Dr. Malia Reckons

"Sometimes your joy is the source of your smile, but sometimes your smile can be the source of your joy." 

-- Thich Nhat Hanh

We are all hearing about H1N1 (swine) flu and the need for behaviors and efforts to limit the spread. And we see ads on billboards and on TV about the need to stop smoking. Now perhaps we should consider a public health effort to increase happiness.  I just read a nice piece in the NYTimes  by Olivia Judson in which she touches upon how all of our behaviors affect each other and our health. http://judson.blogs.nytimes.com/2009/11/10/social-medicine/?ref=science

Our influence on others, and their influence on us (always remember that "social networking effects" flow two ways), includes our eating habits, weight control, smoking, etc.  But, not just that, it also includes our happiness. And research has shown that happiness relates to health, including having a stronger immune system -- so, perhaps efforts to improve happiness should be part of our H1N1 flu health efforts.

Judson's piece alludes to possible public health efforts in helping improve these "social networking health issues," if you will. But I, as a family physician, wonder about how primary care medicine can help, one patient, and one family, at a time.

I find it interesting how discussion frequently focuses on the large, public health aspects of medical care and efforts, but often overlooks the small, face-to-face encounters of primary care medicine. Should not we be focusing on improving the power of the primary care doctors in the effort to improve health in every way possible, including happiness?

Currently, however, the system supports efforts by doctors to see more and more patients and focus on the objective measures of medical care, such as the lab values and blood pressure readings and percentage of patients having completed recommended tests and screenings. But I encourage all of us to consider the subjective measures of good care. They may be harder to measure and quantify, but I suspect you will know if your doctor is measuring up.

Do you leave your doctor's office with a smile on your face and your heart a little bit warmer than before you got there? Do you sometimes get to laugh or chuckle with your physician? Do you feel your doctor appreciates seeing you and spending time with you? If not, than why not? And don't you think you deserve better for your health?

I propose an effort for primary care doctors to help in this effort to improve our patients' happiness by connecting to patients in ways that can not be measured easily. We should ask about life issues that are not related to medical problems, and tell jokes and listen to a few. We should relate to our patients, somewhat, as friends who are over for a visit and to "catch up" if you will.

One great aspect of primary care medicine that is too often overlooked is the continuity of care over time, often over many years. I like to say that each appointment with a patient is just one part of an on-going conversation that stretches back to previous visits and stretches on into the future. It is the one aspect of care that no hospital, emergency room or urgent care center providers can ever offer.

And with that, I as a family physician have another weapon in my armatorium to support health and battle disease -- friendship and a social network to encourage healthful living and wellness, including the promotion of happiness.

Did you have any idea your primary care doc actually had such power?!

Take a look at Judson's article and consider your own life. Realize that you and your lifestyle affect other people. You have power. And be sensible in who you let in your life since they will affect you too (very important for the teens and college students who might be reading this, and for parents who should be teaching them). And, finally, consider how you feel at your doctor appointments, and whether your relationship with him or her is improving your health and happiness.

Finally, I will end by pointing to the quote at the start of this post from the world-famous Vietnamese Buddhist monk, Thich Nhat Hanh, who has often spoken of smiling as "facial yoga" and encourages us to wear a smile because it will stir our soul in positive ways, just as the quote suggests, but also because it can have a positive influence on everyone around us. That idea fits beautifully with the Judson article.

Maybe it should also fit with your doctor visits.

-- Timothy Malia, MD.

I am sorry to say this, and I need to move beyond the emotion, but right now, I feel bitter.

This year, I have not been able to get a small order of 150 influenza shots. In past years I have had a couple flu clinics for my own patients on Saturdays and Sundays when I gave out about half my shots. The other half was given during appointments with high-risk patients, those I scheduled in October and early November with diabetes, heart disease, lung disease, chronic kidney disease, etc. Anticipating the flu shots, and trying to help them get better value from one appointment and not waste time and energy, I plan such appointments many months ahead of time.

Now, in an effort to get the influenza vaccine to high risk populations early, before the H1N1 flu vaccine is more available, and lessening the risk of confusing the two, the seasonal flu shots were sent from manufacturers directly to companies that run community outreach programs and large pharmacies.

That, by itself, would not be a problem if I also could get a supply to offer my patients in my own office. But, this year is incredibly frustrating, and I, like many, many other primary care docs around the country, am not getting an order of flu shots.

Adding insult to injury, at least one pharmacy is letting patients schedule times for flu shots but they do not yet have a formal protocol for giving them and therefore have to get a formal approval from me to give the shots. I'm spending time every day explaining to patients about the hassles I have had trying to get flu shots, encouraging them to get the shots, and then asking them to find the community outreach programs and pharmacies where the shots are available.

Like so often happens in primary care, this is a situation where I am trying to work for the benefit of my patients but then others in the system are getting paid while I'm left empty handed. It is a business model with fundamental flaws.

Consider this: for my own patients, with whom I have long, on-going relationships, and for whose care I maintain malpractice insurance, I spend time and energy getting them to go to a pharmacist (a pharmacist!) of a large corporation to get a flu shot. And, I must wonder, what happens to my patients if they have severe reactions? A post-vaccination reaction will be dealt with by whom? The pharmacist? Or me? Who gets the phone call if there are questions after the vaccination?

I am bitter, but not proud of it. I can not get flu shots, but large corporations can. I have to encourage my patients to get the flu shots, but then someone else in healthcare will profit from my efforts.

Watch for other blog posts later about this, but here I present a major problem in the American system and primary care. Society has two trump cards that get thrown at primary docs depending on the situation and on what the powers-that-be need at one time or another. Either docs are told: "this health care stuff costs a lot of money, so you better run a good business model and focus on value for the patients," OR, when it serves other needs, we are told: "but doctor, don't you have a moral obligation for the welfare of your patients and to not think of care as a business?"

In the end, the system is making doctors who can't maintain the business model and are so burnt out they can't maintain the proper moral tone. In discussion groups among doctors working hard to make primary care better, I see this feeling again, and again. And I fear the general public does not understand the situation or what the doctors are feeling.

I'm sorry, but, right now, I'm bitter.

--Timothy Malia, MD