How a cardiologist helps patients reduce blood pressure meds with a five minute talk
Gregory Sanders, MD, is a non-interventional cardiologist practicing at Arizona Cardiology Group in the Phoenix area and the founder of Hybrid Chart, a hospital rounding software solution. He is a big believer in the power of lifestyle interventions to help his patients and reduce the burden of chronic disease in America. In this interview, Dr. Sanders discusses his approach to lifestyle counseling, the impact of healthcare reforms on his practice, and the potential impact of investing in lifestyle interventions on a large scale.
Learn how he motivates patients to make changes and reduce their meds with just a five minute talk…
The sodium talk that gets results
How do you define a lifestyle intervention?
“The traditional lifestyle intervention is one where a doctor sits down with patients and gives dietary advice or tells them to stop smoking. However, it’s very easy for doctors to say “you should eat better” without any specific examples.
For example, it is imperative for my patients with congestive heart failure or hypertension to eat less sodium. Doctors will say, “You should eat less salt.” Patients then reply, “I don’t eat salt,” because they are only thinking of a salt shaker. When I ask them how much sodium they eat a day, they have no idea.
At this point, 20% of my job is to tell patients to eat less salt and 80% of my job is to be more specific. I tell them to eat less than 1500mg of sodium per day. If I just stop there, they will say, “Ok great. I’ll add this to my pile of info that I need to store.” Then, I give them guidelines and specific examples of sodium. One dill pickle is 1000mg and they say, “Uh-oh. I eat pickles every day.”
If you really dig, then you uncover the fact that a lot of it is about education. If you want to help patients make meaningful lifestyle change you have to ask real questions. For example, their definition of exercise is often different than yours. “I do a lot of yard work” or “I’m walking like crazy at work.” You work at an office! You walk to the coffee maker and back. That’s not a lot of walking.”
Do you have the time to discuss lifestyle with your patients?
“Of course not, but I make the time. I don’t have to make the speech every visit. My sodium speech takes five minutes. If I’m really managing my time properly with my patient and I’m not being clicked to death by my EHR then yes. Sometimes they tune out. They don’t want to be hassled, nagged, and lectured to. I have a patient on 3 medications with high blood pressure. He comes in to see me and thinks I am going to add a medication. I tell the patient, “I’m going to get rid of your meds.” Now he starts taking notes.”
What kind of results have you seen from your sodium talk?
Patients will come back two months later on a low sodium diet and their blood pressure looks fantastic. Then I say, “Let’s take away one of your meds.” And they are shocked! Almost all my patients that have hypertension make some changes and have some success with this.
“I always tell people it’s not your fault because you were never told. Almost 80% of the time I am able to take down at least one med if they do a low sodium diet. Very rarely do I see a patient that doesn’t see a difference.
We also start to see the difference between environment and genetics. I have a few instances of patients where it is literally all environment. I have a patient who is vegetarian and a triathlete, but is on five blood pressure meds! I start with my salt speech and he puts his hands up and says “I don’t eat salt.” “I am healthy.”
I walk through my salt speech with him and three days later he calls me and says, “You won’t believe this. I’ve just added it up. I have 13,000 mg of sodium per day. I have a lot of veggie burgers and cheese, which are too high in sodium.”
He took himself down to 1000 mg of sodium a day and his wife called me and said he had passed out 3 times today. I stopped all five of his blood pressure meds in a week. He was militant about it. Finally, his blood pressure was back to normal without any meds.”
Free cooking classes and connecting patients to weight loss programs
Tell me about the cooking exercise classes you used to offer to patients.
“One day we decided to put together a program for diabetic patients that would actually provide concrete suggestions on what to do. We realized our diabetic population was very confused about what to eat. Many end up with nutritionists, which is great, but a big chunk of them don’t.
We found a chef who specializes in healthy lifestyles. We put on cooking classes for patients in our lobby after hours. First we did a little bit of a lecture on the glycemic index and the American Diabetes Association (ADA) diet for diabetics. They did a cooking demo and everyone got to sample the food. The chef did a great job of going over very basic concepts and offering simple techniques that could easily be extrapolated to other meals. We did a bunch of cooking classes in a row and both the turnout and feedback were fantastic!”
Did you see any correlation between the classes and patients health?
“The qualitative feedback was excellent, but we didn’t measure the impact. Someone should do a study measuring patients’ A1C [a standard measure of blood sugar levels], have them attend the cooking class and then compare them to another group of people. We should do some questionnaires about their changes in eating habits, neuropathy symptoms, energy, etc. and re-measure their A1C.”
Why did you stop offering the classes?
“We eventually stopped offering cooking and exercise classes due to budgetary constraints. We did these programs 8–10 years ago when doctors had a lot more wiggle room. Now a lot of the problem is financial. Reimbursements have gone down 30% over the last six years. Now a doctor goes to the group and says let’s do an exercise class, cooking class, tai chi on front lawn and everyone says, “That’s such a fantastic idea and a great value add. How much will it cost?” In the olden days, doctors had more discretionary income.
Now, expenses are going up and reimbursements are going down, so offering programs for preventive health becomes harder to do. People offering lifestyle programs now have gravitated to the concierge realm. People pay thousands of dollars a year to be a patient, so part of their value-add services are these lifestyle enhancements.
A primary care physician must see at least 35 patients per day to break even. That’s why primary care doctors are selling vitamins, botox, etc. to earn supplemental income. There are only so many hours in the day.”
Lifestyle changes will take an absolute backseat if you have no time and see so many patients in a day.
Do you refer patients to nutritionists or weight loss programs?
“We used to refer to a group of nutritionists, but problem was that it was hard to get patients to go. There are patients that ask for it. The ones that don’t think they have a problem only see another co-pay, a drive, parking, etc. and say “I don’t want to do it.” Same for the lifestyle thing.
Personally, when I do weight loss with patients I divide them into three categories: do it yourself (Jenny Craig, Weight Watchers, Nutrisystem, etc), bariatric surgery, and physician guided weight loss. Bariatric surgery is for patients who are really in trouble and can’t lose the weight. For physician guided weight loss, the Scottsdale Weight Loss Center uses the Optifast diet plus tons of counseling and psychological analysis and Dr Sophia Fountis uses the Cleveland Clinic Ketosis Diet. These options are very expensive and not covered by insurance. But, if you are motivated and desperate enough, you’ll find the money. They do work.”
MACRA and Population Health Management
Do you think MACRA (Medicare Access and CHIP Reauthorization Act of 2015) and the move to value based purchasing will support lifestyle interventions?
“No. I’ve never seen a government program really work. Most doctors will view this as another hoop they have to jump through to get their “treat” at the end and not an opportunity to make meaningful change.
I don’t think MACRA will be the answer because most doctors are already running in circles to meet all the measures.
If you were to have the patients come in, watch a video about sodium intake, take a multiple choice quiz, and then get reimbursed — now that’s different! Now my motivation is to get patients to watch this video. Now we are rewarding the right behavior. These incentives will require different models and approaches, because it doesn’t make sense from a spreadsheet point of view. I am hoping that reimbursements from payers will start to incorporate more forward thinking interventions.”
Are you using any population health management software tools?
“We’re looking into a lot of these tools especially with MACRA. We are talking to our EMR vendor, Centricity, for collateral products, such as Health Catalyst. We are looking into lots of products to manage population health. However, if you are going to make doctors use it, it’s got to be easy for the doctor, collect data, integrate into the EMR, and not slow them down.”
Regulation vs Personal Responsibility
Do you think lifestyle interventions could make a measurable impact if you had the time, money, and incentives to really invest in them?
“100%, yes. Here is the problem we have in America. We have a lack of education on diet and exercise. Kids and adults are up against the food industry which is running completely rampant. They are allowed to make food that is so easily accessible. There is a donut shop on every fifth corner. The food industry puts something in a “green” box, puts a heart in the corner, and smart in the title, but there is nothing healthy about that food at all.
Americans are always creating some new convenience to get out of any type of exercise. Now we have an obesity problem that is spiraling out of control. Pharma is focused on bandaids and not cures. Get everyone fat with diabetes and hypertension and then give them pills.
If we as a society were to invest in preventative health and were to truly promote healthier lifestyle, promote exercise and a better diet, and regulate and educate, our obesity problem would get better. Then we would reduce the need for medications that treat or manage these chronic disease.
We can’t eliminate all disease, but I’m willing to bet we can eliminate a lot. We can reduce the disease burden in our country, but this requires affecting human behavior. We are a free country. We don’t want to over regulate. There is this balance between personal responsibility and regulation. But, it is hard to give someone personal responsibility when they don’t have regulation, options, and tools.”
Conclusions and Reflections
- Creating a support network: If done right, even with a very limited amount of time, a physician can be the catalyst for change in a patient’s life. But, the physician needs a support network for the patients that he can tap into that includes resources, programs, group classes, trained professionals, etc. These resources must be effective and not cost prohibitive to the patient.
- Incentives: The reimbursement incentives need to be in place to make it possible for the practice and the physicians themselves to invest more into lifestyle interventions. It is ironic that health care payment reforms and the cost of technology have led to budget constraints that no longer make it feasible for Dr Sander’s practice to offer the cooking (and exercise) classes that their patients enjoyed so much!
- Technology: Although MACRA will cause a great deal of grief for physicians, it is opening up the market for new population health management tools. These tools typically help practices put together lists of high risk patients to focus on, report on quality metrics, and facilitate care management. Some also offer patient engagement solutions, such as apps and wearables. Consequently, a population health management platform could be an excellent entry to providing technology-based lifestyle interventions, such as apps, wearables, and digital coaching. More on that in a future article!
What do you think?
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