What We Might Learn From Automobile Safety

One of the major advancements in public health has been the decrease in mortality from automobile accidents, as seen in this graph.

This achievement took action on part of engineers, behavioral psychologists, law enforcement, and countless other individuals working together to create a desired effect. For instance, below is a video from the National Highway Transportation Safety Administration (NHTSA) showing the result of a 1959 Bel Air automobile crashing into a 2009 Chevy Malibu. Although the Chevy Malibu is a smaller car, the passenger in the Malibu is much more likely to survive a crash than the passenger in the larger Bel Air. This occurred largely secondary to the impact of improved seat belts, improved crunch zones, and air bags.

Let’s break down how some of this achievement in decreasing automobile fatalities occurred. Here is a graph showing how seat belts (particularly shoulder-restraint rather than lap belts) saved lives, as well as the potential impact from air bags.

 

Further, behavioral modification changes such as greater criminalization of drunken driving have also decreased mortality.

We still have significant challenges, such as the increase in distracted driving by people texting or using their phone to search the internet, the potential increase in death rates from higher speed limits, the potential increase in marijuana-related accidents, and the challenge to decrease mortality from more fuel efficient cars that are often made with less steel. But these are seen as process-oriented problems with a hope for process-oriented solutions.

In short, this improvement in automobile fatalities occurred because many bright people from different fields worked together to help create a desired outcome.

But what would have happened if we just left the outcome to the individual buyer or driver of the car? Would the outcome have been as positive?  What if the buyer were given the option not to purchase that annoying beep when you don’t buckle your seat belt? Or if he/she could have paid a little less money not to have seat belts or air bags?

Yet when it comes to public health, we often state, “Well, it’s up to the individual.” Is this the best way to effect behavioral change? As a country, it is estimated that our obesity rate will be 42% to 50% by 2030. How will we pay for the increased health care costs that wlll result? If we have an outcome we desire as a population, for the individual and society, such as decreased obesity, why don’t we have thought leaders from many disciplines -– healthcare providers, industrial engineers, city planners, nutrition specialists, exercise physiologists, restaurateurs, farmers, basic scientists working on human homeostasis -- all work together to help generate the desired outcome?

Perhaps we may have better opportunity to effect the behavioral change desired if we create cities where people want to walk around, create communities that foster social interaction in healthy behaviors, create more nutritious fast food meals that are satisfying yet low in calories, and work together to decrease the burden for individuals and for society.

Help Your Provider, Help Yourself

I was eating dinner the other day with one of the healthiest appearing 62-year-old women I've ever met. She was vibrant, active and looked 15 years younger than her age. She said that she sees her doctor once a year and every year her doctor appears a little older, a little more harried, and little more distressed. She said, “I just want to give her a hug and tell her everything is going to be okay.”

The truth is that with decreasing reimbursements, liability concerns, office over-head expenses, personal debt concerns, more regulations, the need to see more patients in fewer hours, etc..., many providers feel quite frazzled. I believe some of this stress also occurs from the technological disruption which is occurring in the medical environment. Providers are not Luddites. Most providers I know love using their I-phone, and apps such as Epocrates which allows them to search medications or using web based resources such as E-medicine or Up-To-Date. However, many electronic medical records (EMRs) are not necessarily doctor-patient friendly. Rather, instead of the computer working for the patient and physician (as in the case of Epocrates and Up-To-Date), often providers feel they are working for the computer and they must adapt to it. For instance, here is a discharge note I received from an excellent cardiologist just last week. This is taken verbatim. “Please note that it is difficult to give the exact instructions of amiodarone on our electronic medical record system; but the fact that the patient will take 200 mg twice a day of amiodarone for 1 week followed by 200 mg daily has been explained to the patient and his family members.” It is not the fault of the drug or the physician, but the electronic medical record simply does not allow the input of such directions. Overall, it is a difficult transitions for many providers which I hope will work out for the best, particularly for the patient.

Lastly, new coding guidelines (called ICD-10) require such precision that in the future I am not sure how providers will be able to performs such tasks without either a medical scribe or a more enhanced artificial intelligence build into the medical record. To give an example, below I created a simple medical narrative and how it could be coded with the new ICD-10 guidelines. It could be funny, until you realize all the codes are real.

“John Doe drank a little and bet some money on the 2^nd Annual Llama and Camel Race at the Henderson Race Track. Unfortunately, he drank a little too much, tripped and fell on the driveway outside a local mobile home but was able to regain his balance before falling into a telephone pole and then, catching his balance, falling into it again. Undeterred, he decided to get on one of the llamas himself and ride off into the sunset, but was unfortunately hit by a 1994 Chevy Malibu. Thrown off the animal, he suffered a tri-malleolar fracture and appears to you dishelveled and slightly drunk.”

Now, CODE IT!

Y92024 Drive of mobile home as the place of occurrence of the external cause

W22.02XA Walked into lampost, initial encounter

W22.02XD Walked into lampost, subsequent encountered

V80.919 Hit by motor vehicle while riding an animal

S82.851A Initial encounter for closed fracture of tri-malleolar fracture

R46.1 Bizarre Personal Appearance

Such coding accuracy is often not taught in medical school or residency and requires a great deal of understanding and effort by the provider. Lastly, the simple basic medical narrative which tells of the patient's very real concernces and conditions can get lost.

So, in an effort to “do no evil” as Google might say, using Microsoft Word, my program director, Dr. Michael White, led a simple task force of myself and a college student to create a Microsoft Word template for an individual to construct his/her own medical summary. This can then be handed to the provider by the patient. It's a simple template which allows you to fill in your own medical history. Here is an example.

It can take a little while to accomplish depending upon your medical history but I believe it can be useful for both yourself and for the provider caring for you. One patient gave it to his doctor, and the physician actually started to cry because it was so useful for him and the medical record in general.

I do not know how to embed a formatable Microsoft Word document in Blogger, but if you would like to email me at delippman@yahoo.com with subject line, Medical Record, I will send you a copy for free.

Stress and Health

I am frequently asked if stress causes disease. Stress, I believe, has a huge psychological impact, and maladaptive behaviors in which we often engage in response to stress (such as smoking, overeating, excessive alcohol consumption, excessive rumination, etc...) can have extreme effects on one's physical health. Thus, potential treatment of stress may focus not only on reducing the stress-inducing events themselves, but also on one's response to such an event.

One of the organizations most interested in the physical and psychological impact of stress on the individual is the military. Military soldiers such as special operation forces who have a high probability of being behind enemy lines are often trained in intensely stressful situations with the hope of developing “stress inoculation.” Similar to vaccination theory, in which one is inoculated from a potential disease by vaccination with the virus and allowing one's immune system to fight it, stress inoculation hopes to build hardier soldiers to allow them to survive stressful situations associated with war.

One of the most stressful situations soldiers can experience is a course called Survival, Evasion, Resistance and Escape (SERE) at Fort Bragg's JFK Special Warfare Center. The SERE course is designed to simulate the evasion of an enemy, and if caught, to simulate a prisoner of war experience. Yale University's Dr Morgan, a researcher for the National Center for Post Traumatic Stress Disorder, studied 109 participants in the course.  Dr Morgan, et al. published their work with the title “Hormone Profiles in Humans Experiencing Military Survival Training” in 2000 in the Journal of Biological Psychiatry (2000:47: 891-901). They studied the salivary levels of cortisol and serum levels of testosterone at various stressful episodes of the training. Cortisol is a hormone released from the adrenal glands, which release carbohydrates for use by the brain. Testosterone is the primary male sex hormone.

In examining these individuals during stressful situations, researchers found that cortisol levels increased, while testosterone decreased. There was a change in the cortisol and testosterone during the escape and evasion, but the greatest changes in these hormones occurred when the soldiers were captured and underwent interrogation. During captivity and subsequent interrogation, testosterone levels could decrease to castration levels within 8 hours; the soldiers became effectively sterile during such episodes.

This study and others like it demonstrate that physical and psychological stress can have a profound biochemical effect on the body. It appears that this psychological impact is activated by a small walnut-sized organ in the middle of our brain called the amygdala. The amygdala analyzes for potential threats. If a threat is perceived, then messages are sent to the hypothalamus to release the fight or flight hormones.

From Wiki

It appears that there can be imprinting of a fearful event on the amygdala during a stressful situation. Thus, experiences that remind the amygdala (even unconsciously) of the stressful event can activate the amygdala to send a signal to the hypothalamus to release a cascade of fight/flight hormones. It is similar to someone who is having a panic attack. That person is convinced there is impending doom about to affect them. “Rationality” or “reason” are rarely effective during the acute attack, because one's body is currently being flooded by an activated amygdala subjecting oneself to a cascade of stress hormones.

People can respond to stressful events in different ways.  For instance, many smokers state that they smoke more in response to stress. Smoking releases dopamine, which is a “feel good” hormone. One can understand the desire for the cigarette in the effect that it has on dopamine release. However, when the dopamine wears off, the smoker often feels the need to smoke another cigarette to replenish the dopamine. This often creates a vicious cycle.

Are there other, more healthy means to decrease the impact of an activated amygdala? Actually, our frontal cortex is filled with inhibitory neurons, that, if activated, can calm an over-excited amygdala.  One activity that can help "turn down" the amygdala is meditation.  Meditation activates the inhibitory neurons from the prefrontal cortex and frontal cortex.  When functional MRIs (MRI scans that are performed with radioactive glucose that goes to areas of increased activity) are performed on skilled meditators, the activity in their frontal cortex and prefrontal cortex "light up."

There are various meditative techniques one can use to "silence the amygdala."  Often it is an attempt to decrease the constant inner voice chatter that occurs in our minds, most of which is negative, and allow a more contemplative, passive process.  Dr. Harold Benson, a cardiologist from Harvard, wrote The Relaxation Response in the mid-1970s and still has courses for physicians and other healthcare providers at Harvard.  His technique is at this website.  Christians may find Father Thomas Keating's Centering Prayer helpful; here is a website that offers PDFs that describe his process.  Thich Nhat Hanh, a Buddhist monk who has written extensively on meditation, has a short essay here on one of his simple, yet potentially powerful techniques.