Matthew J. Edlund M.D.

Getting Healthy Now

Whatever Happened to Health?

Can we checklist our way to well-being?

Posted Mar 26, 2015

AJ Cann/
Source: AJ Cann/

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

         Why Are Checklists Taking Over?

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

         What Really Matters In Health?

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

What is increasingly pathetic is the perception the doubling of human lifespans in the last eighty years has been accomplished by medical care, even though many think that’s the case.  Nutrition, sanitation, education and vaccination were far more important in getting and keeping people healthy.

They still are.  If you believe the Swedish Kungsholmen data, which have followed central Stockholm’s varied population for decades, lifestyle added six to seven years of life at age 65, four years at 85.  Medical care adds a small—with time really small—fraction of that.  Many other international studies show the same.

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

You won’t find that healthy stuff on checklists.

         What Makes Checklists So Popular?

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

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

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

Too bad if you don’t feel that way.

Just consider this: If social support is more important to survival and heart health than cholesterol, how many media messages have you heard about social support's importance in heart disease versus ones on cholesterol and saturated fat? 

Have you ever heard any at all?

         Checklist Medicine and Health

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

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

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

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

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