Is prescribed exercise in older people beneficial? The answer: a resounding "maybe"

As Medicine continues its journey to become more “evidence-based” it is humbling to realize how little we really know about prescribed treatments.  A case in point:  Is it good to exercise?  In both health and disease?  As we age?  Dr. Marco Pahor and his colleagues contributed one more brick in the wall of evidence in a recent research paper in JAMA.  The short answer -- probably. 

 

Their paper (Effect of Structured Physical Activity on Prevention of Major Mobility Disability in Older Adults, JAMA 2014;311,(23):2387-2396) attempts to systematically address a fundamental question: Does exercise help prevent or delay loss of mobility in older adults?  This was a well-designed trial.  The patients represented a good cross section of the population, geographically and ethnically.  They were typical people, like those seen in a primary care physician’s office: average age 79, obese, sedentary with multiple chronic health conditions (e.g. hypertension, diabetes, cancer).  The follow up period was adequate to detect some longer-term impact of the intervention (average 2.6 years).

The intervention was something the average person could reasonably replicate.  Participants walked a total of about 2 ½ hours a week, supplemented by brief sessions of strength training (using ankle weights) and stretching of large muscle groups.  It is a program you could actually envision a motivated patient performing.  A control group was given general health education classes (plus a little light stretching).  Over 1600 patients were randomized to the two groups.

The primary outcome measure was simple.  All the participants could walk 400 meters (about ¼ mile) upon entry to the study.  Did they maintain or lose that ability during the course of the project?

Results?  At the end of the study period, 30.1% of the exercise group lost the ability to walk 400 meters.  People in the control group (education only) lost this ability 35.5% of the time.  The results were statistically significant.  So, the answer to the question is affirmative.  Exercise does help elderly patients maintain mobility.

So do we now have evidence to support widespread prescription of exercise to octogenarians? Nothing in medicine is so simple.  Taking nothing away from an excellent and important study, it answers some questions, but raises others.

The impact or exercise is statistically significant, but is it compelling enough to zealously prescribe exercise? Compliance with exercise is not an easy task, even in the young and healthy.  If you were told: “you have a 35% chance of seeing your mobility decline in the next couple of years, but we can reduce that risk to 30% with a long-term structured exercise program” is that a compelling enough effect to motivate you to strap on your gym shoes?  Taking the data from the study, a physician would need to convince 23 previously sedentary people to begin an exercise regimen, and those 23 would need to be compliant with the program, to prevent one person from losing mobility.

The study also looked at some secondary outcome measures, including the need for hospitalization, and the occurrence of “serious adverse events” like heart attacks, strokes, or death.  The trend for both was negative.  Hospitalizations and adverse events increased in the exercise group, but in neither case did the effect reach the level of statistical significance.   Had these trends been significant, it would have created an interesting conundrum…exercise would be good for maintaining function, but could actually increase health care costs.

In summary, this study adds to a growing literature to prove what many might think is intuitively obvious: exercise has positive health benefits.  Enough to justify, from an evidence based medicine perspective, a major public health investment?  Enough to drive down health care costs? Probably not. 

Enough to convince you, as an individual to stay as active as you can, for as long as you can.  Absolutely.

The art of medical literature review -- Lessons from a distant era

It just took me 20 years to write a two page paper.

The specific subject is not important to this posting (a trick to learn and recall a particular area of neuroanatomy). However, the epic adventure of producing this paper spanned a transformational period in the history of knowledge and learning. The roots of the paper were formed in the pre-Internet era; the fruit were harvested in the current environment of instant hyper-connectivity. The benefits of widespread computing and networking are obvious to all. However, reflecting on this experience it occurs to me that there were some benefits to the old ways; there are some lessons the “digital natives” can learn from the ancient “digital immigrants”.

First, the story. In 1990, I was a resident preparing a grand rounds presentation. The topic (again, not important to the story) was neuralgic amyotrophy, or Parsonage-Turner Syndrome. Preparation required an extensive review of the available medical literature. Today, this task would be performed at my desk, and the pertinent papers downloaded instantly, in less time than it took to type this posting. Here is how it worked in 1990. To some, this will seem like monks hand-copying books:

To begin, you identified key words that were used to catalog references in the Index Medicus. The Index Medicus was founded in 1879, and was in continuous print publication until 2004. Ultimately, it evolved into the National Library of Medicine (NLM) and all references may now be accessed electronically via PubMed. (for a brief history of the Index Medicus, click here)

In 1990, the Index Medicus was published as a single volume, bound annually, with monthly updates for the current year. To perform a literature review, you had to physically pull each bound copy, look up your key words, intuit from the title of the article if was pertinent to your topic and write down the reference. You then repeated that task for the previous year…and the year before…and the year before…until you were satisfied you had searched far enough back into the literature.

Next, it was time to find the actual articles. Depending on your project, you might need at least a dozen references; another project may require more than one hundred). With your references written on a legal pad, you entered the library stacks…multiple floors of bookshelves, usually dimly lit, with the unmistakable odor of old books. You had to pull each bound journal, locate the article, and scan it to see if it contained information of interest to your quest. If it passed muster, you would add it to a wheeled cart and proceed to the location of the next journal. Since the stacks were generally multiple floors, and elevator was involved. At times, the bound copy of a particularly important article was missing, or torn out of the journal by some academic miscreant. In these cases, you had to meet with the librarian to request that a copy be mailed (that is, using a stamp and a postman) from another library.




With your cart in tow, you then proceeded to the copy room to make copies of your collected articles. This sometimes involved standing in line, as others were also copying dozens of articles. Then, simple as that, your initial literature review was complete. You were finally ready to read, synthesize and write.

The entire process took at least several hours -- often days, or even weeks. The ability to search the entire medical literature, nearly instantaneously, from virtually any device, is clearly a quantum leap from the old method. It is a leap that we all now take for granted. But was there anything valuable lost in the transition?

Back to my grand rounds. As I was in the “stack wandering” phase of my project, I picked up a journal containing one of my many references. As I flipped to the appropriate page, my eye was caught by a brief paper in the same journal. It was on an entirely unrelated topic – brainstem anatomy. I read it and learned a simple anatomical trick. I started using the trick clinically, found it useful over several years, altered it a bit and started teaching it to others. Eventually, I decided to try and publish it. To this day, I have never been able to locate the article I stumbled across serendipitously. I did find others, and consolidated their concepts with my memory from the mystery paper (http://www.ncbi.nlm.nih.gov/pubmed/24713180).

So what lessons can be learned from the old ways? I think there are several:

Planning. The review process outlined above was incredibly labor intensive, and could not be easily delegated. The potential for lost time forced people to plan their literature review in advance. A primary role of a medical librarian was to assist in the development of a search which was systematic and thorough, but also time efficient.

In the current world of instantaneous searches, it is easy to use the first couple of key words that come to mind, cross reference them and generate what seems to be an adequate number of references.

Modern searchers should still invest in time to plan an important search in advance. Although time efficiency is no longer be an issue, it is still necessary to be systematic and thorough.

Quality trumps quantity. The modern search generates a tremendous volume of references. The old search methods tended to produce a more thoughtfully assembled list. The old methods felt more like being a collector of stamps or porcelain figurines – the collector, over a long period of time, searches for and acquires a particular piece that helps to augment the collection. The new methods feel more like a money whirlwind machine on a game show (Click here if you do not know what this is). The searcher grabs as many bills as possible, as quickly as possible, until time runs out.

Modern searchers could benefit from treating their efforts more like the assembly of a treasured collection.

Create quiet space. The old search process was incredibly inefficient. There was a great deal of inherent wasted time, rifling through the Index Medicus and combing through the stacks. However, it was also a very peaceful experience. The information came slowly, in bits and pieces. There was time for your mind to wander, and to ruminate on something you just read. If ideas tend to come to you in the shower, you would likely have the same experience in the stacks. Modern searchers would be well served by actively working to create quiet, reflective time, free of all distractions.

Faster is not always better.

Family Dinnertime: The Meaningless Nine and Magical Tenth

When my children were younger, my work hours were long; I would routinely get home between 8 and 9 o’clock.  In spite of the inconvenience, my wife and I committed to consistently sitting down at the table for a family dinner – no television or electronic distractions – just conversation.  I believe this was one of the best decisions we made as parents.

If you Google “the importance of family dinners”, you will produce over 2 million references from lay and scholarly sources.  Consistent family dinners have been associated with virtually every positive metric of childrearing (better grades, higher performance on standardized testing, improved self-esteem, etc.); conversely, dinners seem to be protective against almost anything parents might fear (obesity, promiscuity, drug use, etc.). 

In essence, we performed our own, nearly two decade-long nonrandomized and uncontrolled sociological experiment.  In that time, I learned one important lesson.

Cumulatively, I have experienced literally thousands of dinners with my wife and children.  I would estimate that, on average, nine dinners come and go without anything of consequence occurring.  Talk is sparse or inconsequential…nothing is really new…school was fine…

Then, suddenly and unpredictably, during the tenth dinner magic happens, and it takes a variety of forms.  Meaningful information is offered about friends.  Aspirations for the future are revealed.  Fears are acknowledged.  Arguments erupt and resolve.  A mannerism or mood is subtly different, and delicate inquiry lifts the veil of teenage obfuscation ever so slightly.  The magic is simple: real communication occurs, and it is gold.

The one important lesson I learned is that the magic cannot be scheduled.  The nine “meaningless” dinners are far from meaningless.  They are a necessary prerequisite to experience the magical tenth.  The meaningless nine establish the trust and comfort to allow communication to occur.  They build your capacity for emotional pattern recognition, so you intuitively know when something is a little off kilter.  You cannot surgically schedule the tenth, without embracing and relishing the nine.

I believe the same dynamic applies to leading people.  There are numerous gurus of leadership development.  Warren Bennis, perhaps the exemplar of all gurus, believes “ultimately, a leader’s ability to galvanize his or her co-workers resides in both understanding the co-workers’ needs and wants, along with an understanding of…their mission.” (On Becoming a Leader, click here)  What I learned from my nine dinners is the development of empathy and trust is, at least in part, a time dependent activity.  It does not happen without face time.

If a colleague or co-worker has a behavioral issue that needs to be brought to his or her attention, and you do it in the context of your one and only real conversation, it is almost impossible to convey the message effectively.  You will not have a receptive, trustful listener and you should expect a purely defensive reaction.  If you design a truly brilliant strategy in a cave, and emerge like a prophet to enlighten the masses, even flawless oratory is unlikely to galvanize a team.  If you expect to be informed about the little problems, before they blossom into crisis, it will never happen in a culture lacking trust and open communication.  You must embrace and relish the nine, to receive the gift of the tenth.

In the latest Atul Gawande New Yorker gem (click here for article), he asks why some best practices spread rapidly, and others do not.  He cites an example from pharmaceutical sales to physicians.  Apparently, the company detail (i.e. sales) people follow “the rule of seven touches”.  You must interact with a physician seven times before you develop enough trust, and enough of a relationship to influence behaviors.

Healthcare is facing a prolonged period of substantial, foundational change.  The environment is one of ever changing laws and regulations; of accelerating consolidation into larger and larger organizations; of expectations of radical transformation of a delivery system evolved over a century.   Change will come, and effective leadership will be a necessity for success.  As we drive this change, it is important to remain connected to the human part of what we do.  It is not mostly about relationships.  It is entirely about relationships.

Book Review -- Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives

It is always a pleasure when our expectations are unexpectedly exceeded.  When my wife and I were married, we were late getting to the inn where we were spending our honeymoon.  As the restaurant was due to close, I called ahead to ask if they could leave us some sandwiches.  We arrived to find they kept the restaurant open, had a table waiting by the fireplace, with a live classical guitarist.  They could have served sautéed shoe leather, and it would have tasted great.

Although not quite on par with my honeymoon dinner, I had a similar experience reading Connected: The Surprising Power of Our Social Networks and How They Shape Our Lives by Christakis and Fowler (click here for link).  I expected to learn about the various forms of social media that have become such an important part of our communication landscape.  What I actually acquired was a new lens through which to view the world, and a desire to learn more about how this enhanced worldview can be used to drive positive change in communities and organizations.

I took three broad themes away from this well written and referenced work:

1. Social networks have properties, which we tend to not understand.
2. Social networks have complexity, which we tend to underestimate. 
3. Deeper understanding of social networks has the potential to enhance spread of knowledge and behaviors (good and bad).

Upon completion of the book, the authors clearly succeeded in driving home the first two themes – I have a better understanding of network properties and structure, and a greater appreciation of the variability and complexity of network structures.  However, it does not deliver quite as strongly on the third theme.  How can one use this knowledge to enhance communication and engagement of a community?  It is almost as if I had learned for the first time of the existence of DNA, had an intuitive understanding that it should be clinically important, but had no idea how to translate this knowledge into meaningful activity.

Regarding the first point – networks have properties – the authors introduce the uninitiated to an entirely new network descriptive language.  A network, that is, a collection of people plus the specific set and patterns of connections between them, must have something to spread, or a contagion.  The contagion can be an infectious disease, information, happiness, depression, obesity or wealth.  Members of a network vary in terms of their location (central versus peripheral) and connectivity (high or low transitivity).  The nature of the network impacts the pattern and efficiency of spread of the contagion.

The second point – networks have complexity – is equally well covered.  Imagine you are starting a new organization and you outline your communication plan to your board or investors.  As the leader and chief influencer, when you need to engage your organization you plan to talk to one person.  That person will be assigned to talk to one other person, who will talk to one other person, etc., etc.  This is essentially a “bucket brigade” network structure, where the bucket of water, or in this case information, is transmitted from one person to the next sequentially.  Clearly, your board is unlikely to be impressed by this plan.  Although simple, it is full of obvious weaknesses.  It is vulnerable to disruption, since if one person does not carry out his assigned task, the flow stops.  It is also likely the message will change slightly as it is carried forward, and is unlikely to survive in its intended form to the end of the chain.

This is a ridiculous example, which no one would seriously propose.  However, what we generally put in its place is a corporate organizational chart.  As chief influencer, now instead of talking to just one person, you talk to your five direct reports.  Each of them talk to their direct reports, who talk to their reports, etc., etc.  This has the advantage of increased efficiency compared to the bucket brigade, but the improvement is still marginal.  The message is still subject to at least partial transmission failure if one person in the chain fails to complete the task, and the message is still subject to change.  As nonsensical as the bucket brigade model seems, the slightly improved branching tree model is probably the most common organizational structure for businesses, hospitals and physician groups.

In fact, the real social networks, which underlie the “official” organizational chart, tend to be much more complex, and continually evolve in reaction to the environment.  There tend to be hubs of hyper-connected influencers whose behavior has a disproportionate impact on contagion flow.  Instead of laboring over the production of the perfect “org chart”, with the expectation that the ideal design will drive great communication and engagement, perhaps we should concentrate more on identifying those nodes of influence within a group and working hard to engage them.

Understanding the architecture and laws governing networks has the potential for great good.  If we can learn to understand and leverage network dynamics, perhaps weight loss, exercise, anti-smoking and anti-drug campaigns could focus on far fewer individuals with equal or greater results to broader population interventions.  Perhaps the historically slow spread of medical discovery to routine and widespread adoption into medical practice could be accelerated.   Connected is an engaging and thought provoking work, and well worth the time invested for anyone interested in more effective group dynamics in any sort of group -- doctors, nurses, students, patients, employees, etc.

Separated at Birth? Higher Education and Healthcare

A story in the Wall Street Journal last week made some concerning observations about colleges and universities in the United States. (Click here...WSJ subscription required) College tuitions continue to rise, consistently outpacing inflation. The majority of students cannot come close to paying the actual cost of a college education, particularly at private colleges. The funding gap is filled by a complex mosaic of grants, merit awards, need based financial aid and subsidized loan programs. A minority of students pays list price and helps to subsidize those who cannot pay. 

So here we have a socially critical service, access to which many would call a fundamental right. The list prices are steeply discounted for some, and costs shifted to others. In addition, the system depends on a complex stream of government subsidies that obfuscates the true cost to most consumers. If this sounds familiar, it should. This is part of the same dynamic facing the healthcare system, which caused me to wonder what other similarities are there between higher education and healthcare? Here are a few:

• National Love/Hate Relationship. We respect and admire our healthcare system. It is widely acknowledged we have the best “rescue” healthcare system in the world. That is, if you are critically ill and need a coronary artery opened quickly, or access to the latest chemotherapeutic agent for a rare cancer, you will receive treatment faster than anywhere else in the world. However, we are also uncomfortable that our national health outcomes do not justify our investment. We are unsatisfied with our average life expectancy and infant mortality rates. We have large disparities in deliver of care.   In higher education, we take pride in our institutions of higher learning as leading the world in innovation. However, at the same time we are uncomfortable that our outcomes are not what they should be – that other countries are surpassing the United States in areas critical for success in the future global economy. In particular, there is concern we are failing in the so called “STEM” disciplines – Science, Technology, Engineering and Mathematics. 

• Bubbles. The rate of healthcare inflation consistently outpaces the overall inflation rate year after year, making healthcare increasingly unaffordable. The same dynamic is true of higher education. In both cases, the consumer has been insulated from true costs of the service by fiscal intermediaries – in healthcare, free or subsidized insurance; in higher education, ready availability of subsidized loans. The separation of the service from true economic cost over decades has mitigated any power the invisible hand of the market might have had in creating a more sustainable system. In both cases, the public subsidy has grown to the point that it is probably unsustainable.

• Leadership. In healthcare, at least traditionally, physicians are culturally discouraged from assuming increased administrative responsibility. Colleagues, only half jokingly, talk about “going over to the dark side.” There is traditionally very little training in medical school or residency to prepare physicians for leadership roles in the healthcare system. Similarly, in higher education, administration is often viewed as a necessary evil. Advancement through academic leadership positions is sometimes viewed as a distraction from real academic work. Like healthcare, little is done to develop faculty to take on these roles. In both cases, the enterprises are entering a period of transformative change, with very little leadership bench strength.

• Outcomes are not entirely the system’s fault. To be sure, much of the criticism of the healthcare system is justified, and improvements are needed. However, even with “perfect” healthcare, there are other factors that almost certainly have a greater impact on the overall health of the country than the care delivery system. Environmental factors (pollution, absence of green space), genetics (some people appear genetically programmed for more severe disease) and behavioral factors (smoking, obesity, high risk behaviors) are far more critical determinants of health than access to medical care.  In higher education, although the system can clearly improve, it would be naïve to ignore other major determinants of outcome. Cultural, socioeconomic and early childhood developmental factors are clearly critical. It is no more realistic to expect the healthcare system alone to cure a long-standing diabetic, overweight, non-English speaking smoker than it is to expect a university to remediate a socially disadvantaged young adult who never learned basic principles of 8th grade math.

• “Why can’t you run this like a business?” In both healthcare and higher education, there are people in advisory and governance roles that have earned great success in a wide variety of private enterprises. There is often a feeling among these highly accomplished people that if healthcare (or higher education) just adopted sound business principles, our system would be fixed. That is true to a degree. Healthcare and higher education should be managed on a solid business foundation. However, the perverse economic dynamics of the industry, the belief that the service provided is a fundamental right and the resulting regulations to protect those rights creates dynamics you would not find in a typical business. It is unlikely a consumer would show up on a car lot, drive away in a car they cannot afford because they have real need of a car, with the promise that a third party may ultimately pay some fraction of the actual cost.

• Disruptive innovation. Both systems are facing disruptive innovators. In healthcare, Wal-Mart is progressively entering the primary care space. Radiographs can be interpreted by a radiologist on the other side of the planet at a fraction of the cost. In higher education, there has been rapid growth in for-profit colleges, with a heavy on-line emphasis. Massive Open On-line Courses (MOOCs) are attracting thousands of students to courses taught by the nation’s best instructors at little to no cost. No one can fully predict what this all will mean, but when high costs meet the public perception of poor quality or service, the disruptive niche innovators will not be far behind. 

• Shift in the international market. For the past half a century, people world-wide come to the United States for access to the most advanced care possible (and usually paid a premium for that access). They continue to come. However, the role of the global community has changed in the past few years. Many cognitively based tasks can be outsourced to countries with an educated workforce, like India. Specialty hospitals are springing up around the world, promising and delivering high quality outcomes and great customer service at a lower price. Medical schools and educational accreditors are expanding into international markets. In higher education, international students flock to universities in the United States for an exceptional educational experience. Although this continues, since the recession students have become more cost sensitive.  A small, but rapidly growing number are attending prestigious European colleges, where they can obtain an equally (at least) prestigious degree at lower cost than many public and private colleges in the US.

I am sure there are many more parallels. My sense is that both healthcare and higher education are on a trajectory headed steadily to transformational innovation. It also appears that healthcare is slightly further down that path. Hopefully, we will benefit from shared experiences.