from multiple fronts.

The model discussed in this thread isn't the same ol' same ol' prevention message. Let's not confuse things.[/QUOTE]

Really? It seems like that model is pretty light on guidelines and pretty heavy on philosophy. I read the executive summary you posted, and what I got out of it was "Focus on prevention" wrapped in a lot of mumbo jumbo and buzzwords.

I'm not their spokesperson, so you'll have to take that mumbo jumbo verbage up with them. From my understanding of functional medicine, the focus is more about looking at the "web-like interactions" of physiologic/biochemical factors, environmental factors, and genetic predisposition, particularly in complex chronic cases. Chronic cases, implying that the condition already exists. Not just pie-in-the-sky prevention, unless you're talking about preventing a condition from going from bad to worse.

Guidelines are the subject of the "Textbook of Functional Medicine" published a few years ago.
 
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I'm not their spokesperson, so you'll have to take that mumbo jumbo verbage up with them. From my understanding of functional medicine, the focus is more about looking at the "web-like interactions" of physiologic/biochemical factors, environmental factors, and genetic predisposition, particularly in complex chronic cases. Chronic cases, implying that the condition already exists. Not just pie-in-the-sky prevention, unless you're talking about preventing a condition from going from bad to worse.

Guidelines are the subject of the "Textbook of Functional Medicine" published a few years ago.

I see what you mean, but I just feel like this whole concept is dressing up how we already think about modern medicine with a lot of fancy language and then comparing it to a model which looks more like what medicine was 50 years ago. I mean do we really not study and examine the multifactorial nature of disease? Isn't almost every intervention we make in chronic disease focused on ameliorating current symptoms and preventing future complications? How is this different from what we already do?
 
I see what you mean, but I just feel like this whole concept is dressing up how we already think about modern medicine with a lot of fancy language and then comparing it to a model which looks more like what medicine was 50 years ago. I mean do we really not study and examine the multifactorial nature of disease? Isn't almost every intervention we make in chronic disease focused on ameliorating current symptoms and preventing future complications? How is this different from what we already do?


Having read some of the paper and skimmed much more, I do find it interesting. It only starts getting interesting, however, after the painfully dull introductory sections. Skip to chapter 4, by which time the paper has finally gotten its trousers off (to borrow a Christopher Hitchens-ism).

One thing I took from it is their discussion on the limitations of a pure EBM based approach towards clinical decision making--that experientially derived heuristics for integrating EBM with complex individuals are important contributors to effective clinical medicine. And I'm not trying to simplify the document into this idea only. Just an idea that I appreciated.

It does go beyond simple clinician-to-patient "eat your vegetables and exercise" prevention into institutional, organizational, educational, physiological and clinical approaches to improving the treatment of complex individuals and diseases. I do agree with their general point that medicine is at stage of evolution from acute interventions for overt disease to more subtle recognition of emerging sub-clinical states and pre-clinical interventions (screening for biomarkers, applied pharmacogenomics, metabalomics etc). And yes, that last sentence is ridiculously over-simplified, but it's only one sentence. What can you do in one sentence?
 
I guess there's no replacement for checking out for yourself their educational materials. They hold an annual 3 or 3.5 day symposium; this is I think the 17th year and this year will focus on cancer; prior symposia topics have included pain, mood disorders, thyroid and adrenal concerns, cardiovascular issues, etc. Their major training session is the 5 day Applying Functional Medicine in Clinical Practice (AFMCP), held several times/yr in various cities. There are also Advanced Practice Modules; the current one is on GI stuff. There's also the textbook, various webinars, printed materials, audio recordings of prior symposia, etc. The website is www.functionalmedicine.org

(I do kinda sound like their PR person after all!)
 
Succinct article by 3 prominent MDs on 'lifestyle medicine':

http://www.functionalmedicine.org/content_management/files/News/HymanEditorial.pdf

There's a link on page 1 of this article that is also worthwhile.

The keys are that lifestyle medicine works, there is a need to increase reimbursement for it, and there is a need to educate physicians about it and reduce their biases toward it. It's pretty clear to me that simply adding more Americans to our current healthcare system won't make us healthier or save us money.
 
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