The Obligation to Prevent: Prescribing Human Flourishing

by Dallas M. Ducar 

Over the last decade, the number of Americans who took a single prescription drug increased by ten percent while the use of multiple prescription drugs increased by twenty percent.1 According to the Centers for Disease Control and Prevention (CDC), almost half of the U.S. population uses prescription drugs. The most commonly prescribed drugs are those used to manage high blood pressure and heart disease for patients 60 years of age and older.2 Additionally, the most commonly prescribed drugs for people ages 20 to 59 were antidepressants.3 This increase in prescription drug usage comes at a high price. In the past decade, the national pharmaceutical bill has more than doubled to a hefty $234 billion.4 This cost is expected to increase with the rise in population, the increase in acute and chronic medical conditions, and the growing cost of new pharmaceuticals. As these numbers continue to rise, it is important for healthcare providers (HCPs) and patients to seriously reconsider the value of pharmaceutical intervention. Current U.S. healthcare models emphasize the role of HCPs in fixing rather than foreseeing problems. A new, forward-looking preventive model could be effective in improving the public’s health outlook and would also reduce the need for bandaging health concerns by averting them altogether.

Health comprises dynamic and complex processes which encompass various mental and physical states. Similarly, preventive care relies on the dynamic and complex mechanisms at work within the purview of healthcare systems, as well as outside of them. Agencies both inside and outside this system have the ability to offer preventive care measures and have good reason to do so. In this essay, I will focus on the obligation that healthcare systems, HCPs, and governments are tasked with to provide and implement preventive care measures. Moreover, I will offer possible solutions to current barriers in this type of care, which will provide insight into future directions.

Encouraging Preventive Care in the Clinical Setting

Organizations such as hospitals, health systems, and accreditation programs have the ability to create an atmosphere that encourages a preventive model. Unfortunately, doctors-in-training spend less time with patients now than they have in the past. A recent study in 2013 conducted by researchers from the University of Maryland and Johns Hopkins University observed two different internal medicine training programs for a total of 900 hours.5 The researchers found that most of the doctors’ time was spent on indirect patient care such as writing notes, entering orders, and talking with other providers. More shockingly, researchers found that interns allocated only twelve percent of their time – the equivalent of eight minutes each day – to each patient.

Preventive care begins with a didactic conversation – talking to a patient about lifestyle, beliefs, and aspirations. This approach enables HCPs to care more appropriately for the patient as a whole and to provide interventions, which can result in substantial long-term effects. However, a new provider’s experiences can strongly influence her method of practicing.6 The new providers trained in U.S. programs and schools have the potential to reform our methods of practicing medicine. However, current institutional demands can shape what a future provider perceives as acceptable and unacceptable. A provider who hardly has time to converse with a single patient will be hard-pressed to recognize the signs and symptoms of disease before it manifests. Moreover, if a new provider is taught that spending eight minutes or less with a patient is standard, little room is left for the much needed conversations that may encourage behavioral change. If more time is devoted to patient-doctor interactions, specific behavioral interventions could significantly increase a patient’s quality of life.

Health systems must also promote preventive prescriptions. Instead of utilizing the prescription pad for pharmaceutical interventions when treating an illness, HCPs should have the ability to write prescriptions that promote complete physical, mental, and social well-being. Organizations such as Health Leads work to connect low-income patients with basic health-related resources.7 A patient may continually return to a physician’s office with complaints of respiratory problems; however, the etiology of this condition may be due to poor ventilation – a problem that medication neither addresses nor can resolve. Health systems partnering with Health Leads can prescribe food, fuel, housing, and, in the example of the patient with respiratory issues, proper ventilation. Preventive prescriptions can decrease costs and preclude less chronic and reoccurring diseases that are due to environmental factors.8

Taking Time to Talk

Proper preventive care would rely on a strong fiduciary relationship between the patient and HCP. However, this certainly would require time, which is lacking in many clinical settings. Even if healthcare systems change their teaching methods and encourage physicians to spend more time with each patient, the HCPs must also ensure an appropriate amount of time is spent with the patient. Not only does a limited amount of time result in inadequate observations and diagnoses, but it also can lead to lower patient satisfaction, negative outcomes, and inappropriate prescribing.9 HCPs require time to talk with the patient, address hopes, discuss fears, and inspire long-lasting changes in regimens.

The responsibility to be present with the patient requires the HCP to exercise proper self-care. Primary care physicians are just one of many groups of providers who are reporting less time with their patients, which consequently results in greater stress and burnout.10 Moreover, patients of more satisfied HCPs are more likely to show up for appointments and adhere to treatment.11, 12 Encouraging self-care not only improves the metrics over which hospital advisory boards debate, but also encourages a trusting and caring relationship between HCPs and patients. More time allows for an extended conversation about smoking cessation or the risks of over-eating, and may encourage preventative behavioral change before it may be too late.

If given adequate time, HCPs can focus on instilling long-lasting change through behavioral treatment rather than solely relying on pharmacological intervention. For example, in psychiatric treatment, the combined effects of psychotherapy and medications indicate faster recovery rates, decreased rate of relapse, improved compliance and satisfaction, and lower long-term health costs.13 In bariatric medicine, HCPs who provide nutritional counseling have been shown to increase cost-effectiveness and are estimated to extend the life-span of patients.14 Patients also show a two-fold increase in smoking cessation when HCPs intervene and speak directly to their patients about smoking, agree upon a quit date, and schedule follow-up visits.15 Behavioral interventions, when implemented prudentially, have the potential to save money and lives. Educating patients on the value of proper nutrition and exercise could help to lessen the impact of chronic conditions such as cardiovascular disease or diabetes. Instead of prescribing a beta- blocker, HCPs could act earlier in the patient’s life by writing prescriptions for daily cardiovascular exercise or for complete servings of fruits and vegetables with every meal. Whether the intervention is aimed at fostering personal meaning or developing a personal diet, behavioral intervention offers specialized care without immediately prescribing pharmaceuticals that appear to work for the average patient.

Constructing for Health

The duty to provide preventive care does not rest solely in the hands of HCPs or the health system – the surrounding community should also be responsible and held accountable. Governments can encourage preventive care and thereby improve community health by structuring environments towards healthy choices. For instance, rates of daily walking have declined drastically in the United States in recent decades, contributing to increased respiratory problems and childhood obesity.16 Promoting urban design of communities to maximize ease of walking, rather than driving, is one simple way for governments to encourage this change. Moreover, communities that provide shared pedestrian-friendly public spaces are likely to see increased social interaction and a feeling of belonging in the community.

On a city-wide level, localities can work to create biophilic cities that encourage a healthy rapport between human beings and other living organisms. Human interaction with nature has shown to reduce stress, aid in recovery from illness, enhance academic performance, and moderate the effects of childhood illness.17 Urbanists and city planners can advance this design rather than view such healing effects as an afterthought. Implementing biophilic design can also help to eliminate food scarcity and encourage proper nutrition by supporting community gardens. Initiatives such as biophilic cities, guerrilla gardening, and pedestrian-friendly communities can encourage a more equitable distribution of environmental preventive healthcare resources across communities.

A Lifetime of Difference

With the rise in chronic conditions and prescription drug usage, it is imperative for health systems, HCPs, and governments to consider more effective and less costly alternatives. Spending more time with the patient, considering behavioral interventions, and constructing environments to promote healthy behavior will contribute to this process. Preventive models have the ability to extend access to healthcare by reshaping environments while reducing patient costs and stressors. Incentivizing increased time with the patient and the use of prescriptions for basic utilities and goods can start now within our health systems. We should be having these necessary conversations and encouraging preventive care throughout society. The decision to handle health conditions solely as curative rather than integrating preventive care is a moral decision and there is good reason to integrate both into modern healthcare.

Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.18 By encouraging preventive measures, we not only aid in healing, but also foster well-being connectedness, and human flourishing. Similar to health, prevention is multi-faceted and depends on many agents and parties to produce meaningful change. Changes such as spending additional time with patients, encouraging behavioral interventions, and changing our very landscapes have the potential to make a difference for a lifetime.

 

PDF available: Dallas Ducar, “The Obligation to Prevent,” Voices in Bioethics (2015).

References:

1 Gu, Qiuping, Charles F. Dillon, and Vicki L. Burt. “Prescription drug use continues to increase: US

prescription drug data for 2007-2008.” NCHS data brief 42 (2010): 1-8.

2  Ibid.

3  Ibid.

4 Almashat, Sammy, Charles Preston, Timothy Waterman, and Sidney Wolfe. “Rapidly increasing criminal and civil monetary penalties against the pharmaceutical industry: 1991 to 2010.” Washington DC: Public Citizen’s Health Research Group (2010).

5 Block, Lauren, Robert Habicht, Albert W. Wu, Sanjay V. Desai, Kevin Wang, Kathryn Novello Silva, Timothy Niessen, Nora Oliver, and Leonard Feldman. “In the wake of the 2003 and 2011 duty hours regulations, how do internal medicine interns spend their time?.” Journal of general internal medicine 28, no. 8 (2013): 1042-1047.

6 Hafferty, Frederic W. “Beyond curriculum reform: confronting medicine’s hidden curriculum.” Academic Medicine 73, no. 4 (1998): 403-7.

7  “Health Leads.” Health Leads. Accessed January 14, 2015.

8  Sayer, Caroline, and Thomas H. Lee. “Time after Time—Health Policy Implications of a Three-Generation Case Study.” New England Journal of Medicine 371, no. 14 (2014): 1273-1276.

9 Dugdale, David C., Ronald Epstein, and Steven Z. Pantilat. “Time and the patient–physician relationship.” Journal of General Internal Medicine 14, no. S1 (1999): 34-40.

10 Friedberg, Mark William, Peggy G. Chen, Kristin R. Van Busum, Frances Aunon, Chau Pham, John Caloyeras, Soeren Mattke et al. Factors Affecting Physician Professional Satisfaction and Their Implications for Patient Care, Health Systems, and Health Policy. Rand Corporation, 2013.

11 Linn, Lawrence S., Robert H. Brook, Virginia A. Clark, Allyson Ross Davies, Arlene Fink, and Jacqueline Kosecoff. “Physician and patient satisfaction as factors related to the organization of internal medicine group practices.” Medical Care (1985): 1171-1178.

12 DiMatteo, M. Robin, Cathy Donald Sherbourne, Ron D. Hays, Lynn Ordway, Richard L. Kravitz, Elizabeth A. McGlynn, Sherrie Kaplan, and William H. Rogers. “Physicians’ characteristics influence patients’ adherence to medical treatment: results from the Medical Outcomes Study.” Health psychology 12, no. 2 (1993): 93.

13 Teasdale, John D., Zindel V. Segal, J. Mark G. Williams, Valerie A. Ridgeway, Judith M. Soulsby, and Mark A. Lau. “Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy.” Journal of consulting and clinical psychology 68, no. 4 (2000): 615.

14 Olsen, Jens, Ingrid Willaing, Steen Ladelund, Torben Jørgensen, Jens Gundgaard, and Jan Sørensen. “Cost-effectiveness of nutritional counseling for obese patients and patients at risk of ischemic heart disease.” International Journal of Technology Assessment in Health Care 21, no. 02 (2005): 194-202.

15 Wilson, Douglas M., D. Wayne Taylor, J. Raymond Gilbert, J. Allan Best, Elizabeth A. Lindsay, Dennis G. Willms, and Joel Singer. “A randomized trial of a family physician intervention for smoking cessation.” JAMA 260, no. 11 (1988): 1570-1574.

16 Ewing, Reid, Tom Schmid, Richard Killingsworth, Amy Zlot, and Stephen Raudenbush. “Relationship between urban sprawl and physical activity, obesity, and morbidity.” American Journal of Health Promotion 18, no. 1 (2003): 47-57.

17 Beatley, Timothy, Biophilic Cities: Integrating Nature Into Urban Design and Planning, Washington, DC: Island Press, 2010.

18 Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s