"An Ounce of Prevention..."

My grandmother had a life full of folk wisdom and sayings, and one of these was the old truism, "an ounce of prevention is worth a pound of cure." Now, I wish I had listened more carefully to those sayings. That one saying is perhaps the most important piece of health care information I even learned before or after my training as a doctor. And, if you listen to the president's speeches about the proposed future of health care in this country, then you are led to believe that the new system is designed to be prevention based. No less a person that the president of the National Hospital Association made a statement in a national interview that prevention is going to be the important focus of health care. This is significant in that hospitals, by and large, make their money from cases in which prevention care was not implemented or failed.

The real question is whether there is going to be a real prevention based system or whether it will be a retrofitted one, i.e., simply a medical model which is stressing things like breast exams and vaccinations. The ludicrous thing is that these are still illness-based procedures and are not health or wellness based in their approach. Much to President Clinton's credit, he is using the terms wellness and health and prevention, but the medical system, being disease based, doesn't really understand what true health is nor what prevention based care is. You have to recall that these are the same people that for years said that you could get all the vitamins you need from a "balanced diet" and they ridiculed the notion of mind-body interaction.

Bizarre Notions on Prevention

For the medical system prevention has always been a low level priority and I am sure that some MDs are confused how to go about structuring a prevention based system. In the 20th century, a certain elitism evolved in the medical community. This elitism placed the specialists (i.e., neurosurgeons, oncologists, etc.) at the top and the general practitioners where placed at the bottom. As a result of this fact specialization tacked another $100,000 per annum onto the doctor's income, it didn't take long for student's in medical school to drift toward the higher paying areas of specialization and eschew general practitioner roles.

As a result, it has been estimated that this country has twice as many neurologists, cardiologists, and anaesthesiologists as it needs, and around 2.4 times the amount of surgeons it needs. This emphasis on placing more worth on areas of practice to do more "heroic" care and downgrading of the status who serve as portal of entry is obviously going to have to end. In fact, there has been talk of the possible need to send specialists back for retraining to serve as general practitioners.

True Prevention Based Doctors

As a result of the de facto abandonment of the general medcial practitioner, the DOs have moved to fill the family doctor role, especially in the smaller rural communities and with several health maintenance and preferred provider associations. But I assert that the doctors who have been the true champions of prevention and cost containment have been doctors of chiropractic. DCs have been holistic in their approach, concerning themselves with psychological and physiological aspects of a patient.

The Many Faces of Prevention

Really even using the word "prevention" is still a disease-based way of thinking. Health maintenance is perhaps a better way of thinking about the ongoing effort of keeping yourself functioning at a high level of wellness. Of course to be health based means that you have to decide what activities, nutrients, outlooks, promote health. It seems interesting that as we are moving into an era where prevention is de rigueur, that the FDA has renewed their efforts to regulate vitamin taking. Health does not just happen as a result of having clean arteries, regular heart beat, normal EKG and EEG readings. Health is a dynamic continuum, not a static picture in an anatomy test.

If a man or woman is working at a job they hate, constantly worried about finances, constantly arguing with their spouse and kids, drinking too much alcohol, smoking too much, coming home to plop down on a couch without getting regular exercise, eating fat and grease like it is going out of style, do you think that person is at a higher risk for getting sick or having an accident of some type? I do, and these are the things that America must address as part of getting the overall health costs under control.

For example, it costs a lot less to have a chiropractic doctor train patients about proper biomechanics of lifting, than it does to have the same patient sustain a disc herniation and require back surgery (a procedure which has a relatively high failure rate and patients often end up getting two, three or more back surgeries). The same is true about diet and exercise. Better to start observing a leaner diet than end up under the cardiothoracic surgeon's knife.

No High Drama Here

Prevention never has been the kind of thing that gets headlines. Few people come up to you and shake your hand thanking you that they don't have cancer or heart problems. The medical community presents the image of a surgeon peering intently into a body cavity saving a life. It has presented this image in movies, on the news, in documentary presentations, but this often is a dramatic depiction of the failure of both patient and physician to take aggressive roles preventing illness.

Prevention is not high profile. You don't see a safety engineer's picture decorating headlines in the same way you do an EMS person who is dragging a driver from a mangled car. Similarly, we have obituary columns listing those who have died and not a vitality column listing all the people in town who survived another day.

Good Prevention Habits

People tend to be procrastinators and sometimes lazy. But for things that they realize have to be done, such as getting their teeth brushed or getting their care inspected, they seem to make time. For chiropractic doctors, our job (and a tough one) is to help them realize that maintenance care of the spine is certainly as important as maintenance care of their teeth. Periodic adjustments are as important as regular dental hygiene. But, getting spinal manipulative therapy is only part of the overall prevention plan.

The good DC should offer the patient advice on nutrition, stress management techniques and practices, correct breathing (i.e., diaphragmatic as opposed to upper chest, shallow breathing), should suggest good exercise programs, should instruct the patient on good biomechanics and, if the patient is an office worker in a seated position, he would educate the patient about ergonomic considerations.

In the Hot Seat

For patients who are in clerical or desk jobs working on computers all day, there are several potential health problems which are preventable and the chiropractic physician can perform a valuable service by helping the patient make small changes in their work environment to make the job not only safer and easier, but even more enjoyable. Prevention of repetitive stress injuries (RSI) such as carpal tunnel syndrome alone, can be of immense benefit.

Helping employers fit employees with chairs which support the low and mid-back and instructing employees how to sit properly, is an art in and of itself. The fact is that low back problems are one of the biggest reasons for employees missing work and if you can help prevent these problems through assessing a work environment and making it less conducive to creating musculoskeletal injuries, then you will be the hero and this is definitely an area in which prevention based care has a place.

Get the Word out

Chiropractic physicians must be more aggressive in educating the public about prevention and its benefits and in positioning ourselves as prevention doctors. I feel that the national organizations should sponsor a one hour, prime-time television program on one of the networks, discussing prevention based care and how chiropractic has an important place in assisting patients in developing preventitive programs, and has a portal of entry to detect early signs of various health care problems. This requires bucks, but this is a crucial time to establish and associate ourselves with prevention practices. If we don't speak out more before the new system is entrenched, prevention may just come to mean breast exams and vaccinations.

John Raymond Baker, DC
Beaumont, Texas