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Victor S. Sierpina, MD, ABIHM: Hi, I'm Vic Sierpina. I'm a Professor of Medicine at University
of Texas in Galveston, Professor of Family Medicine and Integrative Medicine. I'm also
a Diplomate of the Board of Integrative and Holistic Medicine and the Board of Family
Medicine. I'm going to talk a little bit about healthcare reform today. This is so much in
the news and I wanted to just kind of give us a little bit perhaps, different perspective
on it. This would include a vision of what the doctor of the future might look like,
some issues about workforce imbalance and environmental concerns.
So, here's the doctor of the future. You've got somebody's going to look a little different
than they do now. I put this into two columns ‑‑ process and structure.
In the future, we're going to be increasingly patient‑centered. The doctor, in terms of
the system, is going to be more of a health system navigator than he or she is now. The
process will be more team based and outreach oriented and much more multi‑disciplinary
and collaborative. We'll have both high tech and high touch with
conscious healing, a conscious design of the healing environment.
The process of individualization or personalization in medicine using genomics and functional
medicine will increasingly be penetrated based on evolving scientific principles. This also
requires us to train doctors in different ways, in a systems biology approach and complexity
theory rather than linear, this problem leads to this diagnosis, leads to that drug. So,
the complexity of looking at the whole person in an ecological perspective.
The doctor of the future will also be kind of upstream from disease by being prospective
and preventive and really looking earlier in the course of people's lives to prevent
disease from arising. This reminds us of the Chinese aphorism that says the best doctor
treats the disease before it occurs. Also, we'll be looking at quality and outcomes
focus. We won't just get paid for seeing more patients, but really, we'll by tying our reimbursement
to the quality and outcome that we see and this will be evidence‑based.
There will be more healing, more evidence on self‑healing and homeostasis. The idea
of the doctor as the mechanic, the person as a machine is already obsolete and antiquated
and we have to return to the fact that the body heals itself and we just need to help
with that. This requires empowering the patient, educating
them. We can use web‑based resources, health coaching and other mechanisms to purpose that
future. Natural treatments ‑‑ nutrition, botanicals,
lifestyle, mind/body, complimentary alternative therapies. These are inexpensive. These are
less invasive. These are the kinds of treatments we really will start with first rather than
end up with those when everything else has failed.
Another big thing is we're going to move out of the office and out of the hospital into
the community, into the school. We'll become the patient's advocate and activist to help
them, for example, helping children eat healthier lunches at school, working with churches to
develop fitness programs. This doctor is going to be integrative and
he or she is going to be very involved, as well, in social and environmental policy change
and self‑care strategies. This is how we're going to evolve.
Now, nothing less than our health is in the balance. Right now, our burden of expense
in our healthcare system is huge. It just costs us too much money. The US spends on
average twice as much as the closest country in the developed world, somewhere around $7,000
or $8,000 a person per year compared to other countries like Germany or Great Britain and
our outcomes are worse. We're actually number 38th in the world, right
behind Albania or somebody like that in terms of patient outcomes.
Part of the issue is that we have overloaded our system with specialists. Instead of a
pyramid in which primary care is at the base and the specialty is up at the top, more than
two‑thirds of our doctors are specialists. This is a more expensive form of care.
Most systems that do have a universal healthcare system and access, it's the opposite. The
primary care is the driver and it goes the other way to the specialist. So, this is kind
of the balance is tipping here and that's where it's a lot less expensive and it's more
preventive, more health promotive. In all of our discussion in this country about
the politics and how payment will be made and who's going to have access, we've left
this part out. We have left very little focus on redistributing the workforce and it's estimated
there are 60,000 to 80,000 deficiency in the number of primary care doctors.
Even if every graduate, every medical school in the country went into primary care in the
next 10 years, we wouldn't solve that problem. We've got a long way to go with this and we
need help from our CAM practitioners, our nurse practitioners, our physician's assistants
and also from the system itself to encourage students to go into primary care because one
of the reasons they don't is because they come out of school with $200,000 debt and
they say, "Well, I'm going to go for the specialty care that pays two or three times as much
per year." They're not encouraged by the nature of our
healthcare and education system. This is a quote from one of my childhood heroes,
Thomas Edison. I used to keep this on my wall in medical school. "The doctor of the future
will give no medicine but will interest her or his patients in the care of the human frame,
in the proper diet and in the cause and prevention of disease."
I modified this a little bit because I do give some medicine. The doctor of the future
will give some medicine and will interest his or her patients in the care of human frame.
This is the essential place that we really do need to get to.
Part of it is how we eat. The basis of good health is good nutrition. These are the 14
super foods. In most research, this group of foods has clear health benefits and yet,
it's a smaller part of our American diet because of the way that agriculture is reimbursed
and because of our cultural habits. This is an issue that I feel is important
for us to think about. We have been reimbursing the agricultural industry for many years to
the tune of 50 or more billion dollars and basically, we're not supporting ma and pa
farms. We're supporting giant agribusinesses like this hog farm down here or this monoculture
of corn or the cattle feeding place. The result is like “Super Size Me”. The
average obesity right now in the country - who are overweight - is over 60 percent, like
that movie. You should see that sometime, the guy that ate at McDonald's for 30 days
straight and gained about 30 pounds. The upper left is what we call dead zones.
That red area is areas where there's not enough oxygen in the Gulf of Mexico to sufficiently
provide nutrition for fish. The reason is because all of these farms up in the Midwest
and so forth, they're effluent and their fertilizers have gone into the Mississippi creating a
fertilizer overdose to the Gulf of Mexico. All these phytoplankton grow up, use up the
oxygen, the fish die off so the shrimp and fishing industries are probably more threatened
by this than the Horizon Gulf oil explosion. This is some interesting information I picked
out of "Time Magazine" a couple years ago because our agricultural policies are feeding
our obesity. One of the issues is that poor quality foods cost less and poor people then
buy the cheaper foods. A dollar will buy you about 1,200 calories
in chips, 1,200 calories, 875 calories of Coke, that's Coca‑Cola, but only 250 calories
of broccoli or other vegetables, 170 calories of oranges or blueberries and fresh fruit.
There's a big disparity. If somebody is already overweight, they want to keep their weight
up, they're going to continue to spend their dollar on the high calorie junk food.
This is a tragedy in our society and we're now seeing results of it with childhood obesity,
kids under 10 getting type two diabetes because they're just eating the wrong way and not
exercising. Here's some little recommendations here that
I hope will help change our system. First of all, we need to change our reimbursement
for healthcare to support wellness promotion and prevention on a primary care level. Until
we do this, nothing is really going to change. We're going to still see that scale of the
specialty care raising the prices. The interesting thing, the studies about specialty
care, if there are more specialists in a community, the healthcare costs definitely go up but
the quality of life and the outcomes go down. The reason is because they do more things
that are dangerous to patients. This has been well‑documented.
At the same time, if you have more primary care doctors in an area, it reduces ER visits
and costs, decreases hospitalizations and length of hospitalizations. It increases overall
health outcomes at a much lower cost. But, there's got to be a change in reimbursement
to sustain that. We have to create time for meaningful medical
encounters. Patients have complex problems. We can't really solve those in a 5 or 10‑minute
office visit if we're not getting paid adequately to spend time with patients but we're getting
paid to do procedures. If I can spend a half an hour with a patient discussing their diabetes
and their hypertension but if I take a wart off their foot, I get paid more for that wart
which takes me five minutes to remove than a half hour that really makes more meaningful
impact on their lives. We also have to make it less costly for medical
students to choose primary care. As I mentioned, the student debt is enormous. Some kids are
coming out of college with $50,000 worth of debt and they're coming out of medical school
with $200,000. We have to stop subsidizing unhealthy foods
at agribusinesses and at schools and encourage a culture of increased physical activity in
the United States for children and adults. These upstream changes are going to lower
our downstream costs and until we do them, we can argue all we want to about how much
we're going to distribute the money for this coverage or that coverage. As long as the
expenses keep going up, basically we've got a body shop at the bottom of a cliff and we
need a guardrail at the top. Thank you very much.