noitdi dateE
rth 8 Upu
Fo 201danJohn Wasson, MD and Regina Benjamin, MD, MBAusing www.HowsYourHealth.org

HOW’S
YOUR
HEALTH?
What you can do to make your health and health care better.

Learn how easy it is to:• get information• communicate with doctors and nurses• better manage problems• create a portable electronic health record• and much more!

HOW’SYOUR
HEALTH?
What you can do to make your health and health care better.

Fourth Edition
John Wasson, MD and Regina Benjamin, MD, MBAusing www.HowsYourHealth.org

How’s Your Health?
Notice. The authors and publisher of How’s Your Health? and thewebsite www.howsyourhealth.org have checked with sources
believed to be reliable in their efforts to provide complete andaccurate information. However, in view of the possibility of humanerror and changes in medical sciences, neither the author nor the
publisher nor any other party involved in the preparation of thiswork warrants that the information is accurate and complete inevery respect. Readers are encouraged to confirm information withother sources such as their own doctor, nurse, or pharmacist.

Copies of this book may be ordered at www.HowsYourHealth.com
or www.HowsYourHealth.org. Call 1-800-369-6669 for multiple
copies.
Copyright © 1998-2009 by FNX Corporation. All rights reserved.
Printed in the United States. Except as permitted under the UnitedStates Copyright Act of 1976, no part of this publication may be
reproduced or distributed in any form or by any means, or stored ina data base or retrieval system, without prior permission of the
publisher.
HowsYourHealth is a registered trademark by the FNX Corporation.
www.HowsYourHealth.org and www.HowsYourHealth.com aredeveloped and maintained by FNX Corporation under license with
the Trustees of Dartmouth College.
The text and graphic designer was Luann T. Ebert.
Cataloging-in-Publication data is on file at the Library of Congress.
ISBN 0-9666743-0-8iiPreface to the Fourth Editionof How’s Your Health?
The Highlights
In 2005, the first printing of How’s Your Health? sold out
quickly, the National Business Coalition added its voice
to the many others who have adopted How’s Your Health?,
and we began translating our free HowsYourHealth.org
website into several more languages to meet demand.
Even The New York Times adapted our story of “Wallyand Louise” (see page 111) to tell Americans of betterways to experience health care. That story reminds usthat when doctors and patients are “on the same page,”better health and health care just happens.
By 2006, the world seemed to recognize the importanceof “patient-centered care.” The Journal of Ambulatory CareManagement devoted an entire issue to “Technology for
Patient-Centered, Collaborative Care” based on our work.
You can read those articles at www.HowsYourHealth.org.
Finally, by 2006, doctors really began to understand thepower of HowsYourHealth.org. For example:““

When I started hearing about HowsYourHealth, I did not truly
understand the scope of the program and what it did…
I. Helps the patient by:• Forcing them to think about their health during the survey• Giving them readings directed at the diseases they admit toduring the survey• Giving them an action plan to take to their doctor• Allowing them to have a personal health record
II. Helps the doctor by:• Allowing them to see the action plan of their patients• Allowing them to have practice specific data on issues
such as access, efficiency, etc.
- Dr. JB, Newport News, Virginiaiii

The Lowlights
For the first time in United States history a majorityof Americans said that they were dissatisfied with thequality of health care. In fact, 60% said that they did
not believe the United States has the best health care in
the world. Health care cost remains the leading national
health concern of Americans. And there is huge variation in cost! One study reports that the variation in
charges for a presumed middle ear infection is morethan 250%.
From our ongoing review of the many studies relating
to health and health care, here are a few of the disappointing reports:• 2 of 3 diet books have recommendations unsupported
by scientific studies• about 1 of 6 Americans have little idea why they aretaking their medicines• potent arthritis drugs were taken off the market andthere was good evidence for “cover-up and corruption” in several high places related to this and several
other situations
And from the HowsYourHealth.org website we find that
only about 20% of adult Americans strongly agree that“they receive exactly (the health care) they want andneed exactly when and how they want and need it.”
The table on page 50 shows the differences between the
20% who strongly agree, the 20% who disagree, and the
60% in the middle. In which of the three columns are
you and persons you love?
Let How’s Your Health? Be One ofYour Highlights

iv

How’s Your Health? highlights the path to “same page”
care and helps people more often report that theyreceive exactly the health care they want and needexactly when and how they want and need it.

Origins
The Authors
John H. Wasson, MD John Wasson is Emeritus Professor of Community andFamily Medicine and Medicine and former Herman O. West Professor of
Geriatrics at Dartmouth Medical School. At Dartmouth he has led a number ofprograms including outpatient services at the Veteran’s Administration, the Centerfor the Aging, and the Dartmouth-Northern New England Primary Care Research
Network. He was national co-director of the Institute for HealthCare Improvement
Idealized Office Practice and IMPACT projects. In 2006 he received an award as"pioneer for practice-based research" from the Agency for HealthCare Quality andResearch His publications and research in the improvement of health care ranges
from pediatrics to geriatrics.

Regina Benjamin, MD is a former vice admiral in the U.S. Public HealthService Commissioned Corps who served as the 18th Surgeon General of theUnited States. She is a Professor in the Department of Public Health Sciences at
Xavier University of Louisiana, where she occupies the NOLA.com/TimesPicayune Endowed Chair in Public Health Sciences.
Among many honorary degrees and awards she received both the Nelson
Mandela Award for Health and Human Rights and the National Caring Award
inspired by the work of Mother Teresa. In 2008, she was honored with a
MacArthur Genius Award Fellowship.

The HowsYourHealth Website
During the last three decades, health services researchconcluded that frequently patients and health care professionals were not on the “same page.” This researchvOrigins
also documented that a lack of “same page” care often
results in waste, harms, and poor outcomes. The
HowsYourHealth website evolved to improve “samepage” care.

And Readers Like You
This book summarizes the findings gathered from national use of the HowsYourHealth website. It shows theimportance of “same page” care. This book shows readers how to use the HowsYourHealth website and related
technologies to improve their health and health care.
Many people are not concerned about health care when
they are healthy. And when they are sick they will not instinctively turn to a book or the internet for help. We
hope that you are an exception to these general patternsof behavior. We offer you a website that goes along withthis book at www.howsyourhealth.org withoutcharge, advertising, or any sneaky method to extract
money. In fact, you don’t have to purchase this book to
use the website. We hope that you will take advantage ofHow’s Your Health?, now.
After all, the life you save...
vi

Contents
Part I: Welcome to Our World

1

When Alice visited Wonderland she learned that time
was odd. She heard people saying very strange things. She
saw that common sense was not very common at all.
We physicians work in a world that is normal to us.
However, we know our world appears like Wonderland
to many Americans.
A Map
Doctor Time is Odd
Doctor Language is Often Strange
Common Sense is Not So Very Common
A Very Brief Glossary
Chapter 1: What Are My Chances?

2
4
5
5
7
9

Before you begin to improve your health you need to understand what might damage your health in the firstplace. Misunderstanding risk undermines good healthhabits and effective self-care. Misunderstanding risk canalso be bad for survival.
Misunderstanding risk is bad for survival!
Risk and Health Decisions
Lower than the risk of murder…
“What Are My Chances?”
Postscript: Ways to Get Better Risk
Estimates
The Pressure is On Us Not to Get Risk Right
Chapter 2: As Good As It Gets

9
10
12
13
14
17
19

In the Academy Award movie by this name, Carol(Helen Hunt) wanted to manage her son’s asthma well
but lacked timely, humane support to help her become
confident. The movie mirrors the real world. Peoplevii

Contents
want to manage their health issues and concerns well…but usually lack timely, humane support to help them
become confident.
Getting on the Same Page
Care That Is As Good As It Gets
Me? Confident to Manage and Control My
Problems?
Health Care Quality
What About Cost?
Postscript: Bar Graphs

19
21
22
22
24
25

Part II: Are You Ready to Improve Your
Health and Health Care?

27

You should now have a reasonable understanding of ourhealth care Wonderland. Now it’s time to put your understanding to the test. (If you HATE TESTS, don’t
worry. This brief test is different.)
A Test for Catching Metaphors
Chapter 3: Doesn’t Everyone Worry?

30
31

We think about health everyday. Sometimes we worry
about health and health care. What are Americans mostcommon worries and concerns?
An Apple a Day
Preventing Disease and Premature Death
A Growing Worry: How To Make the Health
System Better
Is the Wolf Near the Door?
Sex, Drugs and Violence
Postscript: Health Care Harm andPrevention Gaps
Harm
Prevention Gaps; Things Not Done
That Should Be Done

viii

31
33
34
36
37
38
38
41

Contents
Chapter 4: Inside a Doctor’s Office

45

Health care is a complex business. People who use
health care can easily suffer from its complexity. Those
who work in health care usually suffer from the complexity too.
A Tale of Two Practices
46
Perfect Care? Are You Kidding?
48
Postscript: Americans’ Views About
Perfect Care and Doctors’ Views of
HowsYourHealth
51
Health Care
51
Access to Health Care and Efficient HealthCare
52
Communication and Coordination
52
Doctors’ Views of HowsYourHealth
53
Chapter 5: Problems Are Made To Solve

55

The moment we are born, we are solving problems. Poor
problem solving is a threat to health and well-being.
Problem-Solving is a Way of Life
55
Problem-Solving Made Simple
57
How Does HowsYourHealth Problem Solving
Work?
59
Which Problems Matter Most?
61
Good Problem-Solvers Can Be Made
63
Postscript: Adult Problem Solving and Risk,
Getting Teens to Problem Solve
64
Adult Problem Solving and Risk
64
Teen Problem Solving
66“Up-the-Stair” Actions
66
When You Have a Problem, Which
Stairway Do You Take?
67
Actions and Consequences
68
Feelings and Actions are Connected
68
Looking at Ourselves
69

ix

Contents
Chapter 6: It’s 100%71

Esther is a very successful businesswoman. She enjoys
her success and close family. Until recently, health has
been an abstract idea and a collection of dull statistics.
Many times in our lives we are all like Esther. We takeour health for granted. And then it’s our 100%concern!
Are You a Sugar or a Person?
Esther’s Mother Can Do Well
If Esther’s Mother Does Not Have Adequate
IncomeThere is a 100% ISSUE Close to You
New-Born Intensive Care
Children Aged 2-8
Pre-teens and Teens
Adult Chronic Diseases
When Relationships Break Down
Elder Issues
When We are Seriously Ill
PostScript: More About Chronic
Conditions Excerpted fromwww.howsyourhealth.org
Hypertension (High Blood Pressure)Heart Disease and Hardening of the Arteries(Sugar) Diabetes
Arthritis
Breathing Problems: Bronchitis, Emphysema,and Asthma
Serious Obesity
Medications

x

71
73
75
76
76
77
80
81
83
83
85

86
86
87
88
90
91
94
95

Contents
Part III: Are You and Your Doctor Ready to
Improve Your Health and Health Care?
97
You now have a good understanding of the promise of“same page” care. Now it’s time to help your Doctor
make care not just “as good as it gets” but as good as it
can be!
Chapter 7:
The Promise of Same Page Care

103

“You should always be careful when reading books
about health. Otherwise you might die of a misprint.”- Mark Twain
Four Steps
PostScript: Using HowsYourHealth
Getting Started
Take Action
Suggested Readings and Helpful Links
Self-Care and Problem Solving
Your Own Portable Health Record
What Does Your Doctor See?
What Does Your Employer, School, orCommunity See?
Chapter 8: The Next Great Idea
Unintended Consequences and the
Next Great Idea
Self-Care and Self-Management at the
Next Level
Bleeding While We Wait?

104
112
112
113
116
118
120
121
122
123
124
126
127

Part IV: It’s Your Journey

131

As Good As It Can Be

132

xi

Contents

xii

Acknowledgements and References

135

Annotated References
About the HowsYourHealth Website
Data Used for This Book
The Artwork
Guide to Figures and Tables

136
136
139
147
148

Part I:
Welcome to Our World“Contrariwise,
if it was so,
it might be;andif it were so,
it would be;but
as it isn't,
it ain't.”
Lewis Carroll.
Alice In
Wonderland

1

Part I: Welcome to Our World

Welcome to Our World
When Alice visited Wonderland she learned that time
was odd. She heard people saying very strange things. She
saw that common sense was not very common at all.
We physicians work in a world that is normal to us.
However, we know our world appears like Wonderland to
many Americans.

Welcome to the Office.
I'd like you to meet the insurance
brokers, lawyers, government
regulators, bankers, LPNS, RNs,
MAs, PAs, NPs, OTs, PTs, MDs, CFOs,
CEOs, billing clerks, receptionists...
he purpose of Part I is to help readers better understand the Health Care Wonderland they usually enter several times a year.

T

A Map
Alice’s journey through Wonderland took her throughmany sTRangE places that in many ways were also familiar. The map (shown at right) illustrates some of theplaces you will visit in How’s Your Health? At times they
will seem strange; but they will also be very familiar.
So let’s begin...

2

Part I: Welcome to Our WorldThe Path to Same Page Care
Welcome to
Our World
What are
My Chances?

Doesn’t
Everyone
Worry?

It’s GoodAs It Gets

Inside theDoctor’s
OfficeIt’s 100%

Problems
Are Made
To Solve

The Next
Great
Idea?

The PromiseSame Page
Care

3Part I: Welcome to Our World
Doctor Time is Odd
Over the course of a year, doctor contact time with patients is very small. Despite the small amount of timespent in contact with a patient, doctor actions result invery large expenses. Because a small amount of time canresult in very large expenses, any miscommunication can
result in a great deal of waste.
The first “pie” diagram below shows how much of our
waking time is spent at work, how much time we should
exercise, and how much time we spend in contact with adoctor or other health professionals. The second “pie”
diagram shows how much of American money is spenton health.
A tiny sliver of doctor
time results in a large
amount of American
expenses.

How Americans Spend
Their Waking TimeTime with
DoctorHow Americans Spend
Their Money
Health $Work

Other Time
Good
Exercise

All Other
Expenses

Doctor time is odd is because it is so focused on doing
things. If you have a 30 minute appointment with us wewill spend only a few minutes listening to you. (Studies
show we will usually interrupt you within 22 seconds!)
Most of the time we will be doing tests, writing things
down, filling out forms, and talking at you. We don't
spend nearly enough time finding out what matters to
you and helping you live with any problems you have.

4Part I: Welcome to Our World
Doctor Language is Often Strange
Doctors, lawyers, and most professions use a special language. The doctor language is designed to communicate
about disease and illness; it is not designed for effective
communication with non-professionals; with people likeyou. Even the sickest person only spends a sliver of timewith a doctor. The small amount of time spent withphysicians should be very well designed to help people
live as healthy a life as they can.
Common Sense is Not So Very Common
In our Wonderland all is not as it seems. Because miscommunication is so common, doctors and their patientsare often not on the “same page.” If you have ever sungwith a group, you know that you need to be on the same
page as everyone else or you will not be singing the same
song, not moving to the same beat.
Common sense says that doctors and patients should beon the same page. But our odd doctor time and ourstrange language often get in the way of “same page”
communication.
When we brush our teeth some bacteria enter our bloodand are cleared by our body’s defenses.
One spring day a healthy young man brushed his teeth
and the bacteria were not cleared from his blood.
Instead a small number of bacteria settled on his heart
valve and began to multiply.
During the next two months he saw several physicians.
He was told he had the flu, to take some cold pills.
Meanwhile the bacteria gradually ate through the heart
valve.
In the nick of time, a very skilled heart surgeon was able
to fix the heart valve. This young man is the son of oneof the authors of How's Your Health?.

5Part I: Welcome to Our World
The story on the previous page illustrates how the healthcare Wonderland can give us both the worst and best. It
can miss simple problems and yet fix horribly difficult
problems. American health care can provide incredibly
powerful treatments but at a cost that is beyond thereach of more and more Americans.
This young man needed someone to notice that something was really wrong…the “flu” and a fever should notlast more than three weeks. He and his doctors needed
to be on the same page.
Had they been on the same page, the correct diagnosis
and the timely antibiotics would have cured his infectedvalve. Instead, he needed one of the few super-specialist
surgeons (and hundreds of thousands of dollars) to fix
the valve.
Don Berwick, a colleague who is at the forefront in trying to improve health care, places in the starkest terms
the challenge confronting health professionals: “we arecausing harm, and we need to stop it.”
We are as impatient for change as Don Berwick. For thisreason we have written How’s Your Health? and createdthe web-based tools that go with it.
Bookshelves and wastebaskets are full of health titles andhealth claims screaming for attention. Some are sensational “blame and shame” books that get your attention
but do not lead to improvement. Some falsely promise
the moon or a new cure.
How’s Your Health? is not going to scream for your attention or promise you the moon. It simply presents a practical method to make health and healthcare better. The
method is based on years of research and depends on
new technologies that will help you and health professionals get on the “same page.” More importantly, themethod will make you more able to manage any healthissues or problems.
6Part I: Welcome to Our World
A Very Brief Glossary
America With apologies to all other people living in theAmericas, throughout this book we use “America” in reference to the United States.
Doctor With apologies to all other members of thehealth team, we use the term Doctor in deference to tradition. Increasingly other professionals and non-professional “providers” of health care are able to give thesupport, education, and technical care that was traditionally the strict domain of a “Doctor.”
Health A state of full physical, psychic and social well-being and not the mere absence of disease.
Health Care System The organized response of a socie-ty to maintain its health and manage its health problems.
The health care a health care system delivers should besafe, effective, patient-centered, timely, efficient and equitable.
Provider A term referring to doctors, nurses, and other

health care workers who “provide” health care services.
Quality The quality of health care is a measure of how

well it delivers care and serves the needs of the society
and patients.
Self-Care; Self-Management This language refers towhat we do everyday to maintain our health and manage long-term problems. The goal of this book is to improve self-care and self-management.
You Refers to the thousands of persons of all ages who

have used or will use HowsYourHealth.org.
We In this book “we” refers primarily to the opinionand experience John Wasson and Regina Benjamin. We
believe that our opinions fairly represent the opinions ofour professional colleagues and the general state ofknowledge. (See Annotated References.)7Chapter 1

What Are My Chances?
Before you begin to improve your health you need tounderstand what might damage your health in the firstplace. Misunderstanding risk undermines good healthhabits and effective self-care. Misunderstanding
risk can also be bad for survival.
Misunderstanding risk is bad forsurvival!
ear is one of the most important reasons why wehave difficulty getting risk right. Most of us havesuch an instinctive fear of sharks we do not realizethat we are many more times more likely to be killed
driving to the beach by our car than being attacked by ashark.

F

Other examples:
When the risk for burglary is 3 chances in 100 in ourcommunity, we will think it is ten times higher (30%);
andWe overestimate the risk of cancer.
The list at right ranks the risks to Americans fromhighest to lowest. About 1 in 6000 Americans die in car
accidents, about 1 in 80,000 die in fires, and about 1 in
5 million die from lightning strikes.
Car accident deaths seem almost “natural” because they
are so familiar. Sharks are unfamiliar and frightening.
Although we are familiar with airplanes and automobiles, many of us believe that riding in a car is safer than
flying in a commercial airplane.
Why? The car gives us a sense of control.

?

Which risks are
the most common
causes of death in
the United States?
(Pick the top three.) Car Accidents
 Alcohol Murder Medical Errors Food poisoning Chartered Flights
 Fires Commercial Flights
 Lightning Nuclear Industry
 Shark attacks

Answer: They are listed fromhighest to lowest.

In fact, being in a car for just a 30 mile trip is more risky
9Chapter 1: What Are My Chances?

?

Which do you fear
the most?

 Driving a car or
riding in a car?

 Riding in a car or
riding in an airplane?

 Riding in a SUV or aminivan?

than flying coast to coast in a commercial airplane.
SUVs are much less safe than minivans. Heart disease isa most common “natural” killer.
Depending on our mind-set on a particular day, we may
be incorrectly care-free or wrongly scared. Today we
may be a Mr. Care-Free Fatalist, a Ms. Scared, a Ms.
Semi-Fearful, or a particular mix of all three types. Tomorrow, after we have heard a news story, we may havea different perspective.

 Biological weapons
or heart disease?

Three Typical “Health-Risk” Types
Mr. Care-Free Fatalist assumes that heredity, environment, and bad luck generally win.
“So what! We are all going to die someday, right?”
Ms. Scared who does EVERYTHING she can to prevent
cancer.
“Gee. My mother died from cancer and I sure don’t
want THAT 1 in 5000 risk!”?

Over the next
10 years, the mostdeaths would be
prevented for a... ?

 Smoking 57 year old
women who quit
smoking 57 year old women
who had annual
mammograms

 57 year old women
who had tests forcolon cancer
Answer: The smoker who quits.

10

Ms. Semi-Fearful, the smoker, wants the health caresystem to rescue her from her habit.
“When are we going to do that special chest x-ray
again to prevent me from getting lung cancer?”

Advertisers and designers understand how our estimatesof risks and benefits can be twisted. That’s why so manyof us still think that SUVs are safer than minivans.
(Deaths from SUVs are 2-4 times more likely thandeaths from minivans).
Risk and Health Decisions
Getting Risk Right is difficult. Our animal survival instincts, clever advertising, and social norms make us
wrongly exaggerate some risks and underestimate others.
How about the question to the left? Can you guess theanswer? This question poses several accepted methods toreduce the risk for preventable death.

Chapter 1: What Are My Chances?
Our estimates of risk influence our choices and decisions; our choices and decisions influence when and how
we will live and die. Once we familiarize ourselves withrisks we are in a much stronger position to make better
choices and decisions.
Special tables in the Postscript at the end of this chapter provide much more detail about common risks. In
those tables, you would see that quitting smoking will
prevent about 70 deaths in 10 years per 1000 middleaged women smokers. Having a mammogram will prevent about 2 deaths per 1000 women and having tests
for colon cancer will prevent about 1 death per 1000.
Of course, some readers may not care about so muchdetail. For those readers here is “the bottom line”… alist of very beneficial choices and decisions. (See tablebelow.)The listed actions would save many more Americans
from premature death than any treatment a doctor,
nurse, or drug company currently has to offer.
Preventing Premature Death
Cause

Percent of All Deaths
That Can Be Prevented

Actions Needed

Smoking

18%

Don’t smoke

Bad Diet/Poor Exercise

17%Life style

Alcohol

4%

Moderation

Infections and Sexual Risks

4%

Immunizations and condoms

Pollution/Toxins

3%

Politics and a baby-safe home

Motor Vehicle2%

Seatbelts and less speed

Firearms

1%

Avoid and lock11

Chapter 1: What Are My Chances?
Lower than the risk of murder…
The risk of death from something done wrong by
the health care system is estimated to be below therisk of murder but above the risk of food poisoning. Examples include giving the wrong medicine or misinterpreting a test. These wrongful actions cause harms anddeaths that often appear in the news.
The annual risk of avoidable deaths resulting from thehealth system NOT doing something that shouldhave been done is probably higher than wrongful actions. About 1-3 per 1000 Americans die of wrongful inaction. Examples include not adequately treating highblood pressure or not giving a pneumonia immunization
to someone at high risk for the disease. These common
causes of death seldom make headlines.

“Doctors who step
forward to warnof unsafe
conditions...saythey have beentargeted.”
Pittsburgh Post
Gazette10/26/03
12

Non-fatal harm from health care is much more common
than death caused by health care. Adults with diseases orsignificant limitations in their ability to engage in everyday activities have a higher chance of harm each year (2in 100) than healthy adults without such problems (1 in100). Persons over age 70 have an even higher risk forharm (3-5 in 100). More than half of these harms are
attributed to a wrong diagnosis or to something a doctor
has done or not done. One in three reported harms are
related to medications. The cause for many of theseharms is poor communication and not being “on thesame page.”
Although victims of poor health care will usually feelthat the cause is a “bad doctor or nurse,” most harms
and deaths result from a combination of health system
failures. It’s unfortunate that some health systems don’t
like to hear about problems. They threaten the staff who
speak up too loudly.
The nicest and smartest doctor can do badly in a poorly
organized office; a well-organized office and staff canmake almost any physician do well. The way a hospitalor clinic is set-up has a large impact on the risk of harm.

Chapter 1: What Are My Chances?
“What Are My Chances?”
One answer to this question is based on the assumptionthat if you are reasonably accurate in assessing the benefits and risks of what you do, you will increase yourchances for living a meaningful and healthy life. For
many lifestyle and preventive health choices there is little
doubt that this assumption is correct.
Another answer to the question “What Are My
Chances?” relates to the health care system because
visits to health professionals are attended by risks thatare often greater than most people imagine.
In 2001, the prestigious Institute of Medicine of the National Academy of Sciences announced that the American health care system “is in need of fundamental
change and that between the health care we have andthe health care we could have lies not just a gap but achasm.” This embarrassing accusation was made of ahealth system that spends more dollars on health carethan any other country and still does not guarantee access to health care nor affordable health insurance.
Despite these problems, we will tell about health systems
and doctors offices that do achieve better results thanothers. We will describe simple questions and methods
you can use to make your health and healthcare “AsGood As It Gets.” To quote again the Institute of Medicine: “Perfect care may be a long way off, but much better care is within our grasp.”

Risks for Adults Living in
the United States
Over Lifetime*
1 in 5: You are in an
auto accident
1 in 100: Your house isdamaged byfire
1 in 115: You will die
prematurely
Annually**
1-2 in 100: Chance forharm fromhealth care
Sources:* Field Guide 2001
from the National Safety
Council** HowsYourHealth.org.
See also, Wasson JH,
Mackenzie TA, and Hall M,“Patients Use an Internet
Technology to Report
When Things Go Wrong”,
Quality & Safety in HealthCare, 2007:16:213-217.

13

Chapter 1: What Are My Chances?

Postscript: Ways to Get Better
Risk Estimates
The chapters entitled Health Habits and Health Decisions (for adults) and Health Habits and Prevention (foradolescents) describe in greater detail the lifestyle andpreventive choices that have the greatest potential benefits. These can be obtained at www.howsyourhealth.org
by entering your age and gender and then selecting thatyou want to review the reading materials. We also
include links to “risk calculators” at
www.howsyourhealth.org if you would like to review
your chances for heart trouble in the future. (This
Postscript about specific risk estimates is based on thework of Lisa Schwartz, MD and Steve Woloshin, MD.
See Annotated References.)
Use these two quizzes to start thinking specifically aboutrisks. The answers are at the bottom of each box.

? ?
What yourinsurance company
knows for MEN...
What do you guess?

What yourinsurance company
knows for WOMEN...
What do you guess?

 Chance that a man

 Chance that a 50-54

aged 50-54 will betold he has prostatecancer in the next 10
years?

 Chance he will die
from prostate cancer
in the next 10 years?

 Chance he will die
from something else?
Answers: About 20/1000;
1/1000; 85/1000.

14year old woman will
be told she has breast
cancer during thenext 10 years?

 Chance she will die
from breast cancer in
the next 10 years?

 Chance she will die
from something else?
Answers: About 30/1000;
8/1000; 75/1000.

Chapter 1: What Are My Chances?
Were your estimates higher or lower? Our bet is thatyour estimates will be a lot higher because fear of cancer
is so common.
When you are 20 years old, the most common cause fordeaths is an accident. When you are 30 years of age orolder, more of the deaths are caused by diseases. Table
One shows that smoking is bad for health regardless of age.
To use the following tables, pick the appropriate genderand age. Then see how many people out of 1000 at thatage will die of a cause during the next 10 years. For
example, among 55 year old males, 124 more deaths per1000 men will occur over 10 years among those who
smoke than in those males who do not smoke: (217 – 93
= 124). The deaths are also much higher for females
who smoke. Insurance companies know that a typicalsmoker loses 10 years of life.
Table One:
The Big Picture for Non-Smokers and Smokers
Chances of Death in 10 Years for Women and Men ofDifferent Ages
(Deaths per 1000 females and males in 10 years)

Age

Non- Smokers
FemaleMale

Smokers
Female
Male

20

4

10

8

23

40

26

38

32

64

55

66

93

125

217

70

247

336

470

786

It should be obvious after you review Table One thatyou can greatly increase your chances for living well andlong by not smoking. Sadly, the highest rate of smoking
occurs among 19-49 year olds. Teenagers and young
women don’t see the impacts of smoking when they areyoung. But they will!
15

Chapter 1: What Are My Chances?
Table Two:
Often Preventable and Treatable Causes of Death
For Females(Deaths per 1000 non-smoking females in 10 years)
Heart
AttackStrokeBreastCancerColon
CancerCervixCancerPneumonia

Influenza

Age
50

4

2

5

2

1

1

0

65

30

10

9

6

1

4

0

80

153

62

12

14

1

30

1

For Males(Deaths per 1000 non-smoking males in 10 years)
Heart
AttackProstate
CancerInfluenza

StrokeColon
CancerPneumonia

Age
50

12

2

2

1

1

0

65

61

12

9

8

6

0

80

196

53

16

32

38

1

Table Two shows causes of death for which there arescreening tests or treatment to help prevent death. By
age 60, heart attacks and stroke are the most common
preventable killers for females and males. Treatment ofeven mildly elevated blood pressure can reduce heart attack and stroke risk at all ages.
To the question, “what are my chances?” the most important the answer is, don’t smoke and treat elevatedblood pressure.
After you have looked at Tables One and Two, you
should recognize how easy it is to get risk wrong. For example, if you ask a woman over the age of 50 what she
thinks her chance of dying from breast cancer might be,16Chapter 1: What Are My Chances?
she will generally tell you a number that is many times
higher than the numbers shown in these Tables. Fear isthe major cause for her perception of high risk for deathfrom breast cancer. Cancer fear causes Americans togreatly overestimate the benefit of screening tests forcancer. In fact, the Tables show that the risk of deathfrom heart disease in women is the same as breast cancer at age 50, 3 times higher at age 65 and over 10 times
higher at age 80.
Are women doing as much to reduce their risk for heartdisease? We don’t think so. About 1 of every three females aged 50-69 smoke or have high blood pressure.
Only about 1/2 of women with high blood pressurecheck the pressure regularly and about 1 of 10 of these
women still have very high blood pressure. (By the way,
men do no better!)If these are the risks, how beneficial are the tests andtreatments?
Some conditions such as high blood pressure, cervicalcancer, and skin cancers have simple tests and very effective treatments for reducing risk. Tests for bowel cancer
are not as simple. Other conditions such as breast cancer
or prostate cancer have less perfect, more complex tests
and less effective treatments.
The Pressure is On Us Not to Get Risk Right
We have made up this silly “advertisement” to illustrate
what we see and hear every day.
Because all of us face some risks and all of us have somehealth concerns, health product advertisers have a hugemarket. They also have an economic incentive to makehealth threats seem large and the benefits of their treatment seem even larger.
Despite the pressure we should try to get risk right.

Have Your Ever Burped
or Felt Bloated?
If you have, you may sufferfrom the gastrointestinal
affective syndrome (GAS).
People who have GAS havefewer friends.
You want to have friends,
don’t you?
Talk to your doctor about
GAS or call 1800 IGOTGAS toreceive our free promotional
educational booklet.
17

Chapter 2

As Good As It Gets
In the Academy Award movie by this name, Carol(Helen Hunt) wanted to manage her son’s asthma well
but lacked timely, humane support to help her become
confident. The movie mirrors the real world. People wantto manage their health issues and concerns well …butusually lack timely, humane support to help them
become confident.
Getting on the Same Page
ecall that only a sliver of our waking hours eachyear is spent with a doctor or nurse. Nevertheless, we usually need doctors and nurses to accurately identify what is wrong, help us manage bothersome problems, and show us ways to avoid importantrisks. We want doctors to be on “that page” with us.

R

The young man with the infected heart valve had no
idea that his heart was under attack by bacteria. He depended on health care professionals to listen to him andfigure out that he was ill. He depended on them to tell
him that a fever should not last a week. Only after it wasalmost too late did some health professionals get on “hispage.”
Health professionals and patients are often not on the“same page.” Lack of good communication can be dangerous and is the most common cause of malpracticeclaims. Bad communication is also frustrating because it
results in rework and misdiagnoses. For example, about
50% of Americans report that their doctor or nurse isunaware of serious emotional problems. Many medications and tests are often ordered before the doctor discovers that emotional problems need to be addressed.
There are many excuses for the lack of “same page”
care.

Sorry about...
waits, waste, errors, costs,
and miscommunication.
Everything seems to
get in the way.

19

Chapter 2: As Good As It Gets

Percentage
Experiencing Harm
Self-care confidence
not good
so-so

good

20%
18
16

L not same page

14
12
10
8

J same page

Doctors and nurses complain that they do not haveenough time to get on the same page. When more things
are being stuffed into a busy 10-20 minute office visit,
less time is devoted to getting on the same page with apatient. With so many demands to do so many things,
the typical physician interrupts a patient within the first
30 seconds of their conversation. The typical doctor intraining spends less than 30 minutes a day talking withpatients. Most of the time spent by student doctors andnurses is spent doing tests and paperwork.

Imagine going to an expensive restaurant where the doctor is the waiter. After you wait a long time for your4table, your waiter comes and you have 30 seconds to say
20what you want before you are interrupted by the waiter.
not good
good
Within a minute the waiter translates what he heard you
medicalmedicalsay into categories known only to him. The kitchen staff
information information
prepares the meal based on the waiter’s information.
Health-related harms You may or may not recognize the dish when it arrives.
in the past year Some meal!
experienced by Another excuse is that human needs are complex andAmericans range from treatments are complex. In the midst of this time-conless than 1 per 100 strained, complex world in which health professionals live,
people to 20 per 100, it seems almost excusable that “same page” care does notdepending on how happen as often as it should. Perhaps that’s why so few
good the information Americans can say that their care is “as good as it gets.”
was that theyreceived from doctors
or nurses and the
Is Your Health Care “As Good As It Gets”?
confidence these
Are there things about your medical care that
Americans have in
could
be better?
self-managing their No, my care is perfect.
health problems.
6

 Yes, some things.
 Yes, a lot of things could be improved.

?

How confident are you that you can manage and control your health problems or health concerns?
 Very confident.
 Somewhat confident.
 Not very confident.
 I do not have any health problems.
20Chapter 2: As Good As It Gets
Care That Is As Good As It Gets
Currently, only about 20% of Americans can answer
that their health care is perfect AND that they are very
confident about their ability to manage health concerns
or problems. We call this care “As Good As It Gets
Care” in reference to the film of that name.
The following diagrams illustrate that if you are lucky
enough to have care that is As Good As It Gets, you will
suffer fewer days sick from illness, experience greatly reduced risk for harms from medical care, avoid emergency department and hospital use, and be less likely toexperience medication side-effects. In short, a combination of Perfect Care with Confident Self-Management
results in the best care for you and your loved ones.
Self-care confidence:

low

so-so

high

Having Sick Day

Reporting Medications
May Be Making Them Ill

50%

50%

45

45

40

40

35

35

30

30

25

25

20

20

15

15

10

10

5

5

0

0

imperfect care perfect care

ED or Hospital Use

imperfect care perfect care

These bar graphs
illustrate how the
impacts of medicalcare and self-care are
additive. If both
medical care and selfcare are good, goodthings happen. Whenneither is good, badthings happen.

Reporting Harm

35%

7%

30

6

25

5

20

4

15

3

10

2

5

1

0

0

imperfect care perfect care

Perfect Medical Careand Confident SelfCare, a Winning
Combination

imperfect care perfect care

21

Chapter 2: As Good As It Gets
Me? Confident to Manage and Control My
Problems?

Congratulations!
By selecting the ACME OpenHeart Self-Surgery Kit, you’ve
decided to take control of yourhealth care.
If you have ever repaired afaulty carburetor, you will haveno problem understanding thesimple procedures….

For most Americans, figuring out how to stay healthy
and get good medical care seems as hard as figuring out
how to do heart surgery.
Why then are Americans being asked to take more responsibility for their health and health care?
A cynic might say…because the insurance companies,
employers, HMOs, and sloppy health care workers wantto pass the buck. A realist would say…because it is theright thing to do…because we are the one who live withour concerns and health problems…because we bear theconsequences of our health decisions andbehaviors…because in all but life-saving treatments andsurgical procedures, what we do has a major impact on
how well we will do.
How’s Your Health? shows why we need to become good
“self-managers.” Whether we are exercising, eating,relaxing, or living with an illness such as asthma or
arthritis, we are “self-managing.” Doctors and nurses
should give information and treatments to help us tobecome better self-managers. But we have to use the information and treatments to become the best self-managers possible.
Health Care Quality
At one time or another, some Americans have received
exactly the health care they want and need exactly whenand how they want and need it. The problem is thatsuch high quality care is not very common and not very
predictable. It may be on target one-time, perhaps twotimes, then it misses several times.
Being “on the same page” should not be one-time;“same page” care should not be hit or miss.

22

Chapter 2: As Good As It Gets
How would you answer these questions?

?

How often is/are your doctors and nurses awareof what really bothers you…what really matters toyou?

 All of the time Most of the time Some of the time They are often not aware
 I have no bothersome problems or health issues

How much help have you received from your doctor or
nurse to help you manage and control most of yourhealth problems?
 As much help and support as I needed I could use some more help and support
 I could use a lot more help and support
 I do not have any health problems

The best health systems are now routinely asking thesequestions and trying to do something about responses
that are less than ideal.
They are using e-mail, telephone, howsyourhealth.org,
and other technologies to be sure that the care they provide is timely, safe, effective and efficient.
And that is not all the best practices are offering. They
offer shared medical appointments so that people canlearn how to manage their problems and their concerns
from each other. They also offer immediate access to theoffice…same day service at your request.
But it may take a long time before the entire health caresystem can deliver “same page,” safe, effective healthcare in a timely and efficient way to all Americans. The
remaining chapters of How’s Your Health? will give you
very simple, effective steps to improve your health andhealth care.

23

Chapter 2: As Good As It Gets
What About Cost?
Year after year, on national poll after national poll, United States citizens indicate great concern about the costsof health care and medicines. Yet no promised solution
seems to work. For example, everyone knows that a lot of
health care cost is wasted...some say as much as 30% iswasted. But one person’s waste is another person’s income. When cost-saving changes are promised, opponents who stand to lose income often successfully undermine the changes.
We would never promise that the approaches in How’s
Your Health? will cure the complicated and costly problems of health care. However, we can promise that thefree methods and technologies of How’s Your Health? arebased on research results indicating that “same page”
care can reduce some costs of health care and improvehealth. That is as good as it gets!

24

Chapter 2: As Good As It Gets

Postscript: Bar Graphs
In this book we will use bar graphs to illustrate many
points. The bar graphs will always show the number orpercentage on the vertical scale. On the other scales ofthe bar graph we list categories.
Our simplest, two-dimensional bar graphs are descriptive. For example, this bar graph (below) shows that “AsGood As It Gets Care” varies from 10-35%. Variation iscommon and often desirable, such as variation in humanappearance or interests. However, some variation is notdesirable. If you knew that your health care was at the
10% level and the care that your neighbor received was
generally better, what would you do? Why does 10%vary from 35%?
As Good As It Gets
healthcare shows wide
variation across theUnited States. The
variation from 10% to
35% is across nineteen
health systems in
Chicago.

35%
30
25
20
15
10
5
0

As Good As It Gets

Why is the best care (35%) vary so greatly from the
100% “As Good As It Gets Care” everyone desires?
The purpose of this bar graph is to help readers understand why these questions matter and how to remedy
undesirable variation.
A more complex bar graph shows relationships. For example, in this chapter we used a complex bar graph toillustrate that when good information from doctors andnurses is combined with good self-management by apatient, the results are “as good as it gets.” (See graph,“Experiencing Harm,” on the next page.)25

Chapter 2: As Good As It Gets

Percentage
Experiencing Harm
Self-care confidence
not good
so-so

good

20%
18
16

Finally, in a later chapter we use complex bar graphs toshow how many individual measures are related to one
other important measure. For example, the bar chart
below illustrates how many measures of growing up well
are lower for poor children than for children living in ahousehold with adequate income.

L not same page

14

Measures of Growing Up Well for Children

1210

J same page8
6

Incomepoor

adequate income

100%

4

90

2

80

0

not good
medicalinformation

good
medicalinformation

70
60
50
40
30
20
10
0

good
physical
activity26

goodsocialactivity

speakingvery well
(2-4)

good
school work
(5-8)

no
sick
days

Part II:Are You Ready to
Improve Your Healthand Health Care?

27

Part II: Are You Ready to Improve Your Health and Health Care?

Are You Ready to
Improve Your Healthand Health Care?
You should now have a reasonable understanding of ourhealth care Wonderland. Now it’s time to put your understanding to the test. (If you HATE TESTS, don’t
worry. This brief test is different.)
Ideas:?

1. In How’s Your Health?, Wonderland refers to: A new theme park in Florida.
 The number of lanterns Paul Revere needed to see
if the British were to attack by land.
 The often odd, strange, and confusing world inwhich doctors, nurses and other healthprofessionals work.

2. In How’s Your Health?, the “same page” idea
(metaphor) refers to: Doctors, nurses, and other health professionals
know about bothersome problems and concerns of
their patients.
 Singing in a choir.
 Reading to children after school.
3. In How’s Your Health?, the care that is as “good as it
gets” will happen when: People with health problems or health concerns areon the “same page” with their doctors and nurses.
 People with health problems or health concerns are
confident that they can manage and control these
problems or concerns.
 The health care these people are receiving is“perfect.” All of the above.
 You take Helen Hunt to the movies.
28

Part II: Are You Ready to Improve Your Health and Health Care?
Facts:?

4. Bad doctors and nurses cause most of the harms inhealth care?
 yes
 no
 not sure
5. People’s confidence that they can manage healthproblems or health concerns has a large impact on
their lives?
 yes
 no
 not sure
6. A typical smoker loses about 10 years of life.
 yes
 no
 not sure
7. When people are afraid they tend to greatly
overestimate risks?
 yes
 no
 not sure

8. Bar graphs in How’s Your Health? are:
 The type of charts you see on the walls of pubs.
 Picture methods that show relationships.
9. As much as 30% of the money spent on health care in
America may be wasted?
 yes
 no
 not sure
10. A 65 year old woman who smokes and has
uncontrolled high blood pressure is more likely to diefrom breast cancer in the next 10 years than fromheart disease?
 yes
 no
 not sure
11. HowsYourHealth is a website designed to placedoctors, nurses and patients “on the same page” andmake health care “as good as it gets?”
 yes
 no
 not sure

Answers are provided on the following page.

29

Part II: Are You Ready to Improve Your Health and Health Care?
A Test for Catching Metaphors
If you honestly missed any of the questions marked withan asterisk (*) we the authors, and you, the reader, are
not “on the same page.” We apologize for any confusion.
We have used the “same page” metaphor to indicate one
central truth about health care: that doctors and nurses
often do not know what really matters to their patients.
Recall that only about 20% of Americans are currently
receiving health care that is “as good as it gets.” “Asgood as it gets” care requires two things: that the service
and care you receive is perfect AND that you feel very
confident that you can manage and control your healthproblems and concerns.
You have to keep your eye on the “same page” and “asgood as it gets” metaphors if you are to catch the importance of HowsYourHealth.

Answers to quiz on theprevious page:
1. The odd doctorworld*2. Doctors and nurses
know*3. All of the above
4. No*5. Yes
6. Yes
7. Yes
8: Show relationships
9: Yes
10: No*11. Yes
30

HowsYourHealth is a website on which you will finda family of tools designed to place doctors, nurses andpatients “on the same page” and make health care“as good as it gets.” When you use HowsYourHealth,
you are tossing a form of care improvement to healthprofessionals.
How do you get doctors, nurses, and other health professionals to catch the “same page” metaphor and the importance of HowsYourHealth and its related technologies? That will be the subject of later chapters. In themeantime, we just want you to see why “same page”
care, and your “confidence” can help you greatly improve your health and health care... even if health careseems at times to be Wonderland.

Chapter 3

Doesn’t Everyone
Worry?
We think about health everyday. Sometimes we worry
about health and health care. What are Americans mostcommon worries and concerns?
hen adults and teens are asked about healthworries and concerns, their answers follow
the order listed in the two gray boxes below
right and on the following page. (We have listed
the responses in order from highest to lowest.)
Males answer in the same order as females.

W

An Apple a Day
Regardless of income or gender, about half of Americans aged 14-69 rate eating, weight, and exercise as their#1 concern.
Based on the information from the preceding chapter“What Are My Chances,” 17% of premature deaths canbe eliminated by better management of eating, weightand exercise.
In 1991 about 15% of American adults were very overweight; today almost 30% are seriously overweight.
Largeness has become such a problem here and abroadthat airlines may have to be redesigned so that we canfit.
Being overweight has a high health and social cost.
Nonetheless, eating is enjoyable and dieting is not. Eating well and maintaining ideal body weight is difficult inboth rich and poor countries because of the high consumption of carbohydrates (sugars) and low levels of exercise. Overall, Americans eat many more calories a day?

Adults Aged 19-69:
Do You Have Any
Concerns About?

 Exercise andnutrition needs
 Preventing disease
and premature death How to make thehealth system work
better for you Preventing injuries or
accidents
 Substance abuse(alcohol/drugs)
 Sexual issues or birthcontrol Violence or abuse AIDS or sexual
diseases31

Chapter 3: Doesn’t Everyone Worry?

?

Pre-Teens and Teens:
Aged 9-18: Do You
Have Any Concerns
About?
 Exercise and eating Violence and abuse Depression or suicide
 Substance abuse Sexual issues
 AIDs or sexual
diseases
A Century of Weightloss Facts and Fads
1898 Fletcher Chewing
1918 Count Calories
1935 Grapefruit Diet
1936 Radio Reducing
Parties
1948 Amphetamines
1958 Saccharin
1961 Weight Watchers
Begins1963 Sugar-Free Tab
Soda
1972 High Protein and
Fat Diet1980 Anorexia Nervosa
Named
1981 Beverly Hills Diet
1982 LipoSuction
Begins1988 Optifast LiquidDiet
1990 Fen-phen Diet
1997 Fen-phen
Withdrawn
2004 Ephedra
Withdrawn;
Atkins battles
South Beach

32

than they did in the 1970… enough calories to gain
many pounds of fat each year.
When adults combine a slightly reduced calorie diet with
3 times per week exercise, they can expect to lose around
5-10% of their weight over 6 months. Currently, only
1/4 of Americans exercise 3 or more days a week hardenough to breathe heavily and sweat. Although a thirdof adult Americans say they are trying to lose weight,
only about1/5 are actually restricting calories and increasing their exercise.
Americans continue to get most of their information
about food and diet from TV (70%) and magazines(60%). In these media, “fads” spread quickly and recycle
to different audiences.
“In” diets now include olive oil, small portions, and even
eggs. “Out” now are stick margarine and other solid fats,
bagels, “super-size”, red meat, and sweets. This table isan overview of the century’s weight-loss facts and fads.
It is said that “Diets are mainly food for thought!” Instead of restricting calories and staying active many
Americans try special diets, herbs, and “tricks” to lose
weight (including cigarettes!). No medicines, herbs, or“tricks” have been shown to have a large or lasting effect.
Being overweight increases the tendency toward highblood pressure and high levels of bad fats in the blood(most often measured as cholesterol). For many people
the first treatment for high blood pressure and high cholesterol is to lose weight and to change their diet.
Being very overweight has a large impact on overall
health. For example, very overweight teens and adults
have about 50% more sick days requiring bed-rest or restricted activity compared to those who are not severely
overweight. About 35% of very overweight adults take 3
or more medicines each day versus 15% of the nonobese. Obesity has many similar adverse impacts on preteens and teens. The tables shown at right list other effects of obesity.

Chapter 3: Doesn’t Everyone Worry?
Adverse Impacts of Obesity on Adults 19-69
Problem

If
Overweight

If NotOverweight

High Blood Pressure

40%

15%

Arthritis

25%

10%

(Sugar) Diabetes

10%

5%

Limits from Pain

25%

15%

Limits from Feelings

20%

15%

Limits in Daily Activities

10%

5%

Not Good Problem
Management

75%

60%

Super Size Me!
A “fast food”
meal now has
1,500 calories;
the same type ofmeal in 1950
had 600 calories.

Adverse Impacts of Obesity on Pre-teens and Teens
Problem

If
Overweight

If NotOverweight

Limits from Pain

35%

15%

Limits from Feelings

30%

20%

Limits in Daily Activities

20%

10%

Poor Problem Solving

25%

10%

The good news is that even if weight loss is difficult formost Americans, regular exercise alone will help maintain health, burn a few calories, and prolong life. The
bad news is that exercise alone is seldom an effective way
to lose weight; we must eat less.
Preventing Disease and Premature Death
The next most frequent concern of adults is the prevention of disease...particularly, heart disease and cancer.
Not surprisingly, the concern about these common
causes of death increases with age, from about 25% in
the healthy young to about 40% in older adults.

An Apple aDay?
If you eat an apple
a day more than yourbody needs, you will beloading about 70 extra
calories a day.
Over 365 days, these 70
calories become about
6 pounds. In 10 years,
you will be 60 pounds
heavier.
What's that about
an extra apple a day
keeping the doctor
away?

33

Chapter 3: Doesn’t Everyone Worry?
Smoking at any level adds a huge risk for premature
death from heart disease. The curve of risk for problems
with the heart and blood vessels increases rapidly withthe level of the upper (systolic) blood pressure. For a systolic blood pressure between 131-150 , there is a small
increase in risk for heart disease, stroke and death; ablood pressure between 151-160 has more risk; and ablood pressure over 160 is really serious... it “takes off.”

Risk for Bad Events in
the Future
High
Risk

Blood pressure levels

hi
60 gh
+)
(1

ve

ry

)

h
-1 igh
60
51
(1

(1

n
00 orm
-1 al
30
sli
)
gh
ti
(1 ncr
31 ea
-1 se
50
)

Low
Risk

The same pattern of rapidly rising risk with very highnumbers occurs for being overweight, having bad fats inthe blood such as cholesterol, or having an elevatedblood sugar.
People differ about the importance of future risk. But
risk for future heart disease is really “serious” when thesystolic blood pressure is more than 160, a person ismore than 20% overweight (a BMI above 30), and thetotal cholesterol is greater than 240. For a person with(sugar) diabetes. the risk for problems becomes greatly
increased when the average blood sugar measured by“A1c” is more than 9.
Preventing premature death from cancer is easy if you
smoke...just stop smoking! “Prevention Gaps” at the endof this chapter provides more information about cancer
prevention opportunities. Diets and vitamins to prevent
cancer are often in the media. Despite the attention
given to diet and vitamins their preventive impact is verysmall, at best.
A Growing Worry: How To Make the Health
System Better
The number three worry for adults is how to make thehealth care system better. Americans recognize that theirhealth care, and the health care given to their lovedones, is falling far short of expectations.
The current rating of care supports this concern. The
bar chart (Distribution of Perfect Care) illustrates ratingsof perfect care for about 50 different doctor’s offices in34

Chapter 3: Doesn’t Everyone Worry?
the United States. Nationwide, the rating for perfect carequality averages about 35%. There is also great variationin the care provided. About 1 in 10 of the doctors offices
have 50% or more patients who rate care as perfect;
about 1 in 10 offices give perfect care to 20% or fewer of
their patients.
Distribution of Perfect Care
70
60
50
40
30
20

Perfect Care rated bypeople using about 75
doctors’ offices acrossthe United States. Note
how the percentage
goes from a low ofabout 5% to a high ofalmost 65%. The
average is about 35%
nationwide. In otherwords, most Americans
do not receive anythingnear Perfect Care.

100

Doctors’ Offices

When care is not excellent, it is hard to separate thecauses. As an example, consider the harm described in
the quote at right. It illustrates several causes: poor communication, an unexpected reaction to a medicine, and awrong diagnosis. The risks for harm and patients’ ratingsof care quality are closely related.
In general a rating of excellent care is greatly increased
above average by good communication between patientsand doctors, easy access, and efficient service. The ability of the doctor, nurse, clinic, or health system to help
you understand and manage your own health is strongly
associated with a rating of excellent care.
Conversely, a low rating of care quality is strongly associated with a lack of these attributes and also not having“Doctor did notlisten to me
regarding a
medical problem
and insisted that it
was somethingelse. Gave meprescription thatburned my skinand caused greatswelling. Could
have been avoided
if doctor had
listened.”
35

Chapter 3: Doesn’t Everyone Worry?
one person you consider your doctor or nurse. The next
chapter, “Inside the Doctor’s Office,” describes ingreater detail what makes “perfect care.” The Postscriptto this chapter gives a very brief summary of harms reported by people like you.
Is the Wolf Near the Door?

?

Do You Have
Enough Money to
Buy the Essentials (suchas Food, Clothing,
Housing?
 Yes, always
 Sometimes
 No

About 85% of United States citizens answer that they always have enough money for the essentials. However,many Americans who have adequate income worry that
their financial well-being will evaporate if they or someone in their family became ill or was unable to purchaseinsurance.
Current private and public payments for health care are
more than $5000 per person per year in the UnitedStates (where many persons do not have insurance) compared to about $3000 in Europe and Canada (where
everyone has insurance). In fact, 20% of middle-income
citizens report that they are currently struggling to pay
medical bills even though most have insurance.
One of the things that seriously impacts health is money.
There are many scientific studies, but one in Englandshowed that 5% of higher paid government workers
died over a ten-year period compared to 20% of lower
paid government workers. These differences persisted
even after adjusting for age, smoking, drinking, and exercise habits. These were the same people, same government, same employer, same health benefits, and same
medical care. The difference was social class and income
levels.
The medically poor find it harder to access the healthcare system for two major reasons. They do not have themoney and they have to work so they do not have thetime. When they do go to the doctor, they are often very
ill, or late in the illness making health care even morecritical.

36Chapter 3: Doesn’t Everyone Worry?
We could insert some tables here to illustrate how thepoor receive less “perfect care” and less often feel confident in managing their health concerns and problems.
But you would expect that. What you might not expect
is that when the poor receive care that is “Same Page”
and “As Good As It Gets,” they are just as likely to benefit as affluent Americans.
Sex, Drugs and Violence
Stories about sex, drugs, and violence are in the news
every day, yet these topics only concern about 20% of
older teens and half that many adults. Despite the low
rate of concern the problems can be all too real.
Teenagers are more likely to die from violence or an accident than any other cause. Domestic abuse is present
in every social class. About 15-20% of women aged 1949 report bad relationships and half of these are likely
to be abused.
Sexually transmitted diseases (STDs) and teenage pregnancies are an increasing risk for our youth. Interestingly, 95% of young women aged 19-49 say they understand how to prevent STDs and unwanted pregnancies,
whereas only 60% of the males report they understandimportant information about birth control and STDs!

37

Chapter 3: Doesn’t Everyone Worry?

Postscript: Health Care Harmand Prevention Gaps
Harm
Health care can result in injury and harms. The riskfor harm from health care increases with age for two
reasons. First, older people are less able to recover as
quickly or as well from injury. Secondly, as we age weare much more likely to have problems that expose us tomore medical care and the risk for harm. Regardless ofage or income, the risk for harm is increased when weare not on the “same page.”
Americans Report Harm from Health Care
In Past Year
Incomelow income

normal income

9
8
7
6
5
4
3
2
1
0

14-18

19-49

50-69

70+

Age

Low income greatly increases the risk for harm.
(HowsYourHealth does not ask teens aged 14-18 about
income so no data is shown for them). Low income
Americans have less access to high quality care than
Americans with an adequate income.

38

Chapter 3: Doesn’t Everyone Worry?
The following examples of harm were chosen fromthousands reported on HowsYourHealth to illustrate
why health care is such a worry for so many Americans.

““ In February when I was in the Emergency room, the doctor prescribed me a medicine I was allergic to.”“I was prescribed a medication for a cough, that if I had taken it,
the pharmacist said I would have had a heart attack. The medicine
would have reacted with my high blood pressure pills prescribed by
the same doctor (and discussed at the appointment) that prescribed
the new medication. A couple of weeks later (still coughing) I wasprescribed amoxycilian and was never told why until I saw my chartand bronchitis was listed. It turns out that I am allergic to amoxycilian and on the 9th day I broke out in hives and had every otherside effect listed in the literature. That is when I switched to my current doctor.”“Cardiologist changed prescription and sent letter to primary physician - letter placed in my file unread - no action taken. I continued
on high dose of medication - fainted hit my head and injured my eye.
Required ongoing attention by Optometrist.”“Wrong medication put in my mediport while in the hospital. Nurse
was in a hurry. I had a diabetic reaction to steroids used in mychemo. When this was first realized I was given an incorrect amountof insulin because the nurse could not read doctors’ orders correctly
because of how it was written.”“My husband had a cancerous skin growth removed from his forehead by a surgeon. A week or so after the stitches were removed thearea became reddened and infected looking and also a black piece ofa stitch rose to the skin surface. My husband called the doctor’s office
and was told that the surgeon was away and that another surgeon
from our primary care physician’s practice was covering for him...myhusband went to the office... the nurse looked at it and agreed that it
was a piece of a stitch that had not been totally removed... the doctor
proceeded to cut the area open again and dig around... there was noneed to cut it open again the way he did.”39

Chapter 3: Doesn’t Everyone Worry?
“My son was 2 months premature. He was prescribed a medication for apnea/bradycardia episodes. When he was transferredfrom the NICU to the local hospital, he was given full strength
doses of the medicine, not the pediatric solution, as prescribed(theophilin – I can’t remember how to spell it). The nurses were
not careful to wash their hands between babies, or even to turn on
his monitor. An infection resulted in his staying in the hospital aweek longer than necessary.”“My husband once received the wrong intravenous. It belonged tothe other patient in the room. It was a blood thinner and he shouldhave had his chemotherapy.”“My wife was being treated for breast cancer and developed symptoms of an upper respiratory infection. We went to XXX and had
blood work done, but the folks at YYY said the infection was not
bad enough to warrant medication and hospitalization. Two days
later we went to YYY and had tests done again in the ER, theysaid the same thing as before. The following night at 11pm we received a call from the YYY emergency room and they told us thatthe crew the night before had misread her labs and in fact she wasvery sick and needed to be hospitalized. She was admitted for several days while they got the infection treated, she was then sent homewith daily IV meds for the infection.”““My 85 year old father was ignored when he complained of leg
swelling until his kidneys shut down and he had to be hospitalized
and eventually have an prostate operation to solve the problem.

40

Chapter 3: Doesn’t Everyone Worry?
Prevention Gaps; Things Not Done That
Should Be Done
From a public health perspective, the most preventablecauses for premature death:
1. smoking (18%),
2. bad diet and poor exercise (17%),
3. alcohol and drugs (4%), and
4. infections and sexual diseases (4%).
From a public health perspective the most frequentcauses for disability are:1. mental illness (25%),
2. alcohol and drug use (12%),
3. musculoskeletal problems such as arthritis or backpain (7%),
4. lung disease (6%), and
5. heart and blood vessel disease (6%).
Some of the causes of disability are preventable. Most
are manageable...particularly when there is “same page”
care.
The following diagrams show the potential prevention
opportunities for women and men between 19-69 whohave completed HowsYourHealth. Wherever possible wehave included several measures that correspond to causes of premature death and disability. We have purposely
eliminated the raw percentages because they differ somewhat by age and income.
At the extremes, fewer than 5% of young women needto learn more about sexually transmitted diseases but
more than 50% of women of all ages need to exercise
more.
For men, there seems to be particular ignorance (or denial) of sexually transmitted diseases. Otherwise, therank of important prevention opportunities is similar to
women.
41

Chapter 3: Doesn’t Everyone Worry?
Opportunities to Prevent Problems for Women Aged 19-69
Not Exercising
Need Bowel Cancer Screen(50+)

Need Education About
Hormone Replacement (50+)
Obesity
SmokerNeed Pap
Need Lipid Screening (50+)
Risk Abuse
Need Mammogram (50+)
Doctor Unaware Emotional
Problems
Blood Pressure Over 150
Excess Drinking
Need Education about Sex
Disease (19-49)
Not Frequent

Frequent

Opportunies to Prevent Problems for Men Aged 19-69
Not Exercising
Need Education about Sex
Disease (19-49)
Need Bowel Cancer Screen(50+)
Obesity
Need PSA Education (50+)
SmokerNeed Lipid Screening
Excess Drinking
Blood Pressure Over 150
Doctor Unaware Emotional
Problems
Not Frequent

42

FrequentChapter 3: Doesn’t Everyone Worry?
About 10-20% of adults are bothered by significant andpersistent emotional problems. About 50% of the time
adults report that a health professional is unaware of theemotional problem. About half of the people who arebothered by emotional problems have the opportunity tomake their doctor or nurse aware of the problem.

Adults Bothered by
Significant andPersistent Emotional
Problems
men
women

When Americans are active self-managers of the health,they are much more likely to prevent problems. Good
self-managers tend to have good health habits. Good
health habits include good prevention.
Information on the howsyourhealth.org web-site entitled
Health Habits and Health Decisions (for adults) and
Health Habits and Prevention (for adolescents) describein greater detail the lifestyle and preventive choices thathave the greatest potential benefits.

16%
14
12
10
8
6
4
2
0

have
emotional
problems

doctor or
nurse isaware

Good Health Habits
100
90
80
70
60
50
40
30
20
10
0

Low

So-So

High

Self-care confidence43Chapter 4

Inside a Doctor’s Office
Health care is a complex business. People who use
health care can easily suffer from its complexity.
Those who work in health care usually suffer fromthe complexity too.
typical patient with (sugar) diabetes has about
15 risks to health. There are about 25 recommendations by experts that apply to the thistypical person with diabetes. This number of risks andrecommendations is just too much for a doctor to remember and too much to accomplish regardless of thelength of an office visit. Errors occur, handoffs don’t
happen, and things are not done.

A

To deal with the errors, missed handoffs, and failures, adoctor’s office will usually hire new people and add morechecklists to manage the chaos. You can see how complexity breeds failure and failure breeds more complexity. Failure and complexity result in more waste and higher costs.
Some practices are more successful than others at minimizing waste, failure, and complexity. The figure on thenext page lists critical “success attributes” of good practices and the responses to these attributes by many doctor’s offices across the United States.
Successful practices most often spend a lot of energy
making the “front-line” team of doctors, nurses, andsupport staff function well. Currently, about 4 out of 10
office practices report that the front line staff functions
well.

Welcome Back to Our Office.
We apologize that members of
our staff sometimes act like busy
restaurant waiters who interrupt
you when taking your order andmess-up your meal.
But we have problems too!

To attain “same page” care, the front line team must understand the needs of its patients. Only a third of healthcare workers in the United States rate themselves as wellfocused on patient needs.
45

Chapter 4: Inside a Doctor’s Office

Report from Inside
The Doctors’ Office
Percent of staff reportingthat the success attributeis present in their office

To get good results, a practice needs to actively measure
and take steps to improve performance. Less than one
quarter of practices do this.
A Tale of Two Practices
Dr. M’s situation was lucky. He had been working forseveral years with the Institute for Healthcare Improvement before setting up his own family practice in a smallcity. Dr. M knew how to build good front line function,
good patient focus and measurement of performance inthe practice.

40%
30
20
10

Dr. M offered patients direct access to his cell-phone. He
offered email communication to answer their questions,refill their medications, and reinforce their self-management. He used a complete electronic health record sothat billing was automatic and information was easy toget. He minimized costs by beginning with NO office
staff and using a very small office. (He did not need aProfessional and large waiting room because patients did not wait to see
non-professional office him). He used HowsYourHealth so that he knew whatpractice staff improve mattered to his patients...he was on the same page withhealth services by them.
examining what theyDr. M says he encourages patients with internet access to
do. The percentages
take the HowsYourHealth survey, even if they choose toreflect their average
do so anonymously. He adds: “For those who feel comratings.
fortable putting in their name – and the majority do –it’s a tool that gives me a very simple means of assessing
my patients’ needs.”
od

Go

Go

od

“F

ro
n
Fu t-Lnc ine
ti ”
Or
ga on
ni
za
Fu ti
nc on
tio al
n
Go
od
Fo
c
Pa u
tie s o
an I
nt n
s
d mp
Pe ro
rfo verm man entce

0

As he describes: “We go over the results together, literally shoulder-to-shoulder, either at the computer or withthe printed summary, and look to see if there are any
gaps. I tell them I want to make sure nothing falls
through the cracks.” So, adds Dr. M, “If I see, for example, that they’ve checked off ‘lacks social support,’ I
ask them to tell me more about that. Then I can begin
to help them work on whatever is lacking.” In otherwords, Dr. M says, “It opens the conversation.”46

Chapter 4: Inside a Doctor’s Office
On a broader scale, Dr. M uses the aggregate data fromhis patients’ HowsYourHealth input to improve his practice. The effects can be substantial. For example, he explains: “From the surveys, I realized that I could segment my population into two groups: those who rated
their care as perfect and those who didn’t.”
Dr. M says when he looked more closely at these twogroups, the main difference was that those less satisfied
were more likely to have chronic diseases and didn’t feel
confident in managing their condition. Based on thisdata, he says, “I hired a nurse to work with me on
chronic disease management – to put in place more supports for this group. I also started offering group visits
for patients with chronic conditions, which the literatureshows can be a very valuable resource.”
A strong benefit of HowsYourHealth is the way it helps
Dr. M’s patients become more confident self-managers.
“It’s a terrific vehicle for confidence-building; for helping
patients track chronic disease and know what to doabout it.”
Dr. M’s clinical practice has been financially secure because the money received from patients is not wasted to
pay for unnecessary space and inefficient processes. He
and his new nurse-associate recently rated their office
100% on “front-line” function, patient focus, and measurement of performance.
In contrast to Dr. M, Dr. O’s situation was far less fortunate. Dr. O was hired to reorganize a clinic of professionals and staff who have long-established, traditionalroles. The clinic has complex policies and procedures.
His professional and non-professional staff rated the office at 0% for every attribute shown in the previous tableentitled “Report From Inside the Doctor’s Office.”
In the snapshot on the next page we compare the performances of Dr. M and Dr. O from the perspective of
their patients. (To make sure the comparisons are fair,
we include only patients with problems; the patterns are
similar for low-income patients and those without the47

Chapter 4: Inside a Doctor’s Officelisted problems). The poor function of Dr. O’s office is reflected in lower ratings of care by the patients who use it.
Clearly Dr. M’s patients feel that they can reach him easily. This ease of access favorably influences the other ratings of care. Dr. M does not provide perfect care all of
the time. For example, only about half of the patientswith emotional problems report that he is aware of the
problem AND that treatment was effective. But compared to the nation and Dr. O’s practice, Dr M is ahead.
Snapshot of Performance for Dr. M, Dr. O, andthe Nation for People with Pain, Emotional Problems,
or Chronic Diseases
Dr. M

Dr. O

National Data

70
60
50
40
30
20
10
0

Very Easy
AccessA rating of “perfectcare” makes a big
difference. However,many doctors say,
“Perfect Care? Are you
kidding? That is too
difficult!”

Patients Are
Confident

Excellent
Information
for Chronic
Disease

Perfect
Care

Doctor Aware
and Treatement
HelpedEmotional
Problem

Perfect Care? Are You Kidding?
A health system or doctor’s office should make you feel
comfortable that it will attain the highest level of performance. What Americans feel about their health careis also very closely related to how well a doctor’s office isworking.
The next figure (Quality of Office Work) shows the relationship between Americans’ ratings of perfect care for
10 doctor’s offices. The entire professional and non-professional staff rated how well they worked together.

48

Chapter 4: Inside a Doctor’s Office

Quality of Office Work and Patient Rating of Perfect CareJ

High
RatingPerfect CareDr. M Office

L

Low
RatingDr. O Office

Office WorkHigh Rating

As you can see, the two ratings are strongly related: thebetter the rating of the staff, the higher the rating of
perfect care by the patients who use the practice.
You and your doctor want to be in the “smiley face”
area. You want your doctor’s office to highly rate theway they work together. When they are doing a goodjob, your care is more likely to be perfect and “as goodas it gets.”
From the point of view of all Americans, they should be
able to say about their health care: “I receive exactly what I
want and need exactly when and how I want and need it.”49

Chapter 4: Inside a Doctor’s OfficeThis table lists
important attributesof health care reportedby Americans whostrongly agree,somewhat agree,
or disagreewith the statement:“I receive exactly
the health care I want
and need exactly whenand how I want andneed it.”

The 20%of Adult
Americans
Who
Strongly
Agree

The 60%of Adult
Americans
Who
Somewhat
Agree

The 20%of Adult
Americans
Who
Disagree“I have one person I thinkof as my personal doctor
or nurse.”

95%

80%

60%

“It is very easy for me
to get medical care when
I need it.”

85%

40%

10%

“Most of the time, when
I visit my doctor’s office,it is well organized,
efficient, and does notwaste my time.”

80%

60%

20%

“The information given tome about health problems
is very good.”

80%

60%

25%

“I am confident that I canmanage and control mostof my health problems.”

75%

45%

15%

“I have not been harmed
by health care in thepast year.”

99%

98%

91%

“Few things about healthcare need to be improved:
health care is almost
perfect.”

75%

30%

0%

This table shows, for example, that 8 of 10 (80%) of
Americans who strongly agree with the statement thatthey “receive exactly the health care they want andneed...” also report that the information given to them isvery good. But only 25% who disagree with the statement report very good information. In which of thethree columns are you and persons you love?
50

Chapter 4: Inside a Doctor’s Office

Postscript: Americans’ Views
About Perfect Care and Doctors’
Views About HowsYourHealthThousands of Americans who use HowsYourHealthsuggest way to make their health and health care better.
Suggestions are similar across America. To illustrate
typical suggestions we use information from the Cityof Chicago.
About 30% of the respondents suggested ways to make
Chicago healthier. The topics listed are ranked from thehighest to the least common.
What might make Chicago a healthier place?
Rank
Air quality

1

Health care

2

Parks, paths & pedways

3

Smoking regulations

4

Indoor exercise

5

Restaurants & food6

Traffic, work, crime, stress

7

Health education events, programs, campaigns

8

Health Care
In Chicago, comments about health care fell into four
broad and inter-related categories: quality, access, costs,
and insurance. A few of the quality respondents notedthat they were not concerned about the quality of theirown care but were concerned for the poor.

51

Chapter 4: Inside a Doctor’s Office
Within the quality responses, most were about customer
service. They want more time with their doctors andnurses. They want to be listened to and they wantanswers to their questions.
Time is also an access issue. Most access respondents
wanted to be able to get appointments sooner andminimize the wait when they did arrive for their
appointment.
For 15 office practices that have recently asked theirpatients, the most common ways to improve healthcare are smoother access, greater efficiency, and better
communication and coordination.
Access to Health Care and Efficient Health Care
About 60% of Americans do not have very easy accessto health care and about 50% report that once they arrive at a doctor's office some of their time is wasted.
“Need to improve call answering. Frequently, the phone is not
answered promptly.”“It would be nice to have ‘one stop shopping’ and to be able
to do mammograms, blood work, and other lab work all in
one visit.”“I would suggest having a summary in the front of patient’s
file listing all past and present known medical problems, past
medicines tried that didn’t work, current medicines, and advised treatments. The nurse or doctor can see at a glance an
overview of patients history; rather than looking throughpages of notes.”Communication and Coordination
Nationally, only 10% of the time do physicians ask
patients if they understand the topic of conversation.
Improving communications problems is the focus of
HowsYourHealth. Adult Americans most often list
communication and coordination of care as areas forthe improvement of health care.
52

Chapter 4: Inside a Doctor’s Office“It’s frustrating going to a doctor because I feel am not being
listened to. I feel most like a number or cattle moving throughthe line. Not a real person with real health concerns.”“The doctor could give me better information about myconditions and also about my medication. The doctor often
seems not to read my chart and doesn’t always remember
prior conversations.”“Be more alert to medical complaints that reveal other medical problems. Ask patients if ‘anything else’ concerns them.”
Doctors’ Views of HowsYourHealth“The first patient to complete HowsYourHealth was seen
today. I picked up the fact that he’d never received pneumovax
and directly addressed his confidence in managing his own
condition. Interestingly his lack of confidence seemed to relatelargely to the fact that he has an implanted defibrillator madeby a company that has had a number of recalls. His cardiologist kept blowing him off about this topic. I pulled out anappropriate article and noted the relatively small absolute risk
reduction from the device in his circumstances. I also used the
manufacturer’s website to reassure him that his model had notbeen recalled. He left much more confident.
“I don’t think the visit would have gone the same way without HYH. So thus far I am 1 for 1.”- Dr. RH, Essex, CT“I just wanted to give a success story for a patient of mine
who recently used HowsYourHealth. She did the survey, andwhen she was done, she hit Print to print the action form.
Unfortunately, her husband was sitting near the printer andshe feared her honesty on the survey with regards to smoking
habits would be seen by her husband (who apparently either
didn’t know or didn’t want to confront her on this). After
sprinting up the stairs, grabbing the form off the printer before her husband could see it and running back downstairs
before he could ask ‘what the hell??’ she began to think maybe
she would be better off not smoking at all. So she kicked thehabit and now has ‘no secrets left from her husband.’53

Chapter 4: Inside a Doctor’s Office“By the way, she was also embarrassed about her 2-3 glassesof wine a day and has cut back on that.
“Wow, a healthier patient and a healthier relationship just by
answering questions. I have to say, I love a success story
when I didn’t have to do anything at all. I’m beginning tolike HYH better and better every day!”- Dr. JB, Newport News, VA“HowsYourHealth used with physicals picked up pain in a
stoic patient yesterday that I only saw once a year ago anduncovered a more insidious chronic issue, and the fact that his
specialist hadn’t bothered to answer his phone call for help
when he had a kidney infection. We reorganized his medical
access and he’ll see me for care next time first.”- Dr. NG, Albuquerque, NM“If you have not already done so, please do the online healthsurvey found at www.howsyourhealth.org and enter accesscode ___, and email it to me at the end. It takes about ten
minutes, and really helps me learn what you need to improveyour health. That website also has great self help and self
management information, in addition to links to credible
medical websites.”- Dr. ME, Woodland Park, CO“When I look at my summary report, I get into the very cool
stuff (from HowsYourHealth). I can look at what percentageof my patients who are limited by pain say I know about it
and what percentage feel that the explanation and treatment
have helped. I can look at how many of my patients withdiabetes report good glycemic control or say they know about
foot care or eye exams. I can see how they judge access to careor quality of information in chronic care. While overall,things look good, I am starting to change as a result ofaccessing these data.
“My response has been to try to become more methodical in
education on the basics of chronic disease. Only half my patients know what to do if they miss a dose of BP medication.
“I’m lousy at teaching about foot care in diabetics. etc, etc...”- Dr. NG, Albuquerque, NM
54

Chapter 5

Problems Are MadeTo Solve
The moment we are born, we are solving problems.
Poor problem solving is a threat to health and wellbeing. By the time we are in our teens about 70%
of us report that we are good problem-solvers.
Problem-Solving is a Way of Lifeome problems are technically difficult to solve,
such as doing your own heart surgery. Other
problems are personally difficult, such as losing
weight or keeping a New Year’s resolution. Most of oureveryday problems are of the personal type.

S

How we solve these personal problems greatly influences
our health and our ability to relate to others. For example, the first figure (following page) illustrates the habits
and behaviors of good problem-solvers aged 9-18 compared to those who have difficulty most or all of the timesolving problems. Poor problem-solving youths are most
likely to engage in risky behaviors (30% versus 10%),have poor health habits (70% versus 40%), and withdraw into the passive world of television (50% versus
30%).

Figuring out how to do my heart
surgery was more difficult than I
thought.
I guess I'll just try to lose someweightThe second and third figures illustrate the increased personal and difficulties and concerns facing poor problemsolving youths compared to good problem-solvers.
In adulthood poor problem solvers are usually not very
confident in managing their health problems. We havepreviously shown in Chapter 3, “As Good As It Gets,”
how poor self-management results in excessive use of thehospital and emergency room and a greater risk of
harm.
55

Chapter 5: Problems Are Made To Solve
Figure 1

Problem Solving Impacts Habits and Behaviorsof Teens
problem solvers

not problem solvers
70%
65
60
55
50
45
40
35
30
25
20
15
10
5

Figure 2

TV

e

ts

of

es
Ob

Lo

Be

Ex Li
er ttlcis eeha Risk
vi y
or

H Po
Ha eal or
bi th
ts

0

Poor Problem Solving Increases General Difficulties
and Concerns of Teens
not problem solvers

problem solvers

50%
45
40
35
30
25
20
15
10
5

56

Dr Alcoug h
Us ol/eViol
Ab enc
us e/
e

n
pr
e
Su ssio
ici n/
de

Pa
i

po
up
lS

cia
So

De

rt

k
W
or
ol

ho
Sc

Fa
m

ily

Re

la

Fe
e

tio

lin

ns

g

0

Chapter 5: Problems Are Made To Solve

Special Difficulties Related to Teen Problem Solving
Ability
not problem solvers

Figure 3

problem solvers

60%
55
50
45
40
35
30
25
20
15
10
5

Br
Pr eath
ob in
le g
m

do
m
Pa en
in

W
ei
g/
tin
Ea

Ab

gh

t

he
ac
ad
He

C
At an’
te t P
nt ay
io
n
Di
zz
y/
Ti
re
d

0

Problem-Solving Made Simple
Before an infant can speak it solves problems by testing
and mimicking. Before risking injury or failure, a childlearns to limit choices based on personal experience or
the advice of others. By the time a child reaches adolescence, he or she has had the opportunity to collect agreat deal of good (and bad) experiences.
Without much thought, adults take many actions andmake many decisions to solve problems. But some issues
and problems are more difficult than others. For example, consider the problems of pain and emotional distress.
We all experience aches and pains. Most aches and pains
go away in a few days. Our bodies have a wonderful capacity to heal. We may help our bodies by changing activities, just waiting (“tincture of time”), or taking aspirin, acetaminophen, or similar non-prescription pain
relievers.

57

Chapter 5: Problems Are Made To Solve

Difficulties Coping with
Pain and Emotional
Distress by Adolescents
not problem solvers
problem solvers
60%
50
40

However, for many people, aches and pains and emotional distress are more persistent and today’s most effective medicines will not make the pain permanently disappear. For example, about 1 in 10 (or 10%) of Americans over the age of 14 begin almost every day withbothersome pain and emotional stress.
Youths who begin the day with bothersome pain andemotional distress have poor school performance; adults
spend many days unable to work. It is not a nice way to
live.

30
20
10
0

sick athome in last
3 months

performing
badly inschoolDifficulties Coping with
Pain and Emotional
Distress by Adults
not problem solvers
problem solvers
70%
60
50
40
30
20
10
0

sick athome in last
3 months

58

We all experience emotional distress. Emotional distressalso often goes away without treatment.

notengaging in
usual
activities

However, among these bothered and distressed adolescents and adults, some manage to control the situation
better than others. These two figures show what happens
to adolescents and adults who have persistent pain andsignificant emotional distress. When people say that they
are good-problem solvers, they suffer less from their painand emotional distress than persons who are not as goodat problem solving.
Our colleagues recently completed a study of problemsolving treatment for pain and emotional distress in theoffice practices of 50 physicians. Half of the patients
received usual medical care. The other half used HowsYourHealth and received some coaching over the telephone about problem-solving and used a “seven step”
approach.
Six months later the health of people using HowsYourHealth and problem solving techniques was much better
than those patients who only received usual care. They
also had better understanding of their pain and they felt
in better control. They were more often “on the samepage” with their doctors. The “Problem-Solving” tool on
www.howsyourhealth.org is based on the results of thissuccessful study.

Chapter 5: Problems Are Made To SolveHow Does HowsYourHealth Problem
Solving Work?
People who use this approach go to www.howsyourhealth.org. Instead of completing the HowsYourHealthsurvey, they use the “Problem-Solving Tool” as manytimes as they wish.
The majority of people who use the “Problem-Solving
Tool” use it to better manage eating and weight. Other
commonly chosen topics are pain, stress, and financial
issues.

On the next page we show six steps two people use tohave healthier eating habits.
Readiness to Improve and Solve Problems

 I don’t have problems (such as pain) or poor health habits (such as I don’t
exercise).

 I have some problems or poor health habits but I am not ready to improvethem now.

?

 I have some problems or poor health habits and I want to start improving them.*
 I have tried to improve some problems or poor health habits but I have not beenable maintain any improvement I made.** Go to www.howsyourhealth.org and complete “Problem Solving.”
59

Chapter 5: Problems Are Made To Solve
Responses of Two People Thinking About a Problem and Their Choices
Problem-Solving Steps fromthe “Problem Solving Tool”

One Person

Another Person1) Identify the problems

EatingEating too much

2) Break the problem into
“bites”

Smaller portions.

Don’t add butter to bread.

No fat and sugar.

Choose fruits and vegetables.

Exercise.
3) Choose the best “bite”

Smaller portions.

Choose fruits and vegetables.

4) List possible steps tomanage the “bite”

Have three balanced meals a dayof smaller portions.

Have a fruit for breakfast.

Make sure the food groups are
represented.

Have a vegetable or fruit for amorning snack.

Reward myself for achieving a goal.

Have dried fruit in a bag for classtime.

Discipline myself.

Drink tomato juice.

5) Choose the best step

Discipline myself to say “no.”Have a vegetable or fruit for amorning snack.

6) What will you actually do,now?

Stop snacking on things.

Bring a snack bag to work.

Stay away from the candy machine.

Have a snack at 11 and lunch at 1.

Think twice before proceeding.

Vary snack bag items.

Move more.

Keep them cold.

The seventh step has them designate two trusted “buddies” who will help them. Using “outsiders” adds definite value by helping us monitor our progress and assist
us in devising strategies to change behavior and solve
problems.

60

In contrast to adolescents who have difficulty solving
problems, good problem-solvers more often talk to someone about their concerns AND report that the information was helpful. The next figure illustrates the comparison.

Chapter 5: Problems Are Made To Solve
Teenagers who have problems with feelings, family relationships, and the other listed concerns can choose to
ask for information from others or not. If they choose toask, the information may or may not be helpful. Over
time good problem solving teens are better at seeking
and getting good information than poor problem-solving
teens.
Asked For and Received Helpful Information
not problem solvers

problem solvers

40%
35
30
25
20
15
10
5

Ha Risk
bi y
ts

n
Pa
i

Su So
pp cia
or l
t

Sc
W hoo
or l
k

Re Fa
la m
tio ily
ns

Fe
e

lin

g

0

This 7-step problem-solving example might seem too
simple or too boring to be effective. But scientific studies
prove that it is really very effective.
Changing behavior and customary activities is very seldom sexy, fun, or exciting. Simple, clear goals andstraight-forward methods to attain the goals will work
most of the time.

Why Solving Problems By Yourself
Seldom Works
Whenever I ask him, the man in
the mirror reflects an excellent
sense of taste and common sense.
Don't you agree, sir?

Which Problems Matter Most?
Let’s presume you wanted to use this problem-solving
method. On which problem or concern should you
focus? The answer may not be a obvious as it seems.
First, ask yourself: “who labeled the problem a problem?”61

Chapter 5: Problems Are Made To Solve
In America, we are often told by others that we have aproblem or that we should be concerned about something. Every day you hear advertisers, friends, families,
political leaders, employers, doctors, pharmacy companies, etc. tell you about a problem they want you to fix(or pay them to fix for you!) Who labeled the problem aproblem?
Second, if the problem seems legitimate and has beenlabeled by a reliable source, ask yourself: "how big is therisk compared to other problems you have?"
For example, we mentioned that a diabetic patient often
confronts many risks. The best way to manage such along list is to work with a trusted health professional on
two categories of actions.
1. What action must I take soon to avoid serious trouble? As a general rule, smoking and a blood pressure
greater than 160 trumps most other risks.
2. What action can I take to reduce many risks at once?
Quitting smoking is clearly the one thing smokers can
do to greatly reduce their risk for heart disease, cancer, and premature death. If someone has a bit ofhigh blood pressure or diabetes, weight loss and regular exercise can greatly reduces the need for medicines. Controlling the blood pressure and diabetes
will greatly reduce risk for heart disease.
Finally, ask yourself: “what really matters?”
You have to be the judge of which problems mattersmost to you. Armed with the information from the firsttwo questions you might find the “Problem-Solving
Tool” useful for helping you sort out your competing
choices and actions.

62

Chapter 5: Problems Are Made To Solve
Good Problem-Solvers Can Be MadeWe are not predestined to be good or bad problem
solvers. Problem-solving is a skill that can be learnedeven by those who have endured difficulties for many
years.
Mr. CV was a 60 year old man who had spent the past 6
years at home because of pain and a paralyzing fear thatwhenever he tried to do something he would become
worse. The less he did, the greater the pain when he tried
to do anything. He had been prescribed many pills forpain and depression but he found that the side-effects ofthe pills were more bothersome than the relief heobtained from the pills.
Literally by chance he was asked to complete
HowsYourHealth. After completing HowsYourHealth hewas telephoned by a nurse educator he had never met.
She talked to him about his pain and emotional stress.
Together they decided to take some very small steps toincrease activity. Four telephone calls later his confidence
had improved enough for him to propose activities thatwere even greater than either of them believed were possible when they developed the first problem-solving plan.
One year later he applied for a job and is now a successful
driver of commercial vehicles.

This true story is one of many that underscores one
basic fact: we have the capacity to become good problem-solvers.

63

Chapter 5: Problems Are Made To Solve

Postscript: Adult Problem
Solving and Risk, Getting
Teens to Problem Solve
Adult Problem Solving and Risk
Information about risk is distracting. Increasingly risk information is not just the product of advertisers and theoffice of homeland security. Even well-meaning healthofficials assault us with risk information to get our attention, make us seek treatment, or influence us to change
our sinful ways.
For example, during the late 1990’s the definition of anelevated blood sugar was lowered from 140 to 126, anelevated cholesterol from 240 to 200, and a worrisome
blood pressure from 160 to 140. Even the measure ofbeing seriously overweight (using the body mass index)
was reduced from 27 to 25. These redefinitions resulted
in a 30% increase in the number of Americans who
have health problems compared to their older brothers
and sisters.
Remember that fear is the major reason we get risk
wrong. Good problem-solving seldom results from apanic situation. Good problem-solving requires us to getrisk right so we can focus on the most threatening problems. If we smoke, we need to remember that smoking
trumps just about any risk. If we have an elevation ofblood pressure (or cholesterol, or blood sugar, or weight),
we need to remember this type of curve to keep the
problem in perspective.
If we are now overweight and at risk for high bloodpressure and diabetes later, we should not forget that you
can do a lot now to avoid taking pills later. Experts estimate that when we are overweight and exercise regularly
and adjust our diet, we can reduce our risk for diabetes
and high blood pressure by 50%.
64

Chapter 5: Problems Are Made To Solve
For example, if our upper blood pressure number (systolic) is 155, we can usually lower our high blood pressure:• by just walking quickly for 20 minutes at least 4 daysa week (155 – 4 = 151)

Risk for Bad Events in
the Future
High
Risk

• by not adding any salt to foods and avoiding high salt
foods (151 – 5 = 146)

)
ve

ry

(1 hig60 h+)

h-1 igh60
51(1

n00 orm
-1 al
30
sli
)
gh
ti
n
(1 cr
31 ea
-1 se
50
)

Now look at the risk curve again!! Nice work.

Low
Risk

(1

• by losing weight when we are over weight. For every
10 pounds, (146 – 4 = 142) Lose another 10 pounds
and we may be down below 140.

Blood pressure levels

65

Chapter 5: Problems Are Made To Solve
Teen Problem Solving
We include here part of the problem-solving approachfrom HowsYourHealth. It was designed by young teens.
It was tested in 16 classrooms of an average publicschool system serving mostly white or hispanic teens. The
average age of the teens was 15 years but ranged from 1219.
Six weeks after the teens completed the problem-solving
approach, 90% said that it had helped. They rated theimpact as a “5” on a scale going from no impact (1) to avery high impact (10). Thirty-five percent had shown the
problem-solving approach to other teens. Only 3% of
the teens thought that the approach was difficult.
The section included here is designed to interest teens in“Problem-solving.”

You might have the following problem.

?

You have a big argument with a close friend. You
think that he or she just did not understand you andwould not listen to what you were saying. Whatwould you do?
First, I would:____________________________________________________________________________

Second, I would:____________________________________________________________________________“Up-the-Stair” Actions
Persons who have talked to many teenagers have foundthat the way in which teenagers solve problems affects
the way teenagers feel. Study the diagram below.
Note how certain methods for dealing with a problem
lead up-the-stairs toward better feelings and often solve
the problem.
66

Chapter 5: Problems Are Made To Solve

Also notice how other methods for solving serious problems go down the stairs to bad feelings and often madethe problem worse. For example, yelling, or hitting is adown-the-stairs way of dealing with a problem.
Were your two methods for dealing with the
problem “up-the-stairs” or “down-the-stairs”
actions?

?

 Both were “up-the-stairs”.
 Both were “down-the-stairs”.
 One was “up the stairs” and one was “down-thestairs”.

When You Have a Problem, Which Stairway
Do You Take? Down-the-Stairs Actions Can Be
Dangerous
Some teenagers who feel depressed or sad have thought
about harming themselves – even committing suicide.
Many persons think about suicide during a very badtime. Then they find better ways to solve the problem
and the thought goes away. Teenagers sometimes needmore time for the thought to go away. Therefore, theyneed to talk to someone about the problem.
Another example: Some teenagers use illegal and dangerous drugs. This is a problem because the drugs can

67Chapter 5: Problems Are Made To Solvekill and often get the teenager in trouble with the law
and they do not solve or change the problem.
Actions and Consequences
Quick actions lead to quick consequences. Quick actions
can lead to quick harms. Talking things through gives
you time to think about actions and consequences.
Most teenagers say they talk to their parents, other
teenagers, and other adults about problem solving. Theirideas about problems, situations, actions, and consequences may be helpful. Therefore, in a class or a smaller group of friends, you may want to talk about yourplans and exchange ideas.
Changing unwanted habits and feelings into desirable
habits and feelings is a challenge. American teenagers
find that getting answers to questions about their health,alcohol, drugs, and school is often easy. However, they
say they have difficulty finding answers to questions
about solving personal problems or about feeling better
about themselves.
Let’s talk about a way to look at personal problems – wecall this problem-action-consequence thinking. All choices and actions have consequences. This means that how
we act and react causes actions and reactions from others. When we yell, someone will get angry. When weblame, someone will get defensive. If you imagine how
the other person might think, feel or act, you usually canunderstand how your actions will affect the other person.
Feelings and Actions are Connected
Can your problems lead to dangerous actions?
“Up-the-Stairs” Actions:• Doing well
• Feeling good about yourself and others

68Chapter 5: Problems Are Made To Solve“Down-the-Stairs” Actions:• Hurting yourself and others – legal problems,
damaged future• Having sex – pregnancy, infections• Drugs and drinking – legal problems, damaged future• Avoiding and failing – school problems
Looking at Ourselves?

Imagine a situation where someone has just given
you a dirty look or has said something bad to you. OR

Imagine that you just noticed that you have lost all of
your important notes for a school paper. You worked
very hard on the notes for almost a week because it isyour favorite class. If you get a good grade on the paper,
you will get a good grade in the class.
For either the dirty looks or the lost homework, what
would you do?
Answer “yes” if the statements below describe actions
that are like you. Answer “no” if the actions are not like
you at all.

1. I would think about something else: try to forget it; or
would do something like watching TV or play a gameto get it off my mind.
 yes
 no
2. I would just accept the situation because I know I cannot do anything about it.
 yes
 no
3. I would keep wishing this thing had never happenedor that I could change what had happened.
 yes
 no
4. I would yell, scream or hit something.
 yes
 no
5. I would try to feel better by eating a lot, smoking,drinking beer or using other drugs.
 yes
 no
6. I would find out who was to blame for the situation,and blame them (or myself) for making me go through
this.
 yes
 no

If you have checked any “yes”
responses, it means that you
sometimes go “down-the-stairs”
towards harmful actions andunhappy feelings. The problem
may not be solved.
69

Chapter 5: Problems Are Made To Solve
Try this exercise one more time, using the following situation:?

You and a parent have been having a serious
argument. Your parent is upset about several problems
and you are told “Don’t you ever talk to me like that!”
What would you do?

1. I would try to see the good side of things and/or concentrate on something good that could come out of
the situation.
 yes
 no
2. I would try to calm myself by talking to myself, praying, taking a walk, or just trying to relax.
 yes
 no
3. I would turn to other adult(s) to help me feel better.
 yes
 no
4. I would talk about how I was feeling to one of myfriends.
 yes
 no5. I would try to solve the problem directly.
 yes
 no
6. I would think of ways to solve the problem and talk toothers to get more facts and information about the
problem.

 yes

 no

If you said “Yes, this is what I might try to do,” youare “going up the stairs” toward solving problems andhappier feelings.
This ends the sample from HowsYourHealth.
Additional information for teens about “How to
Problem Solve,” “Knowing and Setting Limits,” and“Popular Pressure Lines” is available on the website.
70

Chapter 6

It’s 100%
Esther is a very successful businesswoman. She enjoys her
success and close family. Until recently, health has been an
abstract idea and a collection of dull statistics.
Many times in our lives we are all like Esther. We takeour health for granted. And then it’s our 100% concern!
hen Esther’s mother became ill with a chronic(long lasting) disease called “sugar” diabetes,
health became THE ISSUE. Esther suddenly
learned that when we (or someone we care about) become sick, the dull statistical numbers become THE
ISSUE; it’s 100% when it’s you.

W

Esther now has to understand what diabetes means. She
had to understand how diabetes will impact her mother’slife, and her own. She has to figure out how best to help
her mother and help her mother to help herself.
When our 100% time arrives, we all want answers to thesame types of questions that now confront Esther: What
does it mean? How do I best manage it? How’s Your
Health? and its related tools are designed to help us prepare for our 100% days.
Are You a Sugar or a Person?
Esther’s mother has one of the five common chronic diseases. By age 70, at least one of these diseases becomes
THE ISSUE for the majority of Americans.
Esther’s mother was not overweight and no one in her
family had diabetes. “Bad” luck seems to have been thecause of her diabetes. But luck is not the entire explanation; sometimes what we do can make a big difference.

71Chapter 6: It’s 100%
Chronic Disease by Age
Age 50-69

Age 19-49

Age 70+

60%
50
40
30
20
10
0

High Blood
Pressure

Arthritis

When healthprofessionals see
you as “a sugar,”a “blood pressure,”or a “cholesterol,”
you know you arein trouble.
Because healthprofessionals arerushed they often
think: “I’ll focus on
the sugar now anddeal with otherissues later.” They
seldom do.
72

“Hard
Arteries”

Diabetes

Lung
Diseases

Any of These

For example, we previously noted that persons who arevery overweight are at least four times more likely todevelop diabetes than persons who are not overweight.
Regular exercise will help even very heavy persons avoid
diabetes.
But a discussion of statistical causes for diabetes is academic to Esther’s mother. For her, diabetes is now THE
ISSUE. What should she do? What matters most to
people like her?
When Esther first met her mother’s physician, theconversation focused almost entirely on the blood sugar.
Esther kept thinking, “My mother is much more than a‘sugar.’ My mother and I can manage the sugar but
there are a lot of other questions on our minds.” The
next table lists the issues and concerns of typical persons
with diabetes.
Esther’s intuition is correct. Good management of
Esther’s mother will happen when she is more thana “sugar;” when the doctor’s office focuses on whatmatters to Esther and her daughter.

Chapter 6: It’s 100%Moreover, Esther and her mother understand that theymust learn how to self-manage and live with the diabetes
99.99% of the time because a doctor or nurse is notavailable to help round the clock. How does a doctor’s
office or health system help Esther’s mother become agood self-manager?
Recall the previous example of pain management. For
pain and chronic diseases such as diabetes, the first stepis to know about the condition and other important concerns.
The next step is to provide Esther’s mother and Esther
with information that makes sense to them. The information must be actionable...that is, it must help them
live with the problem.
Esther and her mother are fast learners, but even thesmartest person can only remember so much at one
time. The final step is reinforcement of the information
and adjustment of the approach over time...for example
offering phone contact.
These three steps are not rocket science and will often
happen without the help of health professionals with advanced health training. But the health care system often
breaks down when dealing with these three steps.
Esther’s Mother Can Do Well
Depending on how well a person self-manages
their diabetes, the risk for kidney failure in 20 years isfrom 2% to 10%, 5-20% for going blind, and less than
3% for losing a foot. (The lowest percent listed for thesecomplications occurs when blood sugar control is good).
With good self care about 9 out of 10 people with diabetes have no complications. Esther and her mother,(like most of us when we are told that we have a disease), thought the risks of kidney failure, going blind,losing a foot - were many times higher than the actual
risk. Since Esther’s mother is 68, knowing these risks is
comforting since, as she said, “in 20 years I will be 88

Other issues:a diagnosis of diabetes
is not the only thingthat matters toEsther’s mom
Additional
Diagnoses

45%

Arthritis

35%

Obesity

30%

High Blood
Pressure

25%“Hardening of
the Arteries”

20%

Lung Diseases

15%

Functional Limits

50%

Physical

30%

Pain

30%

Emotional

15%

Daily Activity

15%

More Than Two
Symptoms

35%

Eating/Weight
Problems

40%

Joint Pains

35%

Sleep Problems 25%
Dizziness or
Fatigue25%

Foot Pain

20%

Back Ache20%

Unhealthy Habits

30%

73

Chapter 6: It’s 100%and a lot of other things can happen between now andthen.” Furthermore, she is confident that she will be able
to manage her diabetes well.
The next figure (Health Attributes) illustrates the many
important ways that care is better for patients who havewell-controlled diabetes. For example, diabetics having
good blood sugar control experience perfect care about
twice as often as poorly controlled diabetics.
Health Care Attributes and Diabetes Management
not good sugar control

good sugar control

80%
70
60
50
40
30
20
10

Go
In od G
fo e
rm ne
at ra
io l
n
In E
fo ye
rm C
at are
io
n
In Fo
fo ot
Ad
rm C
ju
at are
st
io
in
n
g
M
In ed
fo ic
rm at
at ionionw H
ith elDi p Li
ab vi
et ng
Ve
es
ry
Ea
sy
A
to cce
Ca ss
re
Ef
fic
M
i
e
D
nt
Ca
fo Awarer E re
m a
ot nd
io G
na iv
l D esist In
re fo
ss
Pe
rfe
ct
Ca
re

0

To do well, Esther’s mother must also manage her diabetes and health habits well. The following figure (Taking Care) illustrates how often adults with diabetes engage in good health habits and manage their healthproblems. We again see that there are many small but
important ways that personal actions impact blood sugar
control. For example, diabetics having good blood sugar
control regularly exercise about 3 times more often thanpoorly controlled diabetics.
Good health care combined with good self-care result in
half as much use of the hospital or emergency department (11% versus 22%).
74

Chapter 6: It’s 100%

Taking Care of Ourselves
not good sugar control

good sugar control

100%
90
80
70
60
50
40
30
20
10

nf
Se ide
lf nt
Ca in
re

Co

R
Ex eg
er ula
cis r
e

No

tO

be

se

in
g
m
ok
tS
No

ol
e
No sterm rolal

Ch

G
He ood
al G
th en
Ha er
bi al
ts

Bl

oo
d
Co Pr
nt ess
ro ur
lle e
d

0

If Esther’s Mother Does Not Have Adequate
IncomeThe previous two figures were based only on patients
who have adequate income. If Esther’s mother has a low
income she is likely to experience a very different levelof health care. The next figure illustrates differences byincome for American adults with diabetes.
The lower quality care results in more time spent sick athome (50% over three months for low income versus
30% for adequate income diabetics). Low-income diabetics more often use the hospital or emergency department (30% versus 15%).
In spite of a low income, Esther’s mother could manage
her diabetes well...but it would be more difficult. Approximately 45% of low income Americans have wellcontrolled blood sugar “all or most of the time” (compared to 60% of those with an adequate income).

75

Chapter 6: It’s 100%Care Differences for Diabetes by Income
Poor

Adequate Income

70%
60
50
40
30
20
10

Go
In od G
fo e
rm ne
at ra
io l
n
In E
fo ye
rm C
at are
io
n
In Fo
fo ot
Ad
rm C
ju
at are
st
io
in
n
g
M
In ed
fo ic
rm at
at ionionw H
ith el
p
Di Li
ab vi
et ng
Ve
es
ry
Ea
sy
Ac
to ce
Ca ss
re
Ef
fic
M
ie
D
nt
Ca
fo Awarer E re
m a
ot nd
io G
na iv
l D esist In
re fo
ss
Pe
rfe
ct
Ca
re

0

There is a 100% ISSUE Close to You
Imagine that you, a family member, or a close friend had
just given birth to a very sick or very small baby. The
baby is expected to die unless helped to survive in a hospital. You would feel very vulnerable and very scared.
You would really want to be on the “same page” withthe health care professionals.
HowsYourHealth is being used in situations like this toimprove “same page” care.
Some of the following “100% examples” will interest
you or someone close to you.
New-Born Intensive Care
Neonatal intensive care units (NICU) are used to treat
very small or very sick newborns. Over one-half of the
NICU babies weigh less than five pounds! About 70% of
the babies have been in the NICU for at least a week before their parents have completed the howsyourbaby survey.
76

Most patients (65%) are saying that the care is excellent, butthere is a lot of room for improvement of “same page” care.

Chapter 6: It’s 100%
For example, one-in-five of the parents are really concerned about their child’s pain and a similar number areconcerned about their own financial situation. Yet only
half of the parents have been given adequate help andinformation about these concerns.
Being able to talk to the SAME doctors and nurses
about concerns and being involved in important decisions is very helpful and comforting in a NICU. Having
the same care team and being involved in important decisions is happening only 60% of the time for families
with adequate incomes and less (40%) for low income
patients.
Communication always matters. Of parents who rated
the care as excellent, 70% had been able to talk with thesame doctor or nurse the right amount of time. Of those
who rated their care as fair or poor, only 5% had goodcommunication.
Children Aged 2-8
Sadly, the impact of income on a child is profound. The
next figure illustrates the impact of income on a child’s
environment.
Child Environment
Incomepoor

adequate income

100%
90
80
70
60
50
40
30
20
10

ch
ild ho- p us
ro e
of
co
m
m
sa uni
fe ty
ty
pa
r
he en
al ta
th l g
ha oo
bi d
le
ts
ss
th
a
te n
le 3
vi hr
sio s.
n

go

od
su so
pp cia
or l
t
no
do
m
ab est
us ic
e

0

77

Chapter 6: It’s 100%
The sad, predictable impact of an adverse environment
on child development and problems is shown in the following three figures.
Measures of Growing Up Well for Children
Incomepoor

adequate income

100%
90
80
70
60
50
40
30
20
10
0

good
physical
activitygoodsocialactivity

speakingvery well
(2-4)

good
school work
(5-8)

no
sick
days

good
breathingfew
headaches

Measures of Child Wellness
Incomepoor

adequate income

100%
90
80
70
60
50
40
30
20
10
0

good
feelings

78

good
behavior

goodattention

Chapter 6: It’s 100%More Measures of Child Wellness
Incomepoor

adequate income

100%
90
80
70
60
50
40
30
20
10
0

few
stomach
pains

few
chest
pains

good
sleep

good
energyfew colds,
sore throats

The responsiveness of the health care system to thechild’s problems is shown in the next figure.
Health Care
Incomepoor

adequate income

100%
90
80
70
60
50
40
30
20
10
0

have a“medicalhome”

clinicianstake time

address
concerns

goodaccessperfect
care

Although better “Same Page” health care might take thesting out of the situation, changes in the environment
79

Chapter 6: It’s 100%
are likely to have greater impact. For example, changes
in the school environment are important because of theamount of time a child is in school. Schools use HowsYourHealth to foster both greater awareness of problems
and to foster better discussions with children and theirparents about possible solutions to the problems.
Pre-teens and Teens
Diseases rarely afflict preteens and teens. The most important health issue for pre-teens and teens is their ability to correctly identify and solve problems. The most frequent causes of death and disability in teens relate totheir choices and actions.
Three-fourths of all deaths in teens result from accidents
and violence. Most teens abstractly understand the riskof accidents but many still do not wear helmets or seatbelts. About 50% of accidents involve alcohol or drugs.
The pool of alcohol and drug related deaths is large because 15% say that they “do” drugs, have sex, smoke
cigarettes, or drink alcohol a lot and many more than
the 15% experiment.
There is very little margin of safety for teens who use
drugs or drink. Some overdose and die, others are involved in fatal accidents, and some become addicted.
Less than 5 of 100 users of amphetamines, cocaine, or
narcotics can quit without help; 9 of 10 alcohol users
and 7 of 10 marijuana users will need help. If a family
member has been “hooked” the chances of becoming
hooked are even higher. Seventy percent of teen smokers
are still smoking 5 years later.
There are over 100,000 teen victims of violence eachyear. Over 3000 are murdered (usually by firearms) and2000 successfully commit suicide. As many as 1 in 50
teenagers make a suicide attempt that requires medical
attention.

80

Chapter 6: It’s 100%Is there a positive spin that can be put on all of this bad
news? Most preteens and teens do not place themselves
knowingly at risk. The good problem solvers generally
do well. The previous chapter described a method to improve problem solving.
Adult Chronic Diseases
High Blood Pressure (Hypertension)

This is the most common chronic disease and an easily
treatable silent killer. Recent very large studies reconfirm
what has been suspected for years – that highly effective
medicines (such as chlorthalidone) are well tolerated bymost people, are more effective than many newer medicines, and are dirt-cheap. Compared to newer medicinesthat cost $300-700 a year, chlorthalidone and similar
medicines cost less than $50.

About 55% of persons with high blood pressure reportthey often check their own blood pressure. When people
are well-informed about hypertension and motivated to
be involved in its management, they are unlikely to suffer the risks of poor blood pressure control.
We have described many times the powerful combination of accurate health information and good self-management. The very powerful impact of this “same page”
care is illustrated for control of high blood pressure.
When information is good and self-management is good,
only 2% of people have poorly controlled blood pressure
higher than 150. However, when information and selfmanagement are not good, poor blood pressure control
is more than 7 times worse: (15% versus 2%).

Impact of informationand self-care quality on
blood pressure control
Self management
not goodgood% people with blood pressure higher than 150

Regardless of medicine chosen, side effects need to becarefully balanced against the positive effects. Only 60%
of Americans with high blood pressure report that they
are well-informed about medication side-effects.

16%
14
12
10
8
6
4
2
0

not good
medicalinfo

good
medicalinfo

81Chapter 6: It’s 100%

Inadequate heart pain
control of angina
Self management
not good
good
80%

Heart Disease and Hardening of the Arteries(Atherosclerosis)“Hardening of the Arteries” (or atherosclerotic cardiovascular disease-ASCVD) has many manifestations suchas heart attack, stroke, angina chest pain, and heart failure.

70

Among those with ASCVD, the about one-third have
had a heart attack and 75% report that they are taking a
recommended “beta-blocker” and aspirin.

60
50
40
30
20
10
0

not good
medicalinformation

good
medicalinformation

Not well controlled
heart pain jumps fromless than 5% to over
70% when doctors andpatients are not on the“same page.”

Strokes are a relatively uncommon manifestation of
ASCVD in those below age 70. “Blood thinning” medications such as aspirin and warfarin are recommended
to prevent future strokes. About 70% of those aged 5069 report taking these medications versus over 90% of
those aged 70 years of age or older.
Heart failure and a heart pain called angina affect alarge proportion of persons with ASCVD. Both angina
and heart failure require a lot of self-management. Adequate heart pain control for people who have angina depends on doctors and patients being on the “samepage.” A similar picture can be drawn for heart failure.
Lung Disease

Lung disease includes conditions such as asthma, emphysema and bronchitis. Patient self-management ofasthma and most other lung disease is often required.
For example, people with lung disease often increase
their inhaled medications when short of breath or thereis tightness in the chest. About two-thirds of teens andadults with lung disease report that they have received
good education about ways to adjust their medications.
About 80% understand how to use their inhaler.

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Chapter 6: It’s 100%
When Relationships Break Down
In adult women, domestic abuse is a hidden cause formany health problems. During a four-week period,
about 1 in 7 American women aged 19-49 and 1 in 10
aged 50-69 experience insulting, swearing, threatening,yelling, hitting, or pushing “some, most, or all of thetime.”
Compared to women who have better relationships,
abused women carry a large burden of social and clinical illness.
General Problems Associated with Abuse
Problem

Probable
Abuse

No
Abuse

Bad feelings

40%

15%

Poor social support

35%

10%

Pain

30%

15%

Limited social activity

15%

5%

Limited daily activity

15%

5%

Elder Issues
When Americans are aged 70 years and older, it is usefulto think of them as two groups: those who are successfully aging and those who are ill or frail. “Successful
agers” tend to have a long history of social involvement
and physical activity. “Successful agers” tend to ratethemselves in excellent or very good health. Both groups
have a lot of the common diseases, but the frail aremuch more limited in their daily activities and at higher
risk for falls. Interestingly, a large proportion of the frail
elderly are driving even though 30% say that they havedifficulties driving.

83

Chapter 6: It’s 100%Elder Issues
Age 70+in excellent orvery good health:SÒ uccessful Agers ”

Age 70+in fair orpoor health:“Frail”

High blood pressure

30%

45%

Arthritis

25%

45%

Hard arteries

15%

30%

Diabetes

5%

20%

Lung diseases

5%

20%

Limit in daily activity

5%

40%

High risk for falls

5%

20%

Still driving a car

95%

80%

Common diseases:

Average life expectancy at age 70:Male

15 years

9 years

Female19 years

12 years

Average life expectancy at age 80:

84

Male

11 years

5 years

Female12 years

7 years

Chapter 6: It’s 100%
When We are Seriously Ill
More than one in three seriously ill Americans do not
get the care they want when they are dying. We find thatvery frail HowsYourHealth users are very interested in
making sure that others know what matters to them.
About half are worried about those they will leave behind, being a burden, and pain.

“It’s not that I am
afraid of death.
I just don’t want
to be there when
it happens.”- Woody Allen

About 75% of these seriously ill persons say that theirfamily, friends, or doctor would know would to do ifthey became too sick to speak for themselves. But only
50% have what they want in writing.
Putting down what is wanted in writing is not as easy as
it sounds. It requires a person be on the “same page”
with themselves and others. For this reason we offer asection of HowsYourHealth.org for those who are very
sick or frail.
A family member or friend often helps the sick or frail
use this special section of HowsYourHealth.org. Morethan half of the users of the special section are unable
to leave the house and shop without assistance. Many
need help with personal care.
The web-site automatically prints out for the caregiveror sick person a list of what they desire, want, and fear.
This list can be shared with their family and doctor.
When a person does not have very clear instructions
about where s/he wishes to die, the health system will
decide. When a person dies without clear instructions in
one state, the chance of dying at a hospital can be fivetimes greater than the chance of a hospital death in another state. Five-hundred percent is a big number. Fivehundred percent represents the five-fold variation in hospital deaths across states within the United States today.

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Chapter 6: It’s 100%

PostScript: More About
Chronic Conditions Excerpted
from www.howsyourhealth.org
Hypertension (High Blood Pressure)
Hypertension is not the same as feeling anxious or “highstrung.” Hypertension in adults means that three measurements of blood pressure in the arm average morethan 140/90. (The first number – systolic pressure –is caused when the heart pumps; the second number –diastolic pressure – is the pressure when the heart is relaxed).
High blood pressure is very common. High blood pressure is made worse by eating too much salt, being overweight, or drinking too much alcohol (more than twocans of beer, two glasses of wine, or two mixed drinks ina day). Smokers with high blood pressure are at thegreatest risk for heart disease and hardening of the arteries.
You can expect the systolic blood pressure to drop 10
points if you change to a reduced salt (sodium) diet andeat a diet high in vegetables and low in red meat, sugar,
and saturated fats. You should select only low fat diary
products. Example: 2% milk not cream.
Medications will generally be prescribed for patients
whose blood pressure remains high despite changes inweight or diet if:• your blood pressure remains more than 150/100.
• you are an African-American.
• you have diabetes or “hardening of the arteries.”• you continue to smoke.
• you are in your sixties or older, because blood pressure treatment will have even more benefit than inyounger persons.
86Chapter 6: It’s 100%
In some people, certain medications for hypertension
can cause tiredness, dizziness when standing up, feelingsof depression, being less alert, or decreased interest insex. Health care providers work with you to find themost affordable medicine that controls your blood pressure and causes the least problems for you.
The most effective and inexpensive medication is a thiazide pill. Other “older drugs” are much lower in costand as effective as many of the “newer drugs.”
What should you do? First, remember that hypertension
can cause serious heart and kidney disease, as well as
stroke. Even slightly elevated blood pressure (130-139/
85-89) is a risk. So try very hard to change your lifestyle,regularly take prescribed medicines, and check yourblood pressure frequently. Second, help your doctor findthe treatment that is best for you. Bring to the office
blood pressure measurements you have taken at home orin other community settings and tell your doctor about
any problems you may be having with the medications.
Heart Disease and Hardening of the Arteries
We know that future problems from heart disease andhardening of the arteries can be reduced when you:
• do not smoke.
• exercise regularly.
• keep weight, blood pressure, and cholesterol nearnormal. LDL cholesterol should be no higher than115, if possible.
• keep blood pressure less than 150/90, preferably lessthan 140/90.
• take low dose aspirin (or warfarin if you have a condition called atrial fibrillation).
• take a “beta blocker” if you have had a heart attack.
• take “converting enzyme inhibitors” if you have heart
failure; low dose beta-blockers may also be helpful.
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Chapter 6: It’s 100%
A doctor should also spend time teaching people withangina heart pains and heart failure how to adjust medications so they are as effective as possible. Medication
education always stresses that:• Beta blocker medications should never be stopped
suddenly.
• Nitroglycerin for angina heart pains should be taken
before beginning an activity that usually causes pain.
• Educated patients can safely adjust diuretics (“water
pills”) for heart failure. You must keep track of yourweight, feelings of shortness of breath, and swellingof your legs (edema). Easy “tricks” for controlling
heart failure include lying down for 45 minutes after
taking furosemide and using a combination of low
dosage spironolactone or hydrochlorthiazide with
furosemide.
Patients should always contact their doctor if they notice
worsening of pain, shortness of breath, new pains, or
pain that is lasting longer.
What about surgery, special tests or other methods for“cleaning” blocked blood vessels? What about “blood
thinners” to prevent stroke? Please read Health Habitsand Health Decisions at www.howsyourhealth.org before
you talk about these choices with your doctor or nurse.
(Sugar) Diabetes
Diabetes describes several conditions that cause sugar in
the blood to be higher than normal. People who havehigh blood sugar are more likely to develop hardening of
the arteries, loss of vision, and kidney problems thanpersons who do not have high blood sugar. Kidney problems can lead to kidney failure. If the blood sugar ismade as normal as possible, many problems can be reduced – particularly in people with diabetes who needinsulin.
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Chapter 6: It’s 100%
The best blood sugar goals are:• Fasting: 70-120.
• Before meal: lower than 160.
• At 3 am: higher than 65.
A special (GH) blood test (glycosolated hemoglobin)should be as close as possible to the average for non-diabetics which is less than 7.
Health care professionals find that many people have difficulty reaching these goals. Your doctor should help youcome as close to these goals as possible. People who needinsulin should be careful to avoid too much sugar and fat
in their diet and should exercise regularly. For otherswith diabetes, the same exercise and diet rules should be
followed; weight should be as close to normal as possible;
and medicines may be tried to lower the blood sugar.
Sometimes several medicines and insulin may be needed. A daytime pill and night-time insulin can be very effective in some patients. Metformin seems useful foroverweight diabetics who do not need insulin.
Remember, after you have had diabetes for more than
five years, you have difficulty feeling when the sugar is
too low. That is an important reason for regularly checking your blood sugar when you are taking insulin or pills
for diabetes.
Your vision can be severely affected by diabetes. Eyes
should be checked every two years even if there is not a
problem. The younger you are or the less controlled
your blood sugar, the more often you should have youreyes checked.
Higher risk eyes should be checked every year – preferably using medicine to dilate the pupil. You should consider your eyes at higher risk if it has been found to havechanges in the past, you are below age 50, or your GH(glycosolated hemoglobin) is more than 9.
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Chapter 6: It’s 100%
The following treatments are effective for health problems associated with diabetes:• Regular exercise will reduce the average blood sugar
even if you do not lose weight.
• Eye problems: laser and surgery treatments.
• Blood pressure should be less than 130/80 if possible,and “angiotensin” drugs seem to be the best choice.
• Hardening of the arteries: blood pressure control andcessation of smoking.
• You will want to keep your LDL fat in the blood
below 115 and even lower, if possible.
• Nerve pains: antidepressant drugs, capsaicin.
• Stomach and bowel problems: metoclopromide, cisapride, and occasionally erythromycin.
• Foot problems: carefully check for any sores twice aday. Be particularly careful if you have poor feeling inyour feet and they are badly misshapen; the chance of
having a non-healing sore (an ulcer) is more than 1 in
10 in a year.
Arthritis“Wear and tear” (degenerative) arthritis is very common
as we grow older. Arthritis, or pain in the joints, will usually be most noticeable in an area that has been injured
or is used a lot in everyday work. The distant finger
joints, knees, hips, neck, and low back are commonly affected. Pain is seldom felt when resting except in severecases.
Degenerative arthritis pain in the knees can be helped bystrengthening the muscles in the thigh. For every poundof excess weight lost, 3 pounds of stress are taken off theknee.
Degenerative arthritis usually does not cause warm,
swollen joints, or pain in many joints at the same time.
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Chapter 6: It’s 100%
Please contact your health care professional if this happens.
For better management of pain, check out the many
choices at www.howsyourhealth.org. Learn “tricks” fromothers on the “blog.”
Breathing Problems: Bronchitis,
Emphysema, and Asthma
A “cold” can cause a cough or shortness of breath.
However a “cold” lasts only several weeks at most. If
you have felt short of breath or had a cough lasting
more than a few weeks, you should contact your doctor.
Everyone now knows that chronic bronchitis (a coughwith sputum lasting for at least six weeks) and emphysema (destruction of the lung) are caused by smoking.
When you quit smoking, some of the damage reverses:
shortness of breath and sputum production will decrease. Most of the treatments listed below are also triedin bronchitis and emphysema.
Asthma is a problem that can also make people feelshort of breath and cough a lot. Asthma can be present
with emphysema or bronchitis or it may occur on its
own.
During an asthma attack:• The lining of the airways in the lungs become
swollen.
• The airways produce a thick mucus.
• The muscles around the airways tighten and makethe airways narrower.
These changes block the flow of air, making it hard tobreathe. It is important to treat even mild asthma so thatyou can keep it from getting worse.
Certain things can trigger your asthma or allergy andmake it worse. If you stay away from these triggers, your91

Chapter 6: It’s 100%
asthma will bother you less. Common triggers are: dust,
mold, pollen from trees and grasses, cold air, smoke, cats,dogs, some chemicals, and exercise.
There are a lot of ways to treat asthma so that you canbe active without having asthma bother you. With asthma you can exercise and play sports and sleep throughthe night without coughing. Your asthma attacks can be
managed and your asthma medicines need not make you
sick. But to keep your asthma from bothering you, youhave to know what you are doing.
• Know what your asthma triggers are and plan ways
to avoid them. Many people with asthma havebreathing trouble when they start to exercise. These
people can take some of their medicine just before
they start. If you can’t avoid a trigger, treat it before it
causes problems.
• Develop a medicine plan with your health careprovider that keeps you from having problems. Many
people wait too long before beginning their treatment
and the asthma gets out of control.
• Know what to take when you have asthma problems.
Some medicines are taken as a pill and some are inhaled
into the lungs directly. If you are already getting treatment for asthma, you should bring your medicines to theoffice, so that your doctor can explain the type you aretaking.
There are two types of asthma medicines:• Relaxers (bronchodilators) are medicines that relax
muscles in the airways, making it easier for you tobreathe. Beta 2-agonists, theophylline, and ipratropium are bronchodilators. (Ventolin, Theo-Dur, andProventil are brand names for these bronchodilators.)• Anti-inflammatory medicines reduce the swelling inyour airways that cause asthma symptoms. They also
prevent swelling in the future, which keeps asthma
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Chapter 6: It’s 100%
symptoms from starting. Cromolyn, nedocromil(Intal, Tilade), inhaled corticosteroids (Azmacort,
Vanceril), and oral corticosteroids (Prednisone) are
anti-inflammatory medicines.
Most doctors will tell you to take your inhaled relaxer(bronchodilator) medicine at the earliest sign that yourasthma is getting worse. Watch out for early signs so thatyou can start the asthma medicine right away. An asthma attack is easier to stop if you take your medicine assoon as your symptoms start. Then you won’t have totake as much medicine. Keep taking the medicine forseveral days after a bad attack so that it does not rebound (come back).
Remember: Relaxers (bronchodilators) relieve symptoms, but they cannot reduce or prevent the swelling thatcauses the symptoms. When you have to use a bronchodilator a lot, or if you use it more than 3 or 4 times
in a single day, your asthma may be getting much worse.
You probably need another kind of medicine and should
talk to a doctor right away.
Take your anti-inflammatory medicines exactly the way
your doctor recommends, even if you are feeling well.
This will reduce airway swelling and keep asthma attacks
from starting. This medicine must be taken regularly for
it to work well. This medicine does not work as quickly
as the bronchodilators, but don’t be fooled. The anti-inflammatory medicines work slowly, over time. But they
are very powerful.
NOTE: If you regularly use asthma drugs that containcortisone, you should be taking calcium. Talk to yourdoctor.
Some people are afraid that if medicine is taken all thetime, it will no longer work. This fear is wrong. Asthma
medicines do not stop working over time if you take themas prescribed. Asthma medicines are safe, if taken as
directed. But, sometimes asthma can change. If this happens, your asthma medicines may also have to be changed.
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Chapter 6: It’s 100%
One of the most important ways to keep your asthma
under control is to have a written plan. You take different medicines depending on how well you are breathing
each day, or on your peak flow rate if you use a peakflow meter. Most doctors use the Zone System to help
you follow your plan. The zones are set up like traffic
lights.
• Green: Great! Keep up the good work!
• Yellow: Not too good, watch out and take the right
medicines to get yourself back in the green zone.
• Red: Emergency! Call your doctor and take yourbronchodilator medicine.
Your medicine plan will tell you what kind of medicine
to take every day (when you’re feeling well and in theGreen Zone). It will also tell you what kind of medicine
you need to take when you are feeling badly and you arein the Yellow or Red zone. Your doctor will help youwith this plan, but it is up to you to keep track of how
you are feeling, and then Follow the Plan! As time
passes, you will be the best person to manage your asthma.
Serious Obesity
Many Americans are overweight. If you are more than
15% overweight or have a lot of fat around your waist,
your chances for having heart disease, high blood pressure, and diabetes go up a lot. When you are more than
25% (about 50 pounds) overweight, serious, and immediate health problems can occur. If you are overweightand seriously exercise and change you diet, you cancut by one-half your chance for having (sugar) diabetes or high blood pressure! People who are very
overweight should talk to a doctor or dietician before beginning a diet. Obesity is the commonest reason people
use “problem-solving” at www.howsyourhealth.org.

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Chapter 6: It’s 100%
Medications
Americans use a lot of pills; they are using 50% more
pills than they did 10 years ago. Americans spend much
more than other countries on pills. But medication use
has more than a financial cost. It can also be risky. It is
now estimated that medications are the third most common cause for health problems in the United States andcause up to 150,000 deaths a year. In the past 20 years
one out of every ten medications newly placed on themarket has been withdrawn later because they hurt people more than they helped. In the chapter, “As Good As
It Gets,” we showed how problems with medications arestrongly influenced by “same page” care.
Non-steroidal anti-inflammatory medications (aspirin,
Motrin, Naprosyn, etc.,) account for about 8,000 deaths
each year and seem to increase the chances for kidneydiseases. As many as 40% of these types of prescriptions
may be “unnecessary.” Recent problems with Vioxx remind us that “newer” medicines will not necessarily be
any safer than medicines as old as aspirin.

?

Do you think thatyour medicines(pills) are making
you ill?
 Yes.
 No.
 I am not sure.
 I am not taking
medications.

Are your medications
making you ill?
Yes
6%
Not
sure
22%

No
72%

Adults who take medications each day often take several
different types. Sometimes the medications may cause
problems or side effects. Because of their smaller size,
women are often at higher risk for problems with medications. The challenge for your doctor and for you is tofind and reduce the side effects caused by medications.
Doctors are often able to reduce the dosage or change toanother safe, effective, and inexpensive medication forthe one causing the problem. Sometimes stopping the
medicine completely is the best choice.
Many drugs leave the body through the kidneys. If you
have kidney problems, the dosage or frequency of taking
drugs may need to be reduced. Always talk to your doctor before starting a new medication.
What else can you do? First, make yourself a “Medications I Take” list. Make sure you list all medications you
95Chapter 6: It’s 100%
take at least three times a week, not just the new
ones. Always bring this list with you when you see any
person who is going to help you manage your medical
problems. This type of list is available at the website
www.howsyourhealth.org.
Second, tell your doctor when you are having trouble
taking your medications because they are either too expensive, too easy to mix up, or too easy to forget. For example, “older drugs” for high blood pressure are lower
in cost and as effective as many of the “newer drugs.”
You should consider buying a “pill holder” if you aretaking two or more types of pills each day. (You can also
use an egg carton for the same purpose.) Seven-day pillholders are very useful. No matter which holder you
choose, make sure each section is labeled with the nameof the pill and the time it should be taken. You can obtain electronic devices that remind you when to takepills.
Third, you should have your pharmacist check for druginteractions. You can become sick when one medicine
reacts with another. Be very careful about interactions ofa heart pill called digoxin, all aspirin-like drugs (including Motrin or ibuprofen), breathing pills (theophylline),
stomach pills (cimetidine), and all types of pills for anxiety and “nerves.” Finally, please tell your doctor if you
think that your medications are bothering you.
If you are pregnant or planning pregnancy, please discuss any medications being used. Medications of concern are aspirin, ibuprofen, and similar medications during the third trimester. “ACE inhibitors” should also be
discontinued whenever possible.

96Part III:Are You and Your
Doctor Ready to
Improve Your Healthand Health Care?

97

Part III: Are You and Your Doctor Ready to Improve Your Health and Health Care?

Are You and Your
Doctor Ready to
Improve Your Healthand Health Care?
You now have a good understanding of the promise of“same page” care. Now it’s time to help your Doctor
make care not just “as good as it gets” but as good as it
can be! (If you HATE TESTS, don't worry. This brief
test is for your doctor and all the other people who workin the office! But don’t do anything with it until you havefinished the book.)
Dear Doctor,
If you and your office staff all complete the first six itemsof this brief survey, you will receive a diagnosis of how
well your practice is working. The second four items suggest several changes that make care better.
Inside a Doctor’s Office...The Self-Rating Questions:
How is Team-Work?
1. In this office, I always have the opportunity to do what
I do best everyday.
 Strongly disagree
 Disagree
 Agree Strongly agree (1 point)
2. In the last seven days, I have received recognition or
praise for doing good work.
 Strongly disagree
 Disagree
 Agree Strongly agree (1 point)98

Part III: Are You and Your Doctor Ready to Improve Your Health and Health Care?
3. Our office staff works like a team. We have high levelsof trust and collaboration. We appreciatecomplementary roles and recognize that all contributeto a shared purpose.
 Strongly disagree
 Disagree
 Agree Strongly agree (1 point)
4. I would recommend this office practice as a greatplace to work.
 Strongly disagree
 Disagree
 Unsure Agree Strongly agree (1 point)
How is Communication?
5. How easy is it to ask anyone a question about the way
we care for patients?
 Very easy (1 point) Easy Difficult
 Very difficult
6. Technology in this office smoothly links patient carewith a rich information environment. The information
environment is designed to support the work of theclinical team.
 Strongly disagree
 Disagree
 Unsure Agree Strongly agree (1 point)questions continued next page...
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Part III: Are You and Your Doctor Ready to Improve Your Health and Health Care?
Immediate Improvement Questions
a. Our office has full-staff meeting (doctors, nurses,
clinical assistants, office staff) at least every six weeks
and these meetings focus on how we can best work
together to better address our patients' needs.
 yes
 no
b. Our office keeps an up-to-date display of
information about our performance.
 yes
 no
c. Our office knows how confident individual patientsare in controlling and managing most their healthproblems or concerns.
 yes
 no
d. Our office has regular meetings with groups ofpatients (either in a patient advisory board or inscheduled patient group visits).
 yes
 no

How well a doctor’s office works is strongly related tothe type of care and service the patients receive.
The six questions (Question #1-6) for a doctor’s office
are strongly related to how often Americans will rate
“perfect care.”Questions (a-d) remind doctors’ offices of simple ways
to make the office work better. For example, less than 3of 10 doctor’s offices have brief, regular meetings of all
people who work in the office to discuss how to makethe office work better. Without such meetings, improvement in care is unlikely.
The GRAPH on the next page shows how strongly
patients' rating of practice quality are related to the way
the office staff responds to the six questions.

100Part III: Are You and Your Doctor Ready to Improve Your Health and Health Care?

Quality of Office Work and Patient Rating of Perfect CareJ

High
RatingPerfect CareDr. M Office

L

Low
RatingDr. O Office

Office WorkHigh Rating(Total score of 6
on Questions 1 - 6)

Additional testing by more than 400 office staff and 1200 patients showed the same
pattern. Regardless of patients' illness burden or level of poverty the pattern was
similar.

101

Chapter 7

The Promise of Same
Page Care“You should always be careful when reading books
about health. Otherwise you might die of a misprint.”- Mark Twain
hy have we defied Mark Twain’s advice andwritten a book about health care?

W

Part of the answer is that it is too big a subject to ignore.
All of us are involved one way or another in health care.
Eighty percent of Americans visit a doctor every two
years and 80% of us take some type of pill ever week. In
the last 10 years, we have increased our consumption of
medications by 50%!
In 1950 each American spent $500 (in current dollars)for health care; now we spend $5000 per person. In
comparison, the Spanish, Canadians and Swiss spend
between $2000 and $3000. A large portion (35-50%) of
the American public agrees that the health care system isbroken. (In 2018 this cost difference is worse!!)Another justification for writing this book is based on
scientific evidence: test results show that the tools andapproaches described in this book will add value tohealth care.
How’s Your Health? places the highest priority on thefront-line of health care. The “front-line” is where theproblems are real, not abstract, understandable, notobscure.
The “front-line” is where Esther and her mother workwith the health professionals to understand and manage

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Chapter 7: The Promise of Same Page Care“HowsYourHealth,a simple web-based
health survey tool, isproving remarkably
useful to a wide
variety of users,
including patientsand providers alike,with potential
rewards not only insatisfaction but also
in cost savings andimproved clinicaloutcomes.
“This survey, whichasks a series ofmultiple choicequestions and takes
about ten minutes tocomplete, is used bythousands of patientsand consumers on
their own andthrough programs
sponsored by
employers, healthcare systems andphysician groups.”
Institute for Health Care
Improvement
2004

104

diabetes. The “front-line” are the health professional“waiters” who listen, takes the orders, and start the chainof events that ought to result in a 100% satisfying healthcare for their customers. The “front-line” is us. The“front-line” is our son, or daughter, or parent.
At this “front-line” not being on the “same page” isstrongly linked to errors and harms, unwanted variationin care, and many wasted costs. How’s Your Health? offers
easy-to-follow steps to improve “same page” care andsolve personal problems.
Four Steps
Step One: If you have any ongoing healthproblems get a consistent doctor or healthcare team.
Cost to you: Nothing except persistence.
Cost to the health system: Nothing.
Current situation: Less than 50% of Americans have thesame doctor over a five-year period.
Twenty-five years ago, as director of a large clinicalgroup, I had to make a decision. Should the system
make an extraordinary effort to ensure high levels ofcontinuity between patients and the health professionals
or was it safe and acceptable to have less stringent continuity of care?
A study involving 700 adults answered the question.
Some received very high continuity and the others received “usual” care. Two years later the results showedthat having the same health professionals was a very
healthy choice: patients with the same health care professional were more satisfied and used 30% less hospitalcare than the patients who less often saw the same healthprofessionals.

Chapter 7: The Promise of Same Page Care
This study put to rest any question about the value ofcontinuity. Continuity has many good impacts. Insist onit!
Step Two: Get good health information.
Cost to you: Your time.
Cost to the health system: Nothing.
Current Situation: “Health Information” for preteens
and teens is generally whatever a peer tells them.
Adults use many non-physician sources of health information such as:• Books and pamphlets: 40-50%• Friends and family: 35-45%• Pharmacists: 25-35%• Internet: 20-30%• Health Fairs: 5-15%

Less than half of the information given by health professionals is easy to understand. In contrast, patients consider more than half of the information on the internet
equal to or better than that received in their doctor’s office. However, it is often difficult to find what you wantor what matters to you among the thousands of internet
health sites. Most of these sites electronically track you,have something to sell, or badly overstate opinions. For
this reason we urge familiarity with two reliable gateways
to health information on the internet. Both will direct
you to other high quality, non-commercial sources of information. Both are available in English and Spanish:• medlineplus.org (encyclopedic)• www.howsyourhealth.org (“what matters” by age).

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Chapter 7: The Promise of Same Page Care
Step Three: “Do it yourself ” assessment,
behavioral change, and problem self-management.
Cost to you: Your time, effort, and commitment.
Cost to the health system: Nothing
Current Situation: Our health behaviors may contributeto about 50% of early deaths and a lot of illness. People still smoke despite its huge impact on health; obesity is increasing everywhere; sexually transmitted diseases increase; the list goes on!
None of us live perfectly healthy lives. It is hard to dowhat is best. When given advice by a doctor, 25% of us
will not follow the advice. We most often don’t follow theadvice because the doctor and we are not “on the same
page.” But 25-40% of the time it seems too difficult tofollow the advice.
Nevertheless, over time each of our attempts to improvea behavior or solve a health problem adds up. For example, many younger smokers do quit as they get older.
About 25% of American drinkers stop drinking as theyage.
The more we are supported – surrounded by persons
who know how to manage these issues – the more likely
we will be successful. Advice that is tailored to “whatmatters” is easier to understand and follow.
When we use the HowsYourHealth assessment (about
every 2-5 years), we check-up on how we are doing. We
receive up-to-date information to help us do better. If weneed to solve problems, the HowsYourHealth ProblemSolving program (done as often as needed) is available tokeep us on the path to better health. Use the blog on
HowsYourHealth to share ideas, too.

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Chapter 7: The Promise of Same Page Care
Step Four: Demand the health system get on
the “same page” and support your self-management.
Cost to you: Your time, effort, and commitment.
Cost to the health system: Nothing in the long term; infact, waste reducing and cost saving when the healthsystem is reorganized to deliver better “same page”
care.
Current Situation: The health system is frequently not“on the same page” with patients; productive communications are not the focus of the system; errors,
harms and suboptimal care are the results; resistanceto change by existing educational, research, training,and patient care systems.
Health systems designed to support productive communication always result in better care. The speed withwhich professional health systems focus on communication “at the front line” depends on the speed with which
the message of How’s Your Health? is pushed by persons
like you.
When you are in a doctor’s office, you are often asked toremember many things. Wouldn’t it be great if you wereroutinely re-contacted by phone to find out how a prescribed care plan is working or to receive reinforcement
about changes you are trying to make? Wouldn’t it begreat if e-mail were available for you to ask questions,
get results, or refill medications?
Despite the obvious advantage for “same page” care topatients, health professionals worry about the hassle (andloss of revenue) from using telephone care or e-mail.
In fact, the patients helped most by telephone care are
generally those for whom the office staff is alreadyspending a lot of time in rework--re-asking the same
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Chapter 7: The Promise of Same Page Carequestion, picking up problems that could have been
identified earlier, etc. Most practices are finding that
Email is a very useful tool to increase efficiency andcommunication. Therefore, telephone and E-mail timespent by the practice to truly get “same page” careshould be offset by time saved from frustrating waste.
Remember Esther and her mother? Even if Esther andher mother had excellent telephone follow-up from theoffice visit by phone and used the HowsYourHealthweb-site and its “blog,” they might have unansweredquestions about living with diabetes. Shared medical
appointments (also known as group visits) enable
patients, such as Esther’s mother, to spend up to
90 minutes with clinicians and other patients. Groupvisits work because the 8-14 participants learn how tomanage their problems and their concerns from eachother. Participants may attend many or only one session.
We always find that once health care professionals havebeen involved in a group visit, they improve the style ofinteraction with their patients. They listen better andthey become much better at letting patients take controlof their own care.
The evidence is overwhelming that many of the problems with American health care stem from its inability toplace health professionals and you on the “same page.”
HowsYourHealth and the changes in health care it supports are specifically designed to improve “same page”
care.
We recognize that that many of the financial and organizational difficulties in health care are not going to besolved by “same page” care alone. But getting on the“same page” is a very important and easily implemented
way to improve health and health care.
It may take a long time before the entire health care system can deliver “same page”, safe, effective health carein a timely and efficient way. Take these actions to minimize your risk for harm while you wait for higher quality
health care.
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Chapter 7: The Promise of Same Page Care
Risk Factors
Categories that
Place You at Risk
For Harm

Risk
Increase

What You Can Do to Reduce
Risk

You think your
medicines aremaking you sick(see Note 1 at far
right)

300%

Tell the doctor that your pills
may be making your ill. Keep adiary of your pills and when you
are ill.

Poor access tocare (see Note 2)

150%

Find offices that are willing totelephone patients, use e-mail,or offer same-day appointments.

You don’t feel
confident managing health problems

130%

Make sure the doctor or nurse
knows about your lack of confidence. Use “Problem Solving”
on www.howsyourhealth.org.
Ask about Shared Medical Visits.

The care you receive often
wastes your time(see Note 3)

100%

Work with the office by serving
on a patient advisory board.
Find an efficient office.

You are taking
three or more
medicines (seeNote 1)

90%

Review your medications withyour doctor and try to reduce thenumber. Keep careful track ofwhat, when, and why you takemedications.

You have financial problems

30%

This risk is often related to access. (See Note 2 at right.) Demand good access and same
page care regardless of yourwealth.

Notes to table:
1. Medicines. Among Americans
with chronic diseases, about
25% report that their medicines
may be making them ill andabout 20% do not take their
medicines because of side effects. Another 10% take medications despite serious problems of which their doctor
seems unaware. About 30%
have not had their medicines
formally reviewed in the past
two years.
2. Access. About 15% of all adult
Americans rate that it is noteasy to see their doctor; 30% ifthey are low income. About
25% of all Americans have difficulty seeing a specialist. Whena doctor is seen, about 20% of
Americans report that the doctor did not spend enough time.
Full access to medications islimited by medication cost for
35% of all Americans.
3. Efficiency. About 40% of
Americans report that the carethey receive is inefficient. Common examples of inefficiency
are retelling the same story, thedoctor does not have needed
medical records or test results,
and there is duplicate testing.

How do you get doctors, nurses, and other health professionals to catch the “same page” metaphor and the importance of HowsYourHealth and its related technologies?

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Chapter 7: The Promise of Same Page CareIs Your Health Care
Less than Perfect?
If Yes, Write a Prescription toYour Doctor for:www.IdealMedicalPractices.org
or www.IdealMedicalHome.org
Directions:
Please take one dose of thisimprovement program daily until
your practice is more enjoyableand efficient and your patientsbrag about theirhigh quality of care.

Before her mother became ill, Esther felt that it is was
not her job to help health professionals catch metaphors.
But after her mother became ill, Esther quickly developed a different perspective. She learned that mosthealth professionals and health systems want to do better. They just need proven, specific methods and tools toimprove care. They need to catch the “same page”
metaphor.
To help them catch the importance of HowsYourHealthand other methods of care improvement, we make available without charge www.IdealMedicalPractices.org tohealth professionals. This easy-to-use program is basedon years of testing and refinement so that it requiresvery little time to complete.
We recognize that you are busy and that health care isusually not a “100%” issue for you. But when it is 100%for you, a family member, or someone you care deeply
about, you will benefit from this book. Consider How’s
Your Health? an important preventive medicine that iseasy to take now. Ultimately the quality of your healthand your health care is not what the health system does“to” you; it what the health system does “with” you.

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Chapter 7: The Promise of Same Page Care

Wally, Louise and Doctor X
Wally is a one of my patients. Wally is 80 and shouldhave died several years ago from his hard arteries,
severe heart failure, and mild kidney failure.
But Wally has Louise!! Louise understands every medicine Wally uses and adjusts them based on how he isdoing, how much he weighs, and how well he isbreathing. They call me whenever they have questions
or problems...which is quite rare. They are prepared forhis death if Wally should get very sick. They do notwant aggressive treatments.
Despite Wally’s problems both he and Louise live very
active lives. They recently traveled a great distance onvacation where Wally was hospitalized for a mild pneumonia. After two days in the hospital the doctors
wanted Wally to have surgery on his prostate and special heart tests at another hospital.
Louise called. She informed me that Wally now looked
quite good...better than the many times she had managed his illnesses at home. He was eating, walking,and breathing well.
I talked to Doctor X. Dr. X clearly wanted to treat
Wally’s abnormal lab tests which were actually better
than usual. We could not get Dr. X to agree withLouise, Wally, and me that Wally would do fine at
home. Dr. X. was on his own page, not Wally’s.
Louise insisted and Wally went home. Dr. X gave Wallyand Louise completely new prescriptions with no explanation of what they were for or how to use them. The
prescriptions cost four times more than Wally’s usual
medicines. Louise resumed Wally’s usual medicines.
Wally did fine.

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Chapter 7: The Promise of Same Page Care

PostScript: Using
HowsYourHealth
Getting Started
Go to www.howsyourhealth.org
or www.healthconfidence.org
HowsYourHealthhome page

Choose Begin Your Health Checkup near the middleof the home page.
If you received a pass code from your community, yourdoctor, your employer, or a health system, enter the code
or choose the name from the pull down menu. If you do
not have a code just choose the option for people who do
not have a code.

112Chapter 7: The Promise of Same Page CareEnter your access code
or choose the option
for people who do nothave a code.

Don’t overlook the opportunity to help others. For
example, parents and friends will need to complete
HowsYourHealth for children and very old or frail
persons. About 25% of the poor need assistance.
HowsYourHealth is completely private. You are
not asked to record your name to use HowsYourHealth. Your computer is not electronically identified.
Take Action
Once you complete the survey, you receive a report thatsummarizes the important issues that you have identified. It refers to readings that will help you manage
problems. You will also receive an Action Form to takeor e-mail to your doctor or nurse. (Samples are shownon the following pages.)
Even if you carefully prepare for an office visit, you may
not have the vocabulary and means to communicate
what really matters to you. The advantage of the Action
Form is that allows you and your doctor or nurse toquickly and specifically identify areas in which better
communication and education is needed. It’s the tool to
get them on the “same page” with you. The Action
Form makes Esther’s mother more than a “sugar.”
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Chapter 7: The Promise of Same Page Care
When a doctor or nurse is busy and can’t deal with all of
the problems on the Action Form in one day, they knowthat before the next meeting their patients can look at
pertinent readings offered by the web-site. This is a“win” for them and a “win” for their patients.
Sample report

114Chapter 7: The Promise of Same Page Care
Sample action form

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Chapter 7: The Promise of Same Page Care
Suggested Readings and Helpful Links
Your results from HowsYourHealth will include readings
based on your responses to the survey.
Sample readingsuggestions

You can review these readings online any time. To return to the readings at a later time, merely re-enter
www.howsyourhealth and give your age and gender andthen the readings are re-offered to you. You do not haveto answer the questions again.
Helpful links to the best non-commercially sponsoredweb-sites are included (sample shown next page). For example, for additional information go to www.medlineplus.org. For an important treatment or testing decision,
use the link to www.cochrane.org. If your topic is covered, this is the most up to date information about certain conditions and treatments.
We also suggest several “risk” calculators to help you estimate the impact of your current health and habit on
your future.

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Chapter 7: The Promise of Same Page Care
Sample helpful links
for additional
information and risk
calculators

117

Chapter 7: The Promise of Same Page Care
Self-Care and Problem Solving
Percentage
Experiencing Harm
Self-care confidence
not good
so-so

good

20%
18
16

L not same page

14
12
10

J same page

8
6
4
2
0

not good
medicalinformation

118

good
medicalinformation

Information alone will not improve your health andhealth care. Good self-care and problem-solving skills
are also needed, as illustrated in the chart at the left.
HowsYourHealth offers some helpful tools to improveself-care and problem-solving.
If you have a medical condition such as diabetes, highblood pressure, asthma, or heart disease, you will receivea Condition Management Form. The information on theCondition Management Form (see below) is tailored tochronic conditions. You should use it to anticipate what
you need to know and do. It also enables you to compare
the care you were receiving to good standards of care.
Having a copy of what your have reported is available
in your personal health plan. This allows you tokeep track of your health activities. Read about all thepossibilities it offers you on the next page

Chapter 7: The Promise of Same Page Care

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Chapter 7: The Promise of Same Page Care
You can use the Problem Solving of HowsYourHealthas often as necessary. Problem Solving produces a single
page summary for you.

Your Own Portable Health Record
When someone is very ill and their health record is notavailable, the lack of reliable information increases the
chances for error by other health professionals who are
not aware of important problems, allergies, etc.

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Chapter 7: The Promise of Same Page CareYour health record reflects what health professional report. When they are not on the “same page,” those reports can lead to problems. Studies show that availabilityof health records can improve “same page” communication.
Current health record software sold by Company A canusually not speak to the health record sold by Company
B. If you change doctors, and about 50% of Americans
do every 5 years, your electronic medical record does noteasily move with you.
Perhaps even more risky is the fact that many Americans
have more than one physician. About one in five of
Americans with more than one physician say that they
do not know who is in charge. Bad things can happen
when no one doctor is in charge or when the information one doctor has the other does not know.
To avoid problems, why don’t people have and carry
their own health records?
HowsYourHealth now allows you to start you own shortversion health record in a nationally standard languagethat all health care providers should understand.
You and your doctor can easily edit and update yourtransportable health record. You can ask your physician
or health system to add additional information such aslab tests.
You, emergency professionals, and any one else you trust
can review your portable health record by using an internet browser.
What Does Your Doctor See?
You can always print out any forms from HowsYourHealth and hand deliver them to your doctor. You canalways take your portable health record to your doctor.

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Chapter 7: The Promise of Same Page Care
When you use the access code your doctor gave you toenter HowsYourHealth, your doctor will see a summaryof responses for her/his patients. No personally identifiable information is available.
The summary information is very helpful to your doctor
to see what patient needs exist and how well these needs
are being served by the practice.
If your doctor asks you to send her/him your personal
information and you send the information, your Action
Form and Condition Management Form are sent electronically with your name and date of birth attached.
This information may be stored by your doctor in a
special program that allows the office staff to identify
groups of patients with problems such as those who arebothered by pain or those who require a bowel cancer
test.
What Does Your Employer, School, orCommunity See?
The employer, school or community sponsoring HowsYourHealth will see a summary of responses. No personally identifiable information is available. The summary
information is very helpful to the sponsors to see whatneeds exist and how well these needs are being met.

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Chapter 8

The Next Great Idea
“O.K. Forty-five seconds is not defensible!”- Medical Society, Valencia (Spain)ll residents of Spain have access to medications
and good health care at a much lower cost thancitizens of the United States. Since Spanish
health care prices are low, doctors’ salaries are low. But
the low government salary of Spanish physicians has
also resulted an unintended consequence. The consequence is that many Spanish doctors see their government-assigned patients very quickly... an investigative report found that 45 seconds was the total time somephysicians spent with each patient in the office. Needlessto say, some Spanish patients are willing to pay extra for
extra time with their doctor. There are now two healthsystems: a basic, universal health system and an “I’ll pay
for extra time” health system

A

Health care is a very expensive, complex product, comprised of political, economic, social, and scientificprocesses. A mix of people, organizations, and technologies deliver this health care product. When a product isthis complicated, change is difficult: quality is difficult toimprove, costs are difficult to contain, and unintended
consequences are difficult to foresee. The Swiss recently
tried to contain costs by enhancing competition among
insurers. They found that the insurers selected healthy
patients to avoid high premiums. In the United States recent cost-containment pressure on hospitals and insurers
has resulted in market consolidations to exploit monopolistic power and increase prices.
Even relatively successful experiments, such as “managed care” in the United States and government control
in Canada have unintended consequences. Both of these

The Underlying Truth
about Health Care
Spending?
Several experts speak.
“Health care has analmost limitless
capacity to absorb
resources. Moreover, theadditional utilization
among residents of highcapacity regions in the
United States is devoted
to services that do notappear to improvehealth or the quality ofcare and that may makethings worse...
“Physicians in highspending regions report
greater difficulty
obtaining needed
services and providing
high quality care.”- Elliott Fisher, MPH,
MD and Brenda
Sirovich MD
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Chapter 8: The Next Great Idea
Blame, Shame, andComplain is the Name of
the Health Care Cost
Game
“Hospitals blame healthcare users for the crisis
because employees want
to be able to go to any
hospital or physician
they choose rather thanbeing restricted to
specific systems for thesake of volume
discounts.
“Health insurance
brokers blame
businesses that buy
health insurance plansthat permit employees tovisit any physician or
hospital, thus
eliminating discounts forsteering patients tospecific providers.
“Health insurancecompanies blame
businesses for wanting
to provide rich benefits
and broad provider
networks, whilebusinesses say healthinsurance companies
don’t work hard enoughat negotiating discounts.”- Milwaukee News
8/23/04124

experiments have caused a lot of patients and physicians
to become angry. People served by government-controlled health systems tend to complain that more shouldbe spent; their American counterparts complain thatcosts should be contained.
Unintended Consequences and the Next
Great Idea
Health policy-makers now recognize that just trying tosqueeze costs does not work. Having seen failures andunintended consequences within most healthcare
schemes, few policy-makers try to sell one great idea tosolve the problems of quality and cost in health care. Instead, they now proffer the need for health care reformhaving several components such as:• measurement of and payment for quality so that doctors and health systems have incentives to use themost effective medicine;• greater use of information technology so that communication errors are minimized;• transformation of training so that all health care
workers know how to better design and delivery complex healthcare products; and• increased involvement of consumers to produce better health and also exert greater direct control on
costs.
The devil, of course, is in the details. How will eachcomponent develop when one person’s waste is anotherperson’s income; one person’s change in job might resultin another’s loss of job? For example:• Technology. We are already hearing government
leaders over-promising that the use of electronic
health records alone (often at a cost of $20,000 per
physician) will solve many of the quality and costproblems in health care. Really? How will healthrecords do that?

Chapter 8: The Next Great Idea
• Consumer Involvement. We know that low income
Americans are less likely to receive some needed carewhen they have to pay more for health. How will thisundesired consequence be minimized?
The table below contains some of our thoughts and concerns about possible unintended consequences of these“next great ideas.” What are your guesses?
The Next Great Ideas?
A Next Great Idea

Anticipated Results

Possible Unintended Consequences

Measurement of andpayment for quality

Incentives to use the mosteffective medicine. For example, practices receive
payment if they are a“medical home.”• Subtle selection of healthy patients• Winners concentrate power• Deceptive advertising• Costs of a measurement industry• Patients become “sugars” and“evidence-based” numbers for bonus
payments to physicians• Your guesses?

Greater use of
information technology

Communication errors areminimized• Costs• “Sexiness” of electronic health diverts attention from more cost-effective opportunities• “Big brother” concerns• Your guesses?

Transformation oftraining

Better design and deliveryof complex health-care
products• Training for health delivery science takes
valuable resources from basic sciences• Reduction of the traditional physician role
• Diffusion of accountability• Your guesses?

Increased involvementof consumers

Helps produce better health• Intrusive• Those who are slow learners of self-care arepenalized• Your guesses?

Exerts greater direct control
on costs• Excessive cost-sharing for those who canafford the least• Avoidance of needed care to save money• “Blame the victim” if some wrong choices
are made• Your guesses?
125Chapter 8: The Next Great Idea
Self-Care and Self-Management at the Next
Level
Remember Dr. O who had low performance but a commitment to do better? We are convinced that Dr. O will
eventually be able to greatly improve his office practicebecause he and the office are motivated to improve. But
thousands of practices and physician are not as motivated as Dr. O.
So let’s take a brief mind-walk. How might we better
health care without depending on the motivation of allhealth professionals.
Remember the son of one of the authors who had tohave heart surgery? After the heart surgery his heart
became irregular in a way that exposed him to developing blood clots. These blood clots are dangerous because
they can move to the brain and cause a stroke. Warfarin
is a great drug because it stops clotting. But too much
warfarin causes death from bleeding.
If you prevent rodents
from eating their feces
they bleed to deathbecause the feces
contain a vitamin thatprevents bleeding.
Rather than fitting
vermin with diapers,
an easier way to rid
your house of rats andmice is to give them adrug called warfarinthat blocks theprotective vitamin.

126

Millions of Americans take warfarin to prevent bloodclots in their legs (because of “thrombophlebitis) orhearts (because of “atrial fibrillation”). They have to adjust their warfarin dose for as long as they take the drug.
By keeping track of how quickly the blood clots, doctors,
nurses, or simple computer programs can tell patients
how to safely adjust the warfarin dose.
Typically, blood is drawn and tested and then a doctor
or nurse calls the patient to adjust the medication. All ofthese transactions take time. There is also a chance of
miscommunication on the phone and mis-adjustment of
the dose by the doctor or nurse.
In fact, when people check their own bleeding test andadjust their warfarin dose, they have fewer problems
than people who go to the clinic to get the test and wait
for a doctor or nurse to call them. The cost of the test
done this way is potentially many times lower than the
traditional cost of $60-80.

Chapter 8: The Next Great Idea
Bleeding While We Wait?
The point of the example should be obvious: if patients
can safely manage a medication as finicky as warfarin
they can certainly do a lot more than they get credit for.
Inexpensive technologies are now available to help patients and members of the population assess their healthneeds, learn methods to modify their behaviors, monitor
important markers of health and disease, and self-manage their illnesses. If they wish, we now offer a simple,
cost-free method to enter this information into transportable health records. The examples shown in the following table represent an expanding technology.
A Sample of Self-Testing and Self-Care Options
ServiceEquipment Needed

Estimated Cost

Self-assessment and tailorededucation for health andpreventive needs; Problem
solving for improved selfmanagement

Access to computer andHowsYourHealth.org

No costPortable health record

Access to computer andHowsYourHealth.org

No cost except memory stick, if
desired (less than $50)

Computer memory stick or diskette
Self-monitoring of vital signs

Blood pressure machines andscalesOften free in supermarkets andpharmacies

Blood sugar

Finger prick devices and aself-testing machineLess than $2 per test but needs
one-time $500 for testingmachine.

Blood fats

Finger prick devices and a selftesting machineLess than $5 per test but needs
one-time $500 for testingmachine.

Blood coagulation (Portabledevice; for example, Protime)

Finger prick devices and a selftesting machineLess than $15 per test but needs
one-time $2,500 for testingmachine.

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Chapter 8: The Next Great Idea
We can offer HowsYourHealth for free; blood pressuremachines and scales are also available for free. So far, so
good.
But when testing machines are needed we mustask...Who would pay for and maintain the machines?
Who would keep the finger-stick supplies on hand andcharge a fair price for them?
Let’s continue our mind-walk and think about answers
to these questions.
One obvious answer is that retail stores and consumer
cooperatives might increase their traffic by offering “retail health.” For example, large pharmacies might recognize an advantage in having customers use a tiny fraction of their space for routine preventive care andchronic disease self-management.
It is inconvenient (and costly) for Americans to take time
off from work and travel to wait in a busy clinic or hospital. Furthermore, Americans are paying more costs forroutine tests and procedures out of their own pockets.
Direct out-of-pocket dollar costs and the time for travel
and waiting impede a number of people from having theright things done at the right time. This impedimentmakes care less effective.
The advantages of retail health to the population are
greater convenience, lower costs, and more effective
care. With retail health customers should be able to access health information tailored to their needs. They
might use a special “hot line” to schedule needed preventive tests such as mammography. They should be able
to obtain some basic blood and vital sign results to keep
track of certain diseases during most hours of the day.
All this information would be easily transported to theirdoctor on a transportable health record maintained by
the customer.

128Chapter 8: The Next Great Idea
Many doctors might find “retail health” a good substitute for some of the routine work that constipates the office schedule. But some doctors, clinics and hospitals
would face a loss of revenue since the cost for many of
the tests and procedures is artificially elevated to coverother costs. In health care one person’s waste is often another’s income.
Health care is indeed a complex business. The purposeof this mind-walk is to emphasize the capacity of emerging technology and greater consumer involvement to improve health care despite its complexity. We hope thatusers of HowsYourHealth will demand that care becomeas good as it can be even if that care requires restructuring of the way tests are done, information is obtained
and transferred, and support is given for better self-management.
After all, the life you save...

129

Part IV:
It’s Your Journey131Part IV: It’s Your Journey

It’s Your Journey

Which Picture About Health Care Do You Want to Believe?
 Picture B?
Copyright © 1929 the Norman Rockwell Family Entities

 Picture A

As Good As It Can Be
Picture B is by the famous American illustrator, Norman
Rockwell. Rockwell’s vision of the patient-doctor relationship involves trust. A girl holds her doll for the doctor to listen to the doll’s “heartbeat.” The girl trusts her
doctor.
Most Americans say that they trust their doctor. However,most Americans also worry about the quality of healthcare and doctors in general. Picture A reflects some of132

Part IV: It’s Your Journey
the anxieties Americans feel about health care. We
physicians work in a world that is normal to us but weknow that our world is a perplexing Wonderland to
many Americans.
Given the complexity and “business” of modern healthcare, few physicians are able to take the time to “playdoctor” with a child and her doll. However, all healthcare professionals continue to have a primary duty to engage the patient in a mutually respectful, high quality,
trust-filled relationship.
How’s Your Health? lays out a path to build a mutually respectful, high quality, trust-filled relationship. In How’s
Your Health? Rockwell’s all-knowing, fatherly doctor is replaced by a patient-doctor relationship with an equal
sign (=) between the two parties. The doctor and patientare on the “same page.”Technology plays a critical role in the change to “samepage” care. You already have a lot of experience withtechnology and want it to enhance communication andincrease convenience; you do not want technology to interfere with a relationship. Technology may include telephone “house calls” to help you better manage healthproblems. Technology may be e-mail or a portable electronic health record to facilitate communication of information. Technology may be the website www.HowsYourHealth.org. that offers information about “whatmatters” to you and makes what matters to you a matterof importance to your doctor.
Often (partly because of fads and commercialism) people become concerned about issues that are not, in fact,that threatening. To better manage your health andbehaviors you must accurately identify the real risks.
HowsYourHealth can help you better recognize andunderstand the threats that matter.
You can improve your health, emotional well-being, andself-care confidence as well as adopt more healthy be133

Part IV: It’s Your Journeyhaviors by learning good problem-solving skills. HowsYourHealth provides useful, proven problem-solving
tools aimed specifically at adults and teens.
Eventually, most of us will face a serious health issue that
becomes our 100% concern. Often it is one or a combination of common chronic diseases. With good medical
information and confident self-care, we can live long,
happy lives despite these chronic conditions. HowsYourHealth can help prepare for this time, and better
manage it if and when it comes.
And should we need to be in a hospital, there is aversion of HowsYourHealth that can improve our care.
In summary, How’s Your Health? lays out a path throughthe Health Care Wonderland so that you will be able tosay:• All of the time my doctor and nurse are aware ofwhat really bothers me...what really matters to me.
• I have received as much help and support as I neededfrom my doctor and nurse to help me manage andcontrol most of my health problems.
• I receive exactly the health care I want and needexactly when and how I want and need it.
That is as good as it can be!

134Acknowledgements andReferences

135

Annotated References

Annotated
References
About the HowsYourHealth Website
Who Made HowsYourHealth Possible?
The HowsYourHealth website is the creation of many
people and organizations. Foremost among them has
been a group of community physicians, nurses, patients,
and researchers affiliated with Dartmouth Medical
School who have worked to make medical care truly responsive to patient needs. Generous support from The
Commonwealth Fund with additional assistance by the
National Library of Medicine, The John A. Hartford
Foundation of New York City, The Henry J. Kaiser
Foundation, The W.T Grant Foundation, The Robert
Wood Johnson Foundation, The Agency for Healthcare
Research and Quality, The Bureau of Health Professions, and The Institute for HealthCare Improvement
made the technology and this book possible.
How is the HowsYourHealth Website Designed
and Tested?
Howsyourhealth.org offers you two parts:
1. the questions you are asked
2. the information you receive after you answer thequestions
We use four methods to make sure that all these parts
are accurate:
1. research
2. word review
3. information review
4. update of information
136

Annotated References
1. Research

We use research to make sure the questions and information really helps you take better care of yourself andhelps you get better health care. For more than twenty
years, a cooperative network of physicians, nurses, andresearchers affiliated with Dartmouth Medical School
has developed approaches to make care truly responsive
to the needs of the population. HowsYourHealth.org isderived from this experience and has been shown to beeffective and useful in several published research studies.
In 1992, the underlying approach forhowsyourhealth.org was officially adopted for international use in more than 20 languages by the World Organization of Primary Care.
2. Word Review

After extensive testing, HowsYourHealth was designed tobe easy on eyes, easy to navigate, and easy for even theslowest computer to read. We have the words reviewed
by non-medical people. Language translations arechecked by at least two persons to make sure they arecorrect. AstraZeneca Pharmaceuticals is supportingtranslation of HowsYourHealth into several languages.
3. Information Review

The information has been designed and tested to help
you take better care of yourself and help you get better
health care. The research shows that the informationmust be set up in certain ways to best help you and adoctor or nurse communicate well or “get on the same
page.”
4. Updates

Except for the correction of errors that is done immediately, updates of the questions and information are performed annually. For persons aged 13 or older, thesources for updates are:137

Annotated References• The Journal of the American Medical Association• The New England Journal of Medicine• The British Medical Journal• The ACP Journal Club (This provides reviews of current publications).
• The Journal of the American Geriatric Society• Clinical evidence from the British Medical Journal (Thisprovides comprehensive reviews for common conditions and preventive recommendations).
General References for the HowsYourHealth.org
Web-site
Clinical Development and Testing: [A] Nelson EC,
Landgraf JM, Hays RD, Wasson JH, Kirk JW. The
functional status of patients: How can it be measured inphysicians’ offices? Med Care 1990;28(12):1111-1126.
[B] Nelson EC, Wasson JH, Johnson DJ, Hays RD.
Dartmouth COOP Functional Health Assessment
Charts: Brief Measures for Clinical Practice. In: Spilker
B, ed. Quality of Life and Pharmacoeconomics in Clinical Trials. Philadelphia: Lippincott-Raven. 1996:161168. [C] Wasson JH, Jette AM, Johnson DJ, Mohr JJ,
Nelson EC. A Replicable and Customizable Approach
To Improve Ambulatory Care and Research. J Ambulatory Medicine 1997;20(1); 17-27. [D] Wasson JH, Stukel
TA, Weiss JE, et. al. A Randomized Trial of Using Patient Self-Assessment Data to Improve Community Practices. Effective Clinical Practice 1999; 2:1-10. [E] Bronfort G, and Bouter LM. Responsiveness of general
health status in chronic low back pain: a comparison of
the COOP Charts and the SF-36. 1999 Pain 83; 201209 [F] Wasson JH, Jette AM, Anderson J, et.al. Routine, Single-Item Screening to Identify Abusive Relationships in Women. J. Fam. Pract. 2000;49:1017-1022. [G]Ahles TA, Seville J, Wasson JH, et.al. Panel-Based PainManagement in Primary Care: The Journal of Pain And
138

Annotated References
Symptom Management 2001: 22, 584-590. [H] Ahles TA,
Wasson JH, et.al. A Controlled Trial of Methods forControlling Pain in Primary Care Patients with andwithout Psychosocial Problems. Annals of Family Medicine, 2006; 4(3): 341-350. [I] Technology to Support Patient-centered, Collaborative Care. (Many authors/articles.) Entire Journal of Ambulatory Care Management;
July-Sept: 2006, pages 194-297. Available at www.HowsYourHealth.org.
Community/School Development and Testing: [A] Wasson JH, Kairys SW, Nelson EC, Kalishman N, Baribeau
P. A short survey for assessing health and social problemsof adolescents. J Fam Prac 1994; 38(5):489-494. [B]Bracken AC, Hersh AL, Johnson DJ. A Computerized
School-Based Health Assessment with Rapid Feedback
to Improve Adolescent Health. Clin. Pediatrics
1998;677-683. [C] Wasson JH, James C. Implementation of a Web-based Interaction Technology to Improve
the Quality of a City’s Health Care. J. Amb. Care Managem. 2001;24: 1-12 [D] Luce P, Phillips J, Benjamin R,
Wasson JH. Technology to Support Community HealthAlliances. J. Amb. Care Managem. 2004;27: 399-407
Data Used for This Book
The data from HowsYourHealth used in this book is derived from more than 5000 preteens and teens, 5000
older adults aged 70+, and over 50,000 adults aged 1969. To be confident that we are representing health andhealth care in the United States, we cross-check responses across geographic regions and health care systems. We
have also been able to cross-validate responses for respondents having chronic diseases with an international
survey reported by Blendon RJ, Schoen C, et. al. Common Concerns Amid Diverse Systems: Health Care Experiences in Five Countries. Health Affairs. 2003;22:
106-121. Cross-validation for children and adolescents:
Leatherman and McCarthy. Quality of Health Care forChildren and Adolescents. A Chartbook; 2004.
(www.cmwf.org)
139

Annotated References
Chapter One: What Are My Chances?
For a detailed comparison of modifiable behavioral risk
factors we recommend: Mokdad AH, Marks JS, et. al.
Actual Causes of Death in the United States. JAMA.
2004;291: 1238-1245. For a rather technical comparisonof what you will gain from different medical treatments
see Wright JC and Weinstein MC. Gains in Life Expectancy from Medical Interventions. NEJM. 1998; 3806. Kochanek KD and Hudson BL describe preventable
teenage deaths in Monthly Vital Statistics Report, Volume 43, 1994.
A most valuable way to understand threats to health andthe potential benefit of screening or treatment is to use
the Tables we have adapted from the work of Woloshin
and Schwartz. (Woloshin S, Schwartz LM, Welch HG.
Risk charts: Putting cancer in context. J Natl Cancer
Inst 2002; 94:799-804.) In a separate report they notethat Americans are unduly scared of cancer. Schwartz
LM, Woloshin S, et.al. Enthusiasm for Cancer Screening
in the United States. JAMA. 2004;291: 71-78.
In general, we always tend to overestimate the risk of theunfamiliar and frightening. For another example, see
Meltzer D and Egleston B. How Patients with Diabetes
Perceive Their Risk for Major Complications. Effective
Clin. Pract. 2000;3: 7-15.
For a tool to look at risk over time and how diseases andtreatment impact the risk, see Welch GH et. al. Estimating treatment benefits for the elderly: The effect of competing risks. Annals of Internal Medicine; 1996: 577-584.
Chapter Two: As Good As It Gets?
One of the first studies to underscore the extent and importance of poor communication in medical practice
was Nelson EC et.al. Functional health status levels of
primary care patients. JAMA 1983:3331-3338.

140

Annotated References
The now well-recognized importance of patient-provider
communication is well documented in Crossing the
Quality Chasm: A New Health system for the 21st Century. National Academy Press: 2001.
A specific example of “same page” care is described by
Heisler M, Sandeep V, et.al. When Do Patients andTheir Physicians Agree in Diabetes Goals and Strategies,
and What Difference Does it Make? J. Gen. Int. Med.
2003;18:893-902. (By the way, they seldom agree butwhen they do patient outcomes are much better.)
For a summary of typical “problem experiences” see:
Keating NL. How are Patients’ Specific Ambulatory
Care Experiences Related to Trust, Satisfaction, andConsidering Changing Physicians? JGIM 2002: 29-39.
See also: To Err is Human. National Academy Press.
2000.
The Dartmouth Atlas of Health Care(www.dartmouthatlas.org) is a valuable compendiumof information about variation in health services for
the Medicare population.
Chapter Three: Doesn’t Everyone Worry?
How we can be made to worry is well documented.
These two examples intimately involved me (as an expert): Blood Test for Prostate Cancer is Raising Issues of
Reliability, Drug Industry-Role. Wall Street Journal. February 18, 1993. Fletcher SW. Whither Scientific Deliberation In Health Policy Recommendations. NEJM 1997:
1180-1183. See also: Rosenthal MB et. al. Promotion of
Prescription Drugs to Consumers. NEJM. 2002; 498505. Woloshin S, Schwartz LM, et.al. Direct to consumer drug advertisements: What are Americans being
sold? Lancet 2001; 358:1141-6.
Americans have increasing difficulty separating fact frombiased expert opinion. For an early example read:
Stelfox HT et al. Conflict of Interest in the Debate over141

Annotated References
Calcium-Channel Antagonists. NEJM 1998;338: 101106. More recent conflicts even at the once revered
National Institutes of Health have become even moreblatant.
A recent review of obesity causes and the effectiveness ofdifferent treatment options is: Yanovsky SZ and
Yanovsky JA. Obesity. NEJM; 2002:591-602. See also
Tsai AG et al. An Evaluation of Major Commercial
Weight Loss Programs in the United States. Ann Intern
Med 2005;142:56-66. The National Geographic Magazine (August 2004 pages 47-61) offers a very effectiveand “glossy” presentation of the obesity problem. For apractical, well researched review of exercise: Anderson
RE et. al. Encouraging patients to Become More Physically Active. Ann Intern Med. 1997:395-400.
The Food, Diet, and Supplement industries are an endless font for strong opinion. To learn why eggs were“bad” before but “good” now and other myths see:
Kassirer JP and Angel lM. Losing Weight: An ill-fated
New Year’s Resolution. NEJM1998: 51-53. Also consider reading: Clinical Debate. Should a Low Fat, High
Carbohydrate Diet Be Recommended for Everyone?
NEJM;1997: 562-567. Hu FB. Mediterranean Diet andMortality - Olive Oil and Beyond. NEJM 2003;348:
2596. If you remember Vitamin E as a good way to reduce harmful antioxidants see Miller ER et al. Metaanalysis: High Dosage Vitamin E Supplementation May
Increase All Cause Mortality. Ann Inter Med
2005;142:37-46.
Poverty is a very powerful risk factor. Marmot MG et. al.
Health Inequalities among British Civil Servants.
Lancet. 1991;1387-1393. Lynch JW et. al. Cumulative
Impact of Sustained Economic Hardship on Physical,
Cognitive, Psychological and Social Functioning. NEJM
1997;1889-1895. Ickovics JR et. al. Functional Recovery
after Myocardial Infarction in Men: The Independent
Effects of Social Class. Annals of Int. Med. 1997:518142

Annotated References525. The diseases of the poor are similar to those of the
non-poor...they just occur on average, 7 years earlier.
The figure on disability in the United States is from the
President’s New Freedom Commission on Mental
Health. Although critics contend that it may be somewhat biased in overstating the mental health componentof disability, it provides a helpful overview of the causes
for disability. (www.mentalhealthcommission.gov/reports)
For a disturbing review of a common cause of morbidity
in teens and young adults see: Fleming DT et al. Herpes
Simplex Virus Type 2 in the Untied States, 1976-1994.
NEJM. 1997: 1105-1111.
Chapter Four: Inside a Doctor’s Office
Review of care compared to “best practice” documentsthat the greatest gaps are in areas of communication.
(McGlynn EA, Asch SM, et.al. The Quality of HealthCare Delivered to Adults in the United States. NEJM.
2003;348: 2635-2645.) Read also a very good descriptionof the inadequacy of communication “inside the blackbox” of the doctor’s office: Braddock-JAMA
1999;282:2313-2312. Inappropriate prescribing andtesting is a final common pathway of poorly designed
care: see Zhan C et. al. Potentially inappropriate medication use in the community dwelling elderly. JAMA
2001 2823-2829.
The deficiencies of American health care are felt not
only by patients. (Zuger A. Dissatisfaction with Medical
Practice. NEJM 2004; 350: 69-74.) Drs. M and O in thischapter used well-tested rating forms to determine how
well their practices were functioning and the satisfactionof the professionals and non-professionals staff with thepractice. The ratings used to rate clinical practices are
based on: Nelson EC et al. Microsystem in Health Care:Part 1. Learning from high performing front-line clinical143

Annotated References
units. Joint Comm. J. Qual. 2002; 28: 472-493. The rating forms are available at www.improveyourmedicalcare.org.
Just teaching health professionals to be “nice” is generally not enough to make care better. (Brown JB et. al. Effect of Clinician Communication Skills Training on Patient Satisfaction. Ann. Int. Med 1999; 822-829). Practices have to adopt new models of care. A description of
a Care Model for a good practice is: Bodenheimer T,
Wagner EH, Grumbach K. Improving Primary Care forPatients with Chronic Illness. The Chronic Care Model,
Part Two. JAMA 2002;288:1909-1914. Bodenheimer T,
Lorig K, et.al. Patient Self Management of Chronic
Disease in Primary Care. JAMA 2002;288: 2469-2475.
Dr. M’s story is excerpted from http://www.ihi.org.
For much more information see Journal of Ambulatory
Management. July-Sept. 2006: Technology for PatientCentered, Collaborative Care.
Given all that is known about how to deliver good care
we must ask, why isn’t it better? (Wasson JH. Why Isn’t
It Better? Ann. Fam. Med. 2004; 2: 292-293).
Chapter Five: Problems are Made to Solve
Lorig KR et.al. Evidence suggesting that a chronic disease self-management program can improve health status while reducing hospitalization: a randomized trial.
Med Care: 1999;5-14.19.
When you consider self-management and problem-solving, it is best to focus on the most important issues anddiseases. All disease is not created equal! In fact, diseasedefinitions change. (Schwartz LM and Woloshin S.
Changing Disease Definitions. Eff. Clin. Practice.
2000;2:76-85).
For a description of a simple problem solving method
for pain, see Ahles TA et. al. Panel-based pain manage144

Annotated References
ment in primary care. J Pain and Symptom Management 2001:1-7.
For more information about preteen and teen problem
solving see: Wasson JH et.al. Adolescent Health and Social Problems: A method for detection and early management. Arch. Fam. Med.: 1995: 51-56. Also: BrackenAC et.al. A Computerized School-Based health Assessment and Rapid Feedback to Improve Adolescent
Health. Clin. Pediatr: 1998; 677-684. The ProblemSolving exercise included in the postscript was modified
from the insights of Lazarus and Tobin published during
the 1980s and early 1990s.
Chapter Six: It’s 100%
Although Esther and her mother might presume that
Americans seen frequently by their physicians for theirchronic diseases would have no undetected problems,
this is not the case. ( Redelmeir DA et.al. The treatmentof unrelated disorders in patients with chronic medical
diseases. NEJM;1998: 1516-20.)
The disturbing impact of income on child health andbehavior is also described by Starfield B, Robertson BS,
and Riley AW. Social Class Gradients and Health inChildhood. Amb. Pediatrics 2002;2: 238-246.
We highlighted the issue of domestic abuse in adults because clinicians often have misgivings about how to ask
and what to do about it if they do ask. See Wasson JH
et. al. Routine, Single-Item Screening to Identify Abusive Relationships in Women. J. Fam. Pract. 2000; 10171022.
An entire issue of the Journal of Ambulatory CareManagement was devoted to the care of the elderly.
(Wasson JH. Looking at Care form the Inside Out: A
Conceptual Approach to Geriatric Care. 1998; Volume
21, Number 3).
Things that matter in “End-of-Life”care are described in145Annotated References
the aforementioned Journal by Goodlin SJ et. al. End-of
Life Care for Persons Aged 80 or Older. JACM. 1998;
35-39. Also see Teno JM et.al. Medical Care Inconsistent with Patients’ Treatment Goals. JAGS 2002; 496500. The Problem-Solving exercise included in the postscript was modified from the insights of Lazarus andTobin published during the 1980s and early 1990s.
Chapter Seven: The Promise of Same Page Care
Some discrete methods to improve medical practiced are
based on: Wasson JH et al. Telephone care as a substitute for routine clinic follow-up. JAMA 1992;
267(13):1788-1793. Wasson JH et al. Continuity of outpatient medical care in elderly men: A randomized trial.
JAMA 1984:2413-2417. Dietrich AJ. The telephone as a
new weapon in the battle against depression. Eff Clin
Pract. 2000;191-193. Beck A et. al. A randomized trialof group outpatient visits for chronically ill older HMO
members. J Am Geriatr. Soc. 1997: 543-547. Wasson,
JH et. al. A Randomized Trial of Using Patient Self-Assessment Data to Improve Community Practices. Effective Clinical Practice: 1999; 1-10. Barry MJ. Health Decision Aids to Facilitate Shared Decision Making in Clinical Practice. Ann. Intern. Med. 2002;127-136. Murray
M, Bodenheimer T, et.al. Improving Timely Access toe
Primary Care. JAMA. 2003;289:1042-1046.
www.improveyourmedicalcare.org provides busy clinicaloffices the tools and methods to make their practicemore efficient and effective.
Chapter Eight: The Next Great Idea
If you wish up-to-date opinions on health care reform,
read Health Affairs or browse the website of the Commonwealth Fund (www.cmwf.org). A recent review ofmany “next great ideas” is contained in a supplement to
the Economist. “The Health of Nations.” July 17, 2004.

146

Annotated References
The quote from Elliott Fisher is a “letter” from: NEJM
2004;350: 519. The quote form Brenda Sirovich is an“abstract” from: JGIM 2004;19S: 220. Both these quotes
remind us of a huge number of studies. These studies
demonstrate that the high cost and variation of healthcare in the United States are “driven” by the supply ofavailable services.
For physician opinions about how to fix health care read
Blendon RJ, Schoen C, et.al. Physician Views on Quality
Care. Health Affairs 2001:332-245.
The Artwork
John Tenniel drew the delightful illustrations for
Lewis Carroll’s Alice’s Adventures in Wonderland. The
Reverend Charles Dodgson (Lewis Carroll) wrote: “Mr.
Tenniel is the only artist who has drawn for me, who has
resolutely refused a model, and declared that he no moreneeded a model than I...”The first printing of Alice’s Adventures in Wonderland was in
1865.
Norman Rockwell’s illustration of “Doctor and Doll”
first appeared in the Saturday Evening Post on March 9,
1929. Used with permission. Copyright © 1929 theNorman Rockwell Family Entities.

147

Guide to Figures and Tables

Guide to Figures
and Tables
How’s Your Health? uses quotes, quizzes, pictures,
figures, and tables to help readers better understand the
Health Care Wonderland. The following list contains
the question a reader should expect to be answered byeach figure or table.
Part I: Welcome to Our World
Keyword in Figure
Question Answered(f) or Table (t)

148

Page

Sliver (f)How much time do we spend with doctors?

4

Preventing (t)Which behaviors would prevent the most deaths?

11

Risks (t)How do health-related harms compare to other risks?

13

Smokers (t)Speaking of risks, how much does smoking impact health?

15

Treatable (t)How do the common preventable and treatable causes of death
compare?

16

Same Page (f)How can people reduce health-related harms?

20

Confidence (f)What can also reduce many other health problems?

21

Bar Graph 1 (f)How do I read and use bar graphs?

25

Bar Graph 2 (f)How do I read and use bar graphs?

26

Guide to Figures and Tables
Part II: Are You Ready to Improve Your Health and Health Care?
Keyword in Figure
Question Answered(f) or Table (t)PageFads (t)Why didn’t that diet work?

32

Obesity (t)Does being overweight really make much difference?

33

Bad Events (f)When is a risk really bad?

34

Perfect Care (f)How do Americans rate health care?

35

Health-Related
Harms (f)Prevention (f)Do health-related harms differ by age and income?

38

What are the most frequent things men and women can do to prevent
problems?

42

Emotion (f)How often are health professionals aware of what matters to me?

43

Habits (f)Will I prevent problems if I am confident that I can manage problems?

43

Doctor Office (f)How do people who work in doctor’s offices rate what they do?

46

National Rating (f) How do patients rate doctors’ offices?

48

Quality (f)Do doctor office ratings and patients’ ratings tell us the same thing?

49

Care Rating (t)Why do patients rate care good or bad?

50

Chicago (t)What do people across the United States actually say about their healthand health care?

51

Problem-Solving(f)

Does problem-solving ability really make much difference?

Steps (t)How could I become a better problem-solver?

60

Information (f)How do problem-solvers use information?

61

Bad Events (f)When is a risk really bad?

65

56-58

Chronic Disease (f) How often do chronic diseases occur?

72

Other Issues (t)What is it like to have a chronic disease?

73

Care Attributes (f) What improves care of a chronic disease?

74

Taking Care (f)What can I do to take better care of a chronic disease?

75

Income (f)Does money make a difference for chronic disease management in
adults?

76
continued...
149

Guide to Figures and Tables
Part II: Are You Ready to Improve Your Health and Health Care? (continued)
Keyword in Figure(f) or Table (t)Question Answered

Page

Environment (f)Does money make a difference to children’s health?

77-79

Blood Pressure (f)Does being on the “same page” with a doctor or nurse improve bloodpressure control?

81

Heart Pain (f)Does same page care improve heart pain too?

82

Abuse (t)What is it like to be in an abusive relationship?

83

Elder (t)What is it like to be aging successfully?

84

Medication (f)How would I know if my pills are making me sick?

95

Part III: Are You and Your Doctor Ready to Improve Your Health and
Health Care?

150

Keyword in Figure(f) or Table (t)Question Answered

Page

Quality (f)Do doctor office ratings and patients’ ratings tell us the same thing?

101

Risk and Harm (t)What should I focus on now to reduce my risk for harm from health
care?

109

Same Page (f)Same page care will make health and health care better, won’t it?

118

Great Idea (t)Will those big changes by the government ever make my health carebetter?

125

Self-Testing (t)In the meantime, can’t new technologies help me improve my healthand health care?

127

Two doctors and a website combine to bring us
a simple but powerful message:

We can and we should take controlof our health and health care.
This book is based on decades of research and information fromthe free, non-commercial website called HowsYourHealth.org.
Many thousands of people like you have used the website toimprove their health and health care. Learn from them to makeyour health and health care as good as it can be.

John Wasson MD is a national leader in health care quality
and for more than three decades he has overseen thedevelopment and improvement of the HowsYourHealth.org
family of free health websites
Regina Benjamin MD, MBA served as the 18th Surgeon
General of the United State and has received among her
many honors the Nelson Mandela Award for Health andHuman Rights and the National Caring Award inspired by
the work of Mother Teresa.

“We physicians
work in a worldthat is normal tous. However, weknow our world
appears like
Wonderland.”