This Plowboy Interview is with Tom Ferguson, an advocate for the idea of health care being handed back to the consumer.
Whatever else 1978 is remembered for, it will — without a doubt — go down in history as a record year for medical expenses here in the United States. All indications are that before the calendar year is out, 216 million Americans will have spent $139 billion (8.6 percent of the Gross National Product) on drugs, X-rays, surgery, physicians' fees, laboratory tests, hospital overhead, health insurance, etc. That's up from the $39 billion (5.9 percent of GNP) medical care cost in 1965 . . . just 13 years ago.
As Ivan Illich points out in his book, Medical Nemesis (1976, Pantheon Books), medical spending in the U.S. has reached the point where the construction of a new hospital costs in excess of $85,000 per bed, of which two-thirds goes for mechanical equipment that becomes obsolete within less than a decade. "These rates, " Illich observes, "are almost twice those of the cost increases and of the obsolescence prevalent in modern weapons systems. Cost overruns in the Department of Health, Education, and Welfare exceed those in the Pentagon. "
Clearly, the medical establishment has become a threat to the average American's budget (if not his health). Which is one reason why medical self-care — the idea that health care should, to some degree, be taken out of the hands of physicians and put back into the hands of consumers — has started to become so popular in this country over the past few years, and why a fourth-year Yale medical student by the name of Tom Ferguson decided — in the spring of 1976 — to launch a magazine called (appropriately enough) Medical Self-Care.
Ferguson himself describes the periodical — now in its third year of publication — as "a medical Popular Mechanics, a Whole Earth Catalog of the best medical books, tools, and resources, a Consumer Reports focusing on health care." In each (quarterly) issue of the magazine, Tom strives to bring his readers  thumbnail reviews of the best popular medical books,  articles that teach basic paramedical skills,  stories on the way lifestyle can affect health,  information on how to go about using the available "medical literature" (textbooks and journals),  news of the growing medical self-care movement, and  a list of the latest medical self-care classes around the country.
Tom could hardly be better qualified to edit and write a medical access journal. At 34 years of age, Ferguson is a physician, a former health worker for VISTA, Medical Editor of Co-Evolution Quarterly, and the holder of B.A. and M.A. degrees in creative writing from California State University at San Francisco. Thanks to the almost explosive popularity of his magazine, Tom is also now one of the medical self-care movement's most visible — and highly regarded — spokespersons.
"Doctors have been treated as gods for a long time," Tom commented in the first issue of Medical Self-Care. "That's starting to change now, and it's just as hard for doctors to adjust to the change as it is for patients. Lay people and doctors have to help each other co-evolve into new roles in which the layperson can know a little more medicine . . . and the doctor can be a little more human." Medical Self-Care is Tom's way of helping speed that co-evolution process of helping usher in a new era of medical care in which the physician is on tap, not on top.
The physician's changing role, holistic healing, medical self-reliance, malpractice, the dangers of medical self-care, the rising cost of health services . . . these are just a few of the many topics that Tom shed light on when MOTHER EARTH NEWS interviewer Kas Thomas spoke with the young doctor last February in Inverness, California (a small, redwood-studded town on the coast just north of San Francisco). During the conversation that resulted, Tom showed himself to be a gentle, compassionate, good-natured, and knowledgeable person . . . just the kind of guy — in short — that you'd want for your doctor.
Tom, you look like a guy who's spent a good deal of time in northern California. Your long hair, your easygoing manner . . . in fact, everything about you . . . seems to say "northern California" in no uncertain terms. I can see you're starting to crack a smile. I hope you're not going to tell me you just moved out here from Des Moines last week.
Oh no. Actually, I was born not too far from where we are now, in Ross, which is a small town just over the hill in Marin County.
Is that where you grew up?
Initially, yes. My parents moved to Oregon before I started public school and I grew up mostly in a small coastal town up there, Coos Bay. My father was a city councilman and an accountant for a local lumber company . . . he just retired recently. My mother teaches at the local community college. I went to public school in Coos Bay right up through high school, after which I enrolled at Reed College in Portland.
What did you take your bachelor's degree in?
I left Reed College without a degree. What happened, you see, was I studied biology and creative writing for four years there, then — near the end of my studies — I applied to have my curriculum approved as a joint degree. That application was turned down. So I just said, "Fine" and left.
Did you apply to medical school at that point?
No. No, I didn't. I thought about it a lot, but I didn't actually apply then. I was interested in medicine — it was always part of the family mythology that I would grow up to be a doctor — and I'd taken all the required course work as an undergraduate, but I didn't care to pursue a medical career at that point in my life. I guess I just didn't want four more years of schooling.
You know, I was reading a lot of Albert Schweitzer at that time, and it turns out that he had had several other interesting careers before he went into medicine at the age of 30. So I thought to myself, "Maybe I'll come back to medicine when I'm 30."
In the meantime, though, I decided — after coming away from Reed College — to join Volunteers in Service to America (VISTA), the domestic Peace Corps.
Well for one thing, I was torn between wanting to do something along medical lines, and also pursuing my writing interests, which I had cultivated while taking a course under James Dickey at Reed College. Also, there was the danger that if I did nothing at all, I would be drafted. This was back in 1965. Summer of 1965.
VISTA seemed to offer the best of both worlds. On the one hand, I could do health-care-related work . . . they wanted to make me a health coordinator in the Florida Migrant Workers' Program. And on the other hand, I could gain experiences of the type that — I felt — would be helpful to me in my writing. Also, of course, I would not be sent to Vietnam.
How long were you in VISTA?
Two years. The standard stint. I got out in 1967. That was when I moved to San Francisco.
Why San Francisco all of a sudden?
Well as you know, some pretty interesting things were happening in San Francisco in 1967. A lot of young people were converging on the city for a lot of different reasons, and it was a very exciting time. But the other thing is that California State University at San Francisco had the best creative writing program that I knew of, and I knew and liked some of the people who were teaching in the program. So it seemed like a very natural thing to do, to go to San Francisco.
Did you actually enroll at that university, then?
Yes. I went ahead and finished my bachelor's degree in creative writing, and stayed until I got my M.A., also in creative writing. Altogether I was in San Francisco five years before I applied to medical school.
What made you suddenly go from creative writing to medical school at that late date?
Several things happened to me at California State University to spark my interest again in medicine. One was a class in high-altitude biology that I happened to take on the recommendation of a friend who told me that the course was really great. It was a tremendously enjoyable class for me. I met the instructor — got to know him a little — and the class really got me back in touch with all my scientific interests.
Another thing that got me interested in medicine again was my involvement with a student group that was trying to get the student health service on campus to provide birth control information and contraceptives and counseling, which they were not providing at the time. Our group never did get the student health officials to change their policies on that, but we did eventually write up a proposal and get student-government money for our own "sexual peer-counseling center". And, with the help of several faculty members, a dozen or so of us in the group were able to take crash courses in human sexuality and go to work as peer counselors.
Two of us from that group were later sent to the medical school in San Francisco to receive training in Masters' and Johnson's sexual counseling techniques. I was one of the two people chosen, and that got me interested again in becoming a physician.
About this time, I had also become involved — through a friend of mine — in running a free-clinic lab. In addition, I did volunteer work as a suicide-prevention counselor in Berkeley for about a year.
All of which got me remembering what I'd told myself years before about maybe going into medicine when I was 30 . . . you know, the Albert Schweitzer thing. I finally decided, "What the heck . . . I'll never have another chance to apply to medical school" — I was 29 at the time — and I sent applications to about 12 or 15 medical schools.
Then what happened?
Oddly enough, the school I most wanted to get into turned out to be the only one that would have me. That was Yale.
Why wouldn't any of the other schools accept you?
I think the main reason was my age. You know, 29 is actually quite ancient for a medical student. I should say 30 . . . I was 30 when I started medical school and 29 when I applied. It's just a fact of life that most medical schools have arbitrary age limits and won't admit anyone over 26 or 27 years old.
Of course, another thing is that my academic background is somewhat unconventional by traditional medical-school standards. Most people who apply to medical school have their degrees in biology or chemistry . . . not creative writing.
Fortunately, none of this seemed to bother Yale.
At what point in your medical-school career did you become interested in the idea of medical self-care?
Well I'd always had an interest in patient education and preventive medicine . . . "people medicine," in other words. I acquired this interest largely through my work with VISTA and — after that — with the Centro de Salud free clinic in San Francisco. The Centro de Salud clinic was set up to handle the health problems of Bay Area Chicanos who couldn't afford regular fee-for-service medical care. It was a great place. I remember being really impressed by the sort of informality or equality that existed between the doctors and the patients there. The patients weren't just given pills and sent home with directions on when to take them. The staff people would really go out of their way to sit down with the patients, talk with them, and make sure they understood the situation. That — I decided — was the way I wanted to practice medicine, if I ever had a chance to practice.
Unfortunately, Yale — as good as Yale was — was very much geared towards academics and research . . . textbook medicine, not "people medicine". There just weren't a lot of people there who were interested in what I was interested in. The one exception to that was the Yale School of Public Health. Over in the School of Public Health, I did meet a few individuals who were able to guide me and help me learn about preventive medicine. I'm talking mainly about Lowell Levin — one of medical self-care's pioneers — and Alberta Jacoby, my thesis advisor.
What really cemented my interest in medical self-care, however, were the things I saw during my first year in the hospital wards.
Such as . . . .
Mainly, I saw an incredible number of sick people who were suffering from illnesses that could probably have been prevented. I saw sedentary, overweight men who had atherosclerotic heart disease. I saw heavy smokers who were dying of emphysema and lung cancer. Heavy drinkers who had liver disease. People with peptic ulcers that had come about as a result of emotional difficulties. Women with breast cancer who had ignored the symptoms until the disease was totally out of control. Persons who had gone crazy because that was the only way they'd ever learned to cope with stress.
The problem was not that these people lacked good medical care. Most of them had very capable physicians. Somehow, though, there seemed to be a whole area of health maintenance that neither doctors nor patients were taking responsibility for.
After a while, I got to feeling — in treating some of these patients — like I was a mechanic working on cars that'd been wrecked by people who'd never learned how to drive. What was needed were not more mechanics . . . but a little drivers' education.
When it came time for me to choose a thesis project — Yale requires such a project for graduation — the first thing I thought of was, "A lot of the behavior patterns that are leading people into these illnesses are probably behavior patterns that were acquired in childhood. So maybe the place to start is with children." As part of my thesis project, then, I decided to set up a class in health and body awareness for first- and second-grade children at the Foote School in New Haven.
Tell me more about that.
We approached the class from a totally different direction than most people would think to do. I mean, instead of coming in — as other health-education projects at that level had done — with a list of goals . . . you know, "We want the child to learn this and that and this " . . . we tried to find out what the youngsters themselves were interested in, and proceed from there. And that proved to be a viable approach.
What we found was that the children had a tremendously wide range of health and body interests. One little boy, for instance, was very interested in finding out about blood. Another youngster — a little girl — was fascinated by ears. The youngsters didn't all want to know about the same thing, so we set the course up in such a way that each one could study what he or she wanted to study . . . and we found that the children were able to pursue their various areas of interest much farther than we would have anticipated.
I take it the class was a success.
I think so, yes. Of course, we won't know for another 40 years whether we taught them anything that's going to prolong their lives, but I think the class accomplished a lot of worthwhile things.
One little girl — the girl who wanted to know about ears — had had a severe doctor phobia for as long as her parents could remember before taking the class. When the eight-week class was over, her parents called us up one day and mentioned that Suzy had recently had a visit to the doctor without staying awake the night before. Not only that, but when the doctor walked in with his stethoscope on, Suzy had said, "Oh, I have one of those," and they went on to talk about their stethoscopes. For the first time in many years, Suzy had had a truly comfortable doctor's visit.
To answer your question . . . yes. I think the class very definitely was a success.
I understand you recorded the class on videotape.
That's true. I'm making the tape available to teachers, physicians, and anyone else who's interested in seeing it. So far, the people who've seen the tape have been enthusiastic about it.
What about Medical Self-Care magazine? How did that come about? Wasn't that a part of your thesis project for Yale also?
Right. The magazine came about after I finished teaching the children's self-care class. In fact, the publication was conceived while I was taking a copy of the videotape, which we'd just completed, down to New York to show to an independent TV producer, a woman who'd helped make it possible for my colleagues and me to do the videotape. As I was riding on this commuter train from New Haven to New York, I found myself fantasizing about a magazine . . . kind of a Whole Earth Catalog of medical things. By the time I got to New York, I'd drafted a table of contents for the first issue of a "medical access journal".
Exactly what constitutes self-therapy or medical self-care is — at this point — still very much in debate.
Anyway, it kind of grew from there. I'd always had this interest in writing, you know, and I had really liked what the Whole Earth Catalog people had done. I had met the Catalog's staff when I was living in San Francisco, and I remember that even back then I'd talked with some of the staff about what a pity it was that nobody had done an access journal for medical books and supplies. Finally, I decided I'd just put out one issue of the magazine and see how it felt.
At first, I had to decide whether to go through channels and try to write a grant and get funding and all that rigamarole. I talked to a few people about it, and they said, "Yeah . . . you could probably get funding, but it'll take you about a year." My only other alternative was to just borrow some money and do a first issue on a bare-bones budget. And that's what I did.
When did the first issue of Medical Self-Care come out?
I conceived the magazine in February 1976, and the first issue was published the following June.
What kind of reception did that initial issue get?
The response was very good. Newspapers and magazines picked up on what I was doing and spread the word. Medical Dimensions even did a story on us. By the time our second issue was ready to be printed, all 2,500 copies of No. 1 were gone and we had to print more of them.
The response to the magazine was so good that I decided to spend an extra year in school in order to continue doing the publication and write it up as part of my thesis project. My classmates at Yale graduated a year ago.
I take it you feel strongly that there's a need in this country for a new kind of health care. Is that right?
Well first you have to decide what you mean by "health care". What people get trained to do in medical school — and dental school, and other institutions of medical education — is diagnose and treat disease, and a lot of times we tend to call this "health care". In fact, it's illness care. And I think that one reason medical self-care is getting to be so popular now — and my magazine is by no means the equivalent of the medical self-care movement, it's just a small part of it — is that consumers are starting to see professionally delivered illness care for what it is. And one thing it's not is "health care".
People are beginning to realize this now and they're looking for alternatives. Doctors and consumers alike are beginning to look, for instance, at illness care delivered by lay people, wellness care delivered by lay people, and wellness care delivered by professionals. All of these new ways of looking at what we've been lumping together and calling "health care" are addressed in some way by the idea of medical self-care . . . which is simply the notion that the primary health resource in our society is not the physician, but the lay person himself or herself.
What's the difference between self-care and "alternative medicine"?
Alternative medicine — or holistic healing, or "the new medicine" — starts from the premise that our doctors' present tools — drugs, surgery, psychotherapy, etc. — should be supplemented with tools from other healing traditions. That's a whole different concept from medical self-care, really. Self-care proponents see the problem as being that most lay people don't know enough about evaluating and improving their own health before they get sick, number one . . . and number two, coping with illness when illness does occur. Improving one's health and learning to cope with illness are the two main components of self-care.
In other words, then, the holistic health movement would say that we need a new map for health care. The medical self-care movement would say that the wrong person has been holding the map.
I know that one of the concerns some doctors seem to have about medical self-care is that it might not be entirely safe. Is medical self-care safe? Do people run any risks when they begin to take health care out of their doctors' hands and into their own?
It seems to me people are running a lot of risks right now by not becoming better educated in health. Look at all the individuals who are killing themselves with tobacco and alcohol and high-fat diets! Look at all the women who don't tell the doctor about "that lump in my breast" — or who don't even know it's there — until it's too late. Do you realize that of all the people who come to their doctor with a serious medical problem — and that's a minority of patients, by the way, because most persons who go to the doctor don't have much wrong with them — something like 30 percent should have come in sooner, but didn't know how to recognize the danger signals of their disease? Thirty percent. That's way too much.
Exactly what constitutes self-therapy or self-care is — at this point in the movement's development — still very much in debate. Nobody knows precisely which tools and techniques consumers are going to wind up using in the end. No one, however, is asking housewives to learn how to diagnose and treat cholecystitis or lupus erythematosus. I mean, people will still rely on their doctors to deliver illness care. The role of the consumer in self-care is simply to make the physician's job a little easier . . . when a physician is needed in the first place.
A lay person can be trained to examine a sore throat, for example, in such a way that a doctor can tell — just by talking to the person over the phone — whether a throat culture is warranted. That's a lot better than paying a doctor $20 to look at the same throat himself. Better for the patient and the doctor. Doctors don't like to spend all their time looking at sore throats . . . they'd much rather put their time — and talents — to better use. Rightly so, I think.
How can people learn medical self-care skills? Where do you start?
Probably the best way to learn about medical self-care is to attend a medical self-care class. You can find a list of such classes in our magazine. Medical Self-Care comes out four times a year, and in every issue we give a list of the locations of medical self-care classes that are being conducted across the U.S.
The other thing people can do is buy and read some of the excellent medical self-care books that have recently come out. Two that I particularly recommend — I used them as texts in the medical self-care class I taught last year at the Haight-Ashbury Free Clinic — are Take Care of Yourself: A Consumer's Guide to Medical Care by Drs. Donald M. Vickery and James F. Fries . . . and How to Be Your Own Doctor (Sometimes) by Keith W. Sehnert, M.D. Dr. Sehnert, incidentally, is one of the pioneers of medical self-care education in this country. He's kind of the George Washington of medical self-care.
The nice thing about the Vickery and Fries book is that it contains clinical algorithms for the 68 medical problems people are most likely to encounter.
A clinical algorithm is a kind of flow chart that contains — or a given medical condition that a person might come to the doctor with — the appropriate diagnostic questions to ask and a system of branching logic — a "decision tree" that leads you, based on your answers, to the best course of action for your problem.
For instance, you might consult the clinical algorithm for sore throat, and it might ask you if you've also got a skin rash, in which case you should see a physician right away. If you don't have a skin rash, you'd go on to the next question, which might be: "Is there pus on the tonsils?" You'd work your way through a series of questions like this, until eventually you would end up at a box that says "See a doctor immediately", or "See a doctor soon", or "Apply home treatment". Or whatever.
A clinical algorithm is a way of getting immediate advice on how to cope with a given medical problem. It's one of the new, evolving tools of medical self-care. I'd recommend that anyone who's interested in saving money on doctor bills get hold of a set of clinical algorithms, such as are contained in Vickery and Fries' book.
Something like 50 to 80 percent of the people who come in to the doctor have a self-limiting condition.
A minute or two ago you mentioned that most people who go to see the doctor don't have a serious medical problem.
That's right. Something like 50 to 80 percent of the people who come in to the doctor have a self-limiting condition, or some problem that can't be treated or doesn't exist. The doctors themselves put the percentage at 50 to 80 percent . . . the exact figure varies from study to study. But it's clear that most office visits aren't really necessary.
Well, when should a person go to the doctor? And when should a person not go to the doctor?
I think the best way to determine whether a doctor's visit is called for is to get hold of a set of clinical algorithms and — if the symptom or condition is one for which there's a chart — run it through and see what the algorithm tells you. If you can't get hold of a set of algorithms — or you encounter a situation that's not covered in the charts you can call your doctor and ask for advice. A lot of things can be handled over the phone.
This question of when to see and when not to see a doctor is hard to answer in any general sort of way. And I certainly wouldn't want to say anything in this interview that might keep someone from seeing a doctor when they actually should see one. Nonetheless, there are certain instances in which a person probably should not seek a physician's help. The example that comes to mind is that of the person who's had a cold or flu that's lasted only a few days. There's nothing a doctor can do for a common cold, except perhaps to prescribe a decongestant or antihistamine, and these are widely available without a prescription.
Are the cold remedies that a doctor would prescribe any different from the ones you'd buy over the counter?
They might be, in some cases. But there are effective ones available without a prescription, at a much lower cost. Basically, nothing you can get from a doctor will make a cold go away any faster. Doctors know this. Most physicians won't take anything at all when they have a cold.
Some people, though, when they get a cold or the flu or a sore throat immediately trundle off to the doctor so they can get "a shot of penicillin". These persons think that if they can just get a shot of antibiotics, it'll "knock the infection right out."
Yeah, I know. And nothing could be more ridiculous. Because when you have a cold or the flu, you're suffering from a virus-caused illness. Antibiotics don't even touch viruses . . . they only work on bacteria. So when you take penicillin for a cold or the flu, you leave the cold viruses — or influenza viruses — unharmed . . . yet you wipe out a good many of the beneficial bacteria in your digestive tract. You also give any pathogenic bacteria in your system a chance to develop resistance to the antibiotic. In addition, there's the possibility that you could experience an adverse reaction to the antibiotic.
I hate to say it, but the best thing to do when you think you've got a cold or the flu is simply to rest, drink lots of liquids, and take aspirin. And also take vitamin C.
What about the so-called "annual checkup"? Do you think that the average healthy person should go in to see his or her doctor once a year for a complete physical exam?
Not necessarily. There's no question that some parts of an annual checkup are worthwhile. These include the Pap smear for women over 25 . . . skin tests for tuberculosis . . . sigmoidoscopy for men and women over 45, to detect rectal cancer . . . and a blood pressure reading. Most doctors, I'm sure, would agree with me that these procedures are indicated on a regular basis. As for all the other "laying on of hands" stuff that goes with a physical exam . . . I'm not so sure it has any value.
I know that Dr. Sehnert — Keith Sehnert, the author of How to Be Your Own Doctor (Sometimes) — believes that a normal, healthy adult under age 40 need have no more than one checkup every five years. I think you'll find that most doctors haven't had a physical exam themselves since medical school.
You mentioned earlier that medical self-care involves not only knowing how to cope with illnesses when they occur — which is what clinical algorithms are all about — but knowing how to evaluate and upgrade one's current state of health.
OK. What kinds of things can or should a person do to upgrade his or her health . . . that is, to keep from winding up in the hospital ten or twenty or thirty years down the road?
A couple of University of California researchers named Lester Breslow and Nedra Belloc conducted an interesting study a few years ago. In their study, they found seven habits or behaviors that are correlated strongly with good health. People who followed these seven behaviors tended to live longer — sometimes much longer — than people who didn't, according to these two researchers' evaluation. The seven "good health practices" that Breslow and Belloc reported were: Don't eat between meals. Get seven to eight hours of sleep each night. Eat breakfast regularly. Keep within a few pounds of your ideal weight. Engage frequently in sports or exercise. Drink moderately or not at all. And don't smoke.
I don't think Breslow and Belloc's study proves beyond any doubt that if you do these seven things you'll live longer. Because for one thing, correlation doesn't prove causation. But it gives you something to think about.
On the other hand, some of the "good health practices" mentioned by Breslow and Belloc are — I think — genuine life-or-death matters. For instance, there's no doubt in my mind whatsoever that people who smoke cigarettes stand a much greater chance of winding up with lung cancer, heart disease, emphysema, bronchitis, or bladder cancer than people who don't smoke. I remember I was taking care of an emphysema patient once at the hospital. Shortly before he died, he asked me if I would have him taken around on a stretcher to all the high schools in the area so that students could see what can happen to cigarette smokers. But of course, I didn't honor his request.
Then too, I think there's no question that if you want to reduce your chances of ending up in an intensive care unit someday you should keep within a few pounds of your ideal weight. That's one of the reasons why I'm a great believer in exercise.
What kinds of exercise?
Any kind of moderate — not exhausting, but moderate — exercise that you can sustain for ten minutes or more at a time is going to be good for your heart. That includes jogging, biking, swimming, hiking, etc. If you exercise very briskly—on the handball court, say — for ten minutes and then stop, you're not really doing your cardiovascular system a lot of good. However, if you elevate your pulse rate to 135 or 140 beats a minute and keep it there for more than ten minutes . . . then you're starting to have some positive effect on your circulatory system. To get a better understanding of this, you should read The New Aerobics by Dr. Kenneth Cooper. It's really an excellent book.
I understand you're a runner.
A novice runner, yeah. I'm entering my first marathon in July. For my money, running is just a really dynamite way to stay fit. Its benefits are truly astounding. People who take up running — and stick with it — can pretty much count on spontaneously quitting smoking, cutting back on overeating, returning to their ideal weight, being able to handle psychological stress much more easily than ever before, having a better sex life, and lots more. You'll look younger, feel better, have a lower resting pulse rate. Running even causes a change in your body's endocrine balance, and a lot of people attribute the positive psychological effects to this change.
Isn't there a doctor somewhere who has gone so far as to say that if you can maintain a level of fitness that allows you to run a marathon, you'll enjoy absolute protection against heart attacks?
Yes. There's a doctor somewhere who's been monitoring autopsies on distance runners, and he claims you can have absolute protection from heart attacks if you can keep in good enough shape to run a marathon. But the trouble is, you see, he's basing that statement on the results of a fairly small number of autopsies. I mean, the people who are out there running marathons haven't died yet. That's one of the problems (laughter).
You know, as a result of this interview somebody probably is going to put the magazine down right now, go out, run a mile at top speed, and come back gasping for breath. Has that person done himself or herself any good?
No. One of the really important things about running — and I'm glad you brought it up — is that you have to start out very, very slow. Just about everyone who takes up running starts out at too fast a pace, and that's bad. If you run too fast, you stress yourself to the point where you risk injury, and also the subjective experience is quite unpleasant. If you run too slow, however, you don't get much benefit from the exercise.
The question, you know, is how fast do you run to get the most benefit? The answer is, you should run at whatever pace you have to run at to achieve the target pulse that's right for you. By running at a speed that gives you a constant slightly elevated pulse rate, you achieve the maximum benefit for your heart with the minimum possible stress.
What might be a good "target pulse" for a beginning runner who's in poor shape, let's say?
If you're in poor shape — which most people are — you can subtract your age from 150, and use that as your target pulse rate in beats per minute. If you're in excellent physical condition, you can subtract your age from 190 and use that as your optimal pulse. Then what you do is, every time you go running, stop every five or 10 minutes and check your pulse. This only takes 10 seconds, once you get the hang of it . . . you don't have to count for a full minute. If your heart's beating too fast — and it probably will be — you should rest a minute and start running at a slower pace.
You'll be surprised how many times you'll stop and find that your heartbeat is way above what you thought it'd be. It took me three months of three-times-a-week running to learn to run at my target pace.
The main thing to remember if you're just starting a running program is that you should begin slowly and not run past the point of pain. If anything feels uncomfortable, stop and rest. I'd also suggest — if you're a heavy smoker, have high blood pressure, or are overweight — that you see a doctor, and maybe arrange to get a stress electrocardiogram, before you begin any kind of intensive exercise program.
And remember that running isn't the only kind of aerobic exercise that's good for your heart. Swimming and biking are just about as good, although they're usually not as convenient.
The important thing is to get involved with some kind of physical exercise on a regular basis, before it's too late . . . before you have to check into the intensive care ward.
Tom, what's going to happen to medical spending in this country if people stop smoking and stop overeating and stop doing all the other things that lead to chronic diseases such as heart disease and cancer?
Good question! If people begin to eat right and exercise right and avoid chemical poisons and learn how to cope with stress and learn how to recognize the warning signals of various diseases in time to begin treatment . . . then in a few years we're going to have one heck of a lot of empty intensive care wards on our hands. And maybe we wouldn't have to spend $139 billion a year on illness care.
The idea that we might someday actually do away with — or vastly reduce the number of cases of—heart disease isn't really so farfetched. Do you know that the number of heart-disease-related deaths in this country has actually gone down over the past three or four years? There's a lot of speculation going around as to why this is so. Some people like to point out that this decline in mortality more or less parallels the increased emphasis on exercise and running that occurred in the U.S. during the same time frame. No one really knows though. It's a big mystery right now. But something's definitely had an effect on the rate of death due to heart disease.
So you feel it's possible that if medical self-care ever achieves widespread popularity, it could have a big impact on the rising cost of medical services?
Well you can't deny that self-care is going to save people money. I mean, it's damn cost-effective on an individual level. Every time you don't go to the doctor with a sore throat — assuming that the clinical algorithm tells you not to go — you save yourself the cost of an office visit, and maybe the cost of a prescription, too. Combine a Pap smear or a blood pressure check with your next doctor's appointment, and you've saved yourself the cost of a $100 physical. On an individual level, I think you can say that self-care is going to have a big impact on the cost of medical services.
Beyond that, though, there are the long-term savings we've just talked about. Let's just take one example. Cardiovascular disease costs people in this country $22 billion a year, approximately. Obviously, if you can reduce the mortality and morbidity of this disease, you can save a lot of people a lot of money. $22 billion comes to more than $100 for every man, woman, and child in the U.S. I know a lot of people who could use $100.
All of this should, in turn, lead to lower health insurance costs, too. I mean, if people stop dying of these horrible, protracted illnesses that require long hospitalization and ridiculously expensive lab procedures, health insurance companies will spend less money and premiums should be correspondingly lower for everyone.
It seems to me that there's a big incentive there for insurance companies to support medical self-care. Are these companies taking an active interest in medical self-care?
I'm very encouraged by the interest that some groups, such as Blue Cross, have shown in the medical self-care movement. Blue Cross recently bought many thousands of copies of the Vickery and Fries book — Take Care of Yourself — to distribute to its members at cost. Also, Blue Cross representatives have been very much in evidence at recent self-care conferences, and I think that's a good sign.
One of the things that's holding medical self-care back a little right now is the fact that while Blue Cross will allow a coronary bypass operation to be charged as a billable expense, they won't pay for the cost of enrolling in a medical self-care class. Except in Montana, that is. Blue Cross of Montana I think, will pay for the cost of "patient education".
I hope that before too much longer the big insurance companies will begin to see that it's in their own interest to offer medical self-care education as a billable benefit. It's the people who administer these giant health plans that wield the Big Bucks in medicine today. Until the administrators begin to take medical self-care seriously, I'm afraid there's not going to be much change in the way the current "illness care" system is set up.
Tom, you've mentioned some of the obvious — and not-so-obvious — benefits that medical self-care has to offer the medical consumer, and you've pointed out some of the possible benefits to insurance companies. What about the family doctor? How is medical self-care going to benefit the physician?
Doctors should welcome the trend toward medical self-care with open arms. First of all, they're not going to have to waste their time seeing those 50 to 80 percent of all patients who come in with nothing more serious than a cold or a nosebleed. Which means they can spend more time with the other 20 to 50 percent of their patients, the ones who really need the attention. And that's good, because most doctors I've talked to really don't want to waste their time taking throat cultures and prescribing antihistamines. That's not really using their talents very effectively.
Also, the medical self-care movement will place greater emphasis on the doctor's role as a teacher or educator, and I think most physicians will appreciate this. Over the years, we've tended to lose sight of the fact that the root meaning of the word "doctor" is teacher. And I think there's something to be said for the idea that doctors should teach their patients. A teacher/student relationship is — in many ways — much more satisfying for both parties than a healer/sufferer relationship. So there's another reason why physicians should welcome the growing trend toward medical self-care.
I think that medical self-care could — quite possibly — have some positive ramifications in the area of malpractice, too.
Well from what I've been able to observe — and I've talked with a lot of doctors about this — "malpractice" is almost always a reflection of a communications problem. Litigation seems to be — in the great majority of cases — the last resort of the frustrated patient who can't communicate a problem to his or her physician.
A friend of mine is a family practitioner in Kentucky. He decided a few years ago to go without malpractice insurance . . . mainly because he had trained several members of his office staff to work in a paramedical capacity, and the insurance companies wouldn't approve of it. Anyway, he and his staffers now make it very clear to every new patient that they accept that they're operating without malpractice insurance and that they're willing to deal with any problems or complaints that a patient may have at any time. This guy and his staff will bend over backwards to treat his patients fairly. Over the two or three years that he's been without insurance, my friend has been involved in less than a dozen informal complaint proceedings and no malpractice suits.
So I think maybe the key to avoiding malpractice suits is to encourage communication with patients. And I think better communication between physicians and patients will be one of medical self-care's main by-products.
From what you've been saying up to now, it sounds as though medical self-care has a lot to offer physicians in terms of better use of their time and talents, more satisfying relationships with their patients, and less worry about malpractice. It also sounds, however, as if doctors — family practitioners in particular — are going to be called upon to "donate" a lot of their time to medical self-care classes, phone conversations with patients who need advice, and one-on-one patient education.
Do you think physicians are going to want to "volunteer" their services in this fashion? I mean, where's the financial incentive for doctors to support medical self-care?
That's a perfectly valid point, I think, and I suspect it's something that may be holding a lot of physicians back from getting more involved in the medical self-care movement right now. Obviously, it's a lot more lucrative for family practitioners to go on examining those 50 to 80 percent of all patients who don't need treatment than it is to not see them . . . although I don't think most doctors would have any trouble earning a good living even if that 50-to-80-perecent group stopped coming.
A friend of mine — John Travis, who practices over in Mill Valley, just a little ways from here — has pioneered an interesting approach to this problem. John is an M.D. who no longer practices any illness care. He only practices wellness care, on a fee-for-service basis. If you go to see John when you're sick, he'll refer you to another physician for diagnosis and treatment!
John's goal is strictly to evaluate and elevate his clients' — and he calls them clients, not patients — level of wellness. Instead of giving you a physical, for instance, John subjects you to a "wellness evaluation" involving a battery of about ten questionnaires that cover just about every aspect of your present lifestyle. Afterwards, John sits down with you and plans out an individually tailored "wellness enhancement program" that might involve, say, biofeedback training if your evaluation discloses high stress levels, a special diet if you're overweight, and so on.
John Travis' approach, I think, is a very interesting one . . . and — so far — a lucrative one. Lucrative enough, anyway, to allow him to pay his bills and keep some soybeans on the table.
What about yourself? How do you plan to keep soybeans on your table? Do you intend to do a residency in family practice?
Right now I'm just trying to publish the magazine, and that's keeping me pretty busy. It looks as though Medical Self-Care is going to break into the black soon. We're getting an increasing amount of media coverage, and that helps, since we don't have enough money right now to advertise. Also, we're opening the magazine up to advertisements for the first time . . . we may be able to make some money there, although I don't know. Our press run — as of the next issue — is 10,000 copies, and that's not enough to interest most advertisers.
The other thing I'm working on right now is a book. It's basically a compilation of information from past issues of the magazine, with a few extra goodies thrown in. The book will be called Medical Self-Care, and it'll be published by Summit Books in early 1979.
As for whether I'll ever practice illness care or not . . . I don't know at this point. I've decided to postpone any residency training for at least the next two years, and after that I'm not sure what'll happen. I waited until I was 30 to start medical school. Maybe I'll wait till I'm 40 to do an internship (laughter).
One last question. If you had it to do all over again — go to medical school, I mean, and then start a magazine — would you do anything differently?
That's a funny question to try to think about. Wow . . . I don't know. I guess I'm pretty happy with the way things have turned out. I don't think I'd do anything radically different. Maybe I'd apply to medical school at age 28 instead of age 29. It's hard to say, though. All the things that happened to me before medical school were kind of prerequisites for what happened afterwards.
Really, I guess you could say that Medical Self-Care — and this interview — were 34 years in the making!
The magazine Medical Self-Care did not exist after 1989. The book Take Care of Yourself by Donald Vickery and James Fries, which contains clinical algorithms of the type discussed in the above interview, is still available online and in bookstores. Keith Sehnert's How to Be Your Own Doctor (Sometimes) is also available online and in bookstores.