Checklist Health

Can your health be reduced to a bunch of numbers? American medical care is about to test that idea.  Beware the results. Checklists – and the checked off numbers – do not a healthy population make.

Why Are Checklists Taking Over?

People love numbers. They like to count things. Medical care costs enormous sums. To “gauge” what they get for their money, the many profit oriented masters of medical care – half of doctors are “owned” by hospitals and large groups – prefer checklist responses. Yet what you don’t count may be much more important than what you do especially when you goal is overall health.

What Really Matters In Health?

There are different definitions. The WHO statements says health is complete physical, mental and social well-being.  As purpose also has an outsize effect on health – as measured by hard end points like lifespan and survival – spiritual (meaning and purpose) should be added to the list. But do present day checklists survey social and spiritual health? For medical care – virtually never. Attention to “mental” health usually involves a few questions regarding depression. And medical checklist definitions of “physical” health often comprises little more than numbers defining weight, blood pressure, chemistries and cholesterol. Certainly important stuff – but hardly the sum of human health.

What is more disturbing is the perception that the doubling of human lifespans in the last eighty years has been accomplished by medical care. Nutrition, sanitation, education and vaccination were far more important.

They still are. If you believe the Swedish Kungsholmen data – which have followed central Stockholm’s varied population for decades – lifestyle added 6-7 years of life at age 65, four years at 85. Medical care adds a small fraction of that.

And that is looking only at longevity and survival. There is more to life than survival. There is pleasure and purpose, heart and spirit, culture and community – all with their own large impacts on “health” indicators such as blood pressure. For example, having ample green space cuts heart attack risk 30% or more in British housing projects.

You won’t find that healthy stuff on checklists.

Why Are Checklists So Popular?

Medical statistics often provide a sense – and too often the illusion – of mirroring reality. It is a lot easier measuring someone’s cholesterol level than the number, depth and engagement of their acquaintances and friends. Yet one may argue very plausibly that social support has a considerably bigger effect on people’s heart health – like heart attack risk – than all of cardiovascular medical care.

Physician behavior today is heavily influenced by “metrics.” Many of those metrics are driven by insurance reimbursement – and the interests of drug and device companies. Doctors will tell you they will be dropped from insurance coverage unless they upload the results of their “lists.” Put that together with the giant political sop to the IT industry – the anarchic, hackable mess of American electronic health records – and checklists look more and more attractive to corporate clients.

It’s also easier for patients and physicians to check off checklists.   If the “numbers are good,” well, how bad can things be? Of course if the patient suffers from chronic pain or severe depression, that won’t necessarily show up on the CBC, metabolic panel, blood pressure and EKG. But the physician’s job is done. She’s checked off the numbers. If the numbers are fine, you’re fine.

Too bad if you don’t feel that way.

Just consider this – if social support is more important to survival and heart health than cholesterol, how many media messages have you heard about social support decreasing heart disease – versus ones on cholesterol and saturated fat? Have you ever heard any at all?

 

Checklist Medicine and Health

Blood pressure, lipid levels and liver function tests matter a lot. But they are not the sum total of health. That’s even true for the often narrowly defined component of physical health. Waistline, what you eat and your physical activity matter more – if lifespan is your measure of medical health.

Yet health is not what medical care produces. Medical care produces serial treatments of diagnosable disease. There’s plenty of that around – and it still needs lots of work and attention.

Yet checklists might be used to restore health to the primacy of “health” care. Not just doctors, but communities could look at measures of social, family and community ties; the quality and availability of clean drinking water; the capacity of  individuals to think mainly in terms of solutions rather than just problems.

Such checklists would require thinking that goes beyond patient-doctor interactions to consider the actual health of the community. That would save lives and money. It could make a lot of people feel a whole lot better.

It just doesn’t fit into the electronic health record, or the “quality indices” of insurance companies.

Yet.