A lot of people have
never felt the need for an ongoing relationship with a
physician. If you're like me, you see such people only
occasionally- when they have flu, a sore throat, a sprained
ankle. Or they may come to you one time and next time go to
another doctor or the ER. But I've developed a program that
involves them when they're well and helps keep them that
way. Furthermore, they begin to think of me as their doctor,
the person they can turn to when they do get sick.
Some of my regular patients who've often
frustrated me by not taking care of themselves have also
joined the program. Both groups are seeking preventive care.
I've wanted to provide it since medical school, but until
nine years ago, I never took the time to figure out
I call my program HealthTrends, and you
could apply something like it to your practice. It has
certainly rewarded me, both professionally and financially.
And I think it's paying off for the participants in better
health and reduced healthcare costs.
For 12 of my 20 years in practice, I did
the usual: reminded patients to get their tetanus boosters,
flu shots, Paps, mammograms, and so on. I diplomatically
suggested that obese patients lose weight, that smokers
desist, hypertensives avoid salt, and couch potatoes get up
and exercise. I put up posters promoting breast-feeding, and
auto safety for infant and child passengers.
I went further. Even before going to
medical school, I'd published cartoon coloring books on such
health problems as lead poisoning and sickle-cell anemia. So
I wrote and illustrated a publication for my patients on the
need for childhood immunizations. I distributed a quarterly
newsletter. Some patients responded to one thing or another.
Most didn't. And none of my efforts reached any
Finally, I realized that to have an
impact I needed a coherent plan that would monitor patient
compliance and progress, and keep the participants committed
to their own good health.
The personal computer, I decided, not
only was good for billing and sending timely reminders, but
could also be used for patient education. It was ideal for
keeping track of changes in people's health. Therefore, I'd
base my program on the computer.
If the computer was to be the skeleton of
my plan, what would flesh it out? Here, it suddenly occurred
to me, was a sound use for the annual physical. For years,
I'd felt the routine yearly exam cost more than it was
worth. But now I saw a reason for the annual exam-to monitor
changes in people's health, as well as how their lifestyles
affect their well-being.
The main question was whether people
would be willing to pay for the kind of exam I was
proposing. I soon found out: They certainly would. A lot of
people don't know if their cholesterol, blood sugar, or
blood pressure is too high. They have only a vague idea what
they should weigh. They think they should be more active
physically, but don't know the best kind of exercise. They
wonder how the stress in their lives is affecting their
health, and what to do about it. They want to know the
health effects of what they eat. And they can't remember
when they had their last hands-on physical. HealthTrends is
designed to give them answers.
Its core is a computer-scored health-risk
analysis. Before the patient comes in, he fills out a
questionnaire that includes 102 questions on current and
past medical history, additional questions on 43 stressful
events that may have occurred during the past year, and a
daily food log.
I charge $195 for the program, including
an hour-long history and physical, with all testing
appropriate to the patient's age, sex, and race. That fee
also covers a 10- to 15-minute follow-up consultation, but
not such optional tests as an ECG, mammogram, Pap smear, or
lab tests beyond the cbc, urinalysis, stool guiac, and Chem
19. (The ECG, urinalysis, Pap smear, and stool guiac are
done in-office.) There's also an optional physical-fitness
test carried out by a physical therapist. Patients don't
mind paying for the additional tests if I prescribe
Altogether, 150 variables are covered by
the questionnaire and physical. The patient gets a 5- to
15-page computer printout detailing his favorable and
unfavorable health factors, good and bad health practices,
cancer risks and warning signs, a mean projected life
expectancy, and 10-year mortality risk tables.
There are other printouts, which I
developed from medical-education modules on hypertension and
diabetes. These let us calculate ideal body weight, caloric
requirements, and cardiovascular risks. The computer
programs also analyze diet and generate an exercise
The printouts, along with explanatory
flyers, go into a folder that the patient keeps. I write a
covering letter summarizing the results of the physical exam
and laboratory tests and concluding with suggestions for
better health. The participant never has an excuse for not
remembering what the doctor said; it's all there, including
answers to the questions he was afraid to ask.
In the 12 months ending in August 1988,
80 people went through the program. There were 180 last
year. At the present rate, there'll be more than 200 this
year. About half of those who've entered the program in one
year have returned the next. Nearly all of those who've done
a second year have come back for the third exam.
New people enter nearly every week.
They're recruited by word of mouth, from occasional talks I
give, from our explanatory brochure, or from hearing my
explanation when they come as new patients with episodic
I developed the computer programs for all
this, and I'm now creating a program to track trends by
showing the participants the changing risk factors for any
disease for which they have greater- than-average 10-year
mortality risk. Thus we're beginning to make use of the 150
variables stored on each participant each year.
If a participant's health-risk analysis
indicates he stands an increased chance of dying from an
auto accident, for instance, my new program will go into his
personal data base and pull out the factors responsible-the
number of miles he drives each year, the percentage of time
he wears his seat belt, the number of drinks he consumes
each week. Some causes of mortality, such as atherosclerotic
heart disease, have as many as 20 major and minor risk
factors. A participant's risk factors are presented in
graphic form, and in the follow-up session I stress the ones
that the person could modify.
Participants range in age from 22 to 80
and include many Medicare patients. Where health insurers
allow clients a yearly physical, I do a HealthTrends
physical. In other cases, a diagnosis requires a
comprehensive physical. And many of our patients pay for
HealthTrends themselves, seeing it as low-cost health
Some participants who are employers ask
me to put their workers through the program as a preventive
measure. Each employee gets an individual assessment, and
the employer receives an overall picture of the health of
the workforce. This helps in directing health education to
areas of real need. If employees score well, the employer
will have an argument for reduced health insurance
One of my greatest satisfactions with the
program comes when people actually change their habits.
Occasionally a patient I haven't seen since the last annual
exam comes back having lost 40 or 50 pounds. When I ask what
inspired him, he replies that HealthTrends did: "I got tired
of having my weight keep coming up as a risk factor."
I've always been drawn to health
education and preventive medicine. Now I enjoy dealing with
people who want to know how to remain healthy.