Sunday, November 7, 2010

Z Parade

What I learned curbside, watching the parade - my TENTH patient wean herself from insulin.

1. This project had innocuous beginnings; I didn’t even notice until I shared about Patient-5 and my Kaiser/Landmark colleagues (I call them the Kizermarkians) went wild.

2. When Patient-8 was successfully weaned from insulin, I called seven patients and asked, “Why did you do it?” They universally answered, “No one ever said it could be done.” Clearly, we don’t extend the invitation; we don’t tell patients what’s possible.

3. “I don’t eat that much, I don’t like vegetables, and salads are boring.” I rounded on a post-surgical, open-heart patient last Saturday who weighed 288#.

“About sixty days post-op, I want you to seriously consider doing something drastic with your weight,” I said. “I want you to consider joining Weight Watchers or Over Eaters Anonymous or any such organization and I want you to get some of this weight off.”

“I don’t eat that much,” she said.

…If I had a dime for every time I heard THAT, I could retire in splendor. We have formulas to calculate the number of calories needed to maintain body weight. Do you know how many calories must be consumed to maintain a 300# body? That on an 1800-calorie diet, her insulin requirements were reduced by two-thirds, is telling. ALL ten of my patients dealt with their food intake; there is no magic bullet, no magic pill, no panacea.

4. Who is the likely candidate? Not the skinny guy who is mindful of his food and takes insulin 10 units QID (ten units of insulin four times/day). The successful candidate is one with abdominal adiposity (belly fat), eating typical American fare, willing to try new and different food choices. Studies show we consistently underestimate our intake and overestimate our caloric burn. A surprising finding: exercise recommended but not required.

5. Patients, physicians, and healthcare organizations currently have insufficient support and/or structures to turn this corner. This represents a paradigm shift, a new conversation. And while we tout health maintenance, the bulk of our work is aimed at disease management. Reimbursements are not based on health promotion but disease management. While managing disease effectively does secondarily promote health, disease prevention and reversal is largely not incentivized. Follow the money: no reimbursement, no resources.

Case in point: A recently received email: “URGENT: Looking for PHASE Patients for KP Center for Total Health Exhibit.” (Pause in Think: PHASE is an innovative and successful Kaiser initiative called: Prevent Heart Attack and Stroke Everyday.)

“KP wants to capture a PHASE program patient's story on video,” the email continued, “Asking them questions about their condition and risk factors, how they were introduced to the medication protocol, how they feel about it, and how their health is now. If you have two or three members who you think would be compelling on camera talking about their own story, I would love to speak with them about possibly being a part of this. Please let me know just as soon as possible. Thank you! National Public Relations and Media Consultant”

“I have a patient who is also an employee,” I responded. “She lost 50# this year! We pulled away insulin and oral glycemic agents excepting Metformin. Her last two A1c's have been well below the target of 6.9. She is willing to participate and we would have to coordinate her work schedule.” I sent my story of Patient-8 found here entitled: Sourcing Miracles & Keeping Dreams.

They responded: "Lorin -- thanks, this is an inspiring story. We're looking for folks who were part of the PHASE program, though -- who were on that medication protocol to lower their risk of heart attacks and strokes. Was this person on the protocol?"

ME: "Yes - she is your typical metabolic syndrome Diabetes/PHASE patient who came into Diabetes Care Management and suddenly caught fire. We have decreased all of her meds, stopped insulin, though she remains on low-dose ACE, diuretic, and statin."

They were not interested in her. Of course you’re not, I thought sarcastically. WHO would be interested in patients reversing their disease, driving diabetes into submission, and decreasing medicines?

6. We are so cynical and jaded, patient outcomes beyond the bulge of the bell-curve are inconceivable. Even evidence-based results do not silence naysayers. If WE don’t think it’s possible; it’s not.

“They can’t sustain it,” our Endocrinologists said. Resignation and cynicism are ubiquitous. I vowed to give him a wide berth, to protect the possibility from his cynicism.

Yes, patients fall off the wagon. This is not about being perfect every time. This is about making better choices most of the time, it’s about practice, building the muscle, it’s about coaching them to competence and empowerment.

Driving their diabetes into remission. The first time I used that phrase, a physician friend cautioned, “Those are strong words.” And why not? Suspension of disbelief IS the hurdle.

When people seem uninterested or fail to recognize the impact of this work, the ultimate benefit for patients and healthcare organizations, I dismiss them and label them stupid. My bane, I have little patience for the ignorant AND I hold my profession and colleagues to a different/higher standard. Truth be told, stupid they are not; each has a full plate and nibbles a different piece of this pie.

7. What’s next?

Even the lone wolf is a pack animal. Kaiser stopped their Diabetes Support Group meetings because “the people who attended didn’t need them.” In other words, the patient’s who attended had good blood sugar control and lab values to prove it. Knowing human nature, the truth may have been closer to: their numbers were good because they attended and not vice versa. (That would be easy data to mine from our extensive database.)

As an integrated healthcare system, we at Kaiser Permanente have all the pieces for this pathway to reversing diabetes, heart disease, and erectile dysfunction (collateral damage seldom openly addressed). What we do not have is an established pathway, overseeing provider(s), invitation and follow-up mechanisms.

We COULD; we don’t.

I envision a program utilizing existing resources that shepherds patients from novice to expert, administered by one with prescriptive powers and motivational/empowerment skills (moi’ lest you had doubts).

Perhaps the invitation is extended through a large class format. I envision patient contracts to include participation in the Diabetes Care Management Program and a weight management program of their choosing. Support group meetings held after the basic “Invitation Class” allow prospective participants to observe the next step, the support group.

In that class, we might share food and stories. We could review and practice reading food labels, carb counting, and better restaurant choices. We might critique participant food logs.

To that end, and consistent with “not recreating the wheel,” I am scheduled to visit Kaiser Santa Rosa’s monthly support group meeting in December. I have been in contact with the head of the Wellness Institute at the Cleveland Clinic and am planning a three-day visit in early 2011.

THEN I intend to create a proposal for a pilot program and present it to anyone who will listen. Fortunately, I have generous people with large ears of listening for me.

8. A Larger Parade Marches On:

Study headlines in the last month: “Americans are the Fattest,” “A majority of adults in California are obese or overweight,” “Mediterranean Diet Halves Diabetes.”

None of these headlines surprises me. Halting this parade requires national conversations on many levels and in multiple directions. This surge has more momentum than a simple diet can cure… and a simple diet IS the cure!

Stemming the tide, changing directions, and turning the Titanic requires new, out-loud conversations. It starts in your home, at your table, in your pantry, and with the foods you choose to eat and feed your family.

You COULD start a new conversation around food and health with your family, your friends, your workplace. BE the change.

We are what we eat. Eat Well to Live Well and Be Well.

No problem can be solved from the same level of consciousness that created it. Albert Einstein