Expert Patients (and most everybody else)
Recently there was an item in a British medical journal about a new initiative for the 21st century. The London Health Department is promoting expertise for patients with chronic diseases. This would permit them to manage much more of their own care as if they were their own physicians and their visits to doctors would be more to enhance their expertise and less for day to day decisions. Compare with what we have been doing or trying to do with diabetic education for a generation. I obtained the 60 page brochure from the London Health Department over the internet for the price of the paper. (I felt very modern.) The brochure convinced me that the London Department of Health is really on to something. Within a week or so I decided that for diseases of civilization we need an expert public. Some examples follow with emphasis on items of general applicability rather than specific chronic diseases.
Civilization has been afflicted with some long term fads harmful to public health. An example of one, well on the way toward resolution, is tobacco. Its advertisement is being severely restricted or eliminated. Such advertisement is not "commercial free speech", a rare aberrant opinion by the Supreme Court, but in reality a serious health hazard.
Society is already taking on another similar public health problem. Alcohol is more far reaching than tobacco in its ill effects because of automobile accidents and other violence perpetrated on innocent bystanders. On the other hand, in small doses alcohol is (probably) beneficial to health. This latter concept is perhaps better presented to the public with careful consideration to whom the concept is imparted. Already the majority of beverage alcohol is consumed by problem drinkers. Correction of society's current errors about alcohol had better be accomplished by general education than by commercial advertising. In the case of both alcohol and tobacco we are confused as a society by their status as entirely legal. I suggest a new status which prohibits their commercial promotion and restricts sales to certain limited stores to make it easier to eliminate sales to minors.
Caffeine is clearly not toxic to adults and therefore should not be controlled in spite of the fact that it is habit-forming. The consequences of attempts to control it are out of the question with one exception: caffeine is not known to be harmless for children. Many of them scarcely drink water because of promotion of soft drinks. Soft drinks are easier to sell if they contain caffeine. Some manufacturers have even started to advertise that their product contains "more caffeine". As of now the government requires that labels indicate only that caffeine is present, not the amount. The newly expert public is entitled to know the actual caffeine content in each container in the same way that the caloric count is already stated. Escalating obesity in grade school children is an emerging public health problem. So-called "adult onset diabetes" is now occurring in significant numbers of obese children.
Frivolous, "useless", activity is a prerogative of youth. Our emerging expert adult patients can set an example. A level of exercise unnecessary in our mechanized labor-saving society contributes to health and fitness in many ways. The most obvious is athletic fitness and the resulting ability to enjoy many strenuous activities. Such activities increase food requirements enough that appetite has to turn on to maintain the activity. At the extreme of work effort the digestion cannot continuously provide energy to sustain the effort. At lesser but significant work loads the appetite is still quite effective in matching food intake to requirement. The sense of well-being achieved by the trained athlete is a positive addiction in that the side effects and consequences of the addiction are beneficial. All of this is still true in chronic illness. For instance the expert emphysema patient learns how to balance needed exercise against exhaustion which might lead to inadequate food intake. Thus the patient learns not to try to come off oxygen therapy if the attempt results in chronic lack of oxygen similar to altitude sickness but at sea level, again resulting in loss of appetite and strength. Many emphysema patients are in the same difficulty as the rest of us would be trying to live continuously at 18,000 feet.
The expert patient especially needs knowledge of the details of life style leading to maximum benefit for his particular affliction. When more and more disease-specific support groups are available many sufferers of chronic disease will have advantages already available to recovering alcoholic patients. Alcoholics anonymous is a good example of such a support group for "expert patients".
John A. Frantz M.D. May 10, 2002
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