Building Better Patients
Medical science is looking at ways to help the
“worried well” get beyond their obsession with symptoms
 Dr. Charles E.
Lewis has spent much of his career suggesting that efforts in this
country to promote health and prevent illness are failing, largely due
to the way in which physicians and patients are socialized. Primary care
physicians, for their part, are schooled according to a medical model of
treating maladies as they arise, rather than encouraging the preemptive
measures that might keep patients out of their offices in the first place.
And patients range from those who neglect vital preventive health services
— for example, women who don’t get regular mammograms or Pap smears — to
the “worried well,” who overutilize the system, wasting precious resources.
Where do patients learn how to be savvy health consumers? Lewis, professor
of medicine, public health and nursing, and director of UCLA’s Center for
Health Promotion and Disease Prevention, long ago suspected that consumption
patterns developed in early childhood persist into adulthood. His wife,
Dr. Mary Ann Lewis, a professor of nursing at UCLA whose background is
in pediatrics, concurred and suggested an experiment. In 1972, the Lewises
began a two year study at UCLA’s University Elementary School in which
313 children, ages 5 to 12, were encouraged to take responsibility for
their own health. Without asking for teacher approval, they were invited
to present a “care card” directly to the school nurse (Mary Ann Lewis)
whenever they deemed it necessary. Once the nurse had evaluated the problem
— assuming, as was almost always the case, that it did not require medical
intervention — the children were given an active role in deciding how the
problem should be resolved.
The child initiated care system produced utilization patterns mirroring
those of adults in prepaid health maintenance organizations. Seventeen
percent of the children made no visits to the nurse during the two year
period, while approximately 15 percent accounted for more than half of
all visits — a pattern not associated with any particular level of medical
problems.
The study also suggested certain shared characteristics among frequent
users, the significance of which would be amplified when Charles Lewis
followed up with the same population more than a decade later. All but
two of the 75 subjects who had made frequent visits as children were not
experiencing medically diagnosable symptoms when they reported to the nurse’s
office. However, these children tended to see themselves as being more
vulnerable to disease than their peers — and, perhaps not incidentally,
tended to suffer from measurably poor self esteem. Moreover, the two most
common reasons for visits were headaches and stomachaches, often related
to emotional discomfort traceable to classroom experiences. “The children
were able to properly identify the cause of their problems,” Lewis explains.
“They would tell the nurse, ‘I have a new math headache.’ They would typically
choose to lie down and rest for a while, then go back to the environment
that had produced the problem.”
In 1986, Lewis’ group conducted the follow up study in which more than
80 percent of the patients in the original groups were located and interviewed.
Of these 260 young persons, 71 percent later responded to a questionnaire.
Those who had been frequent visitors to the school nurse during the first
study were, almost without exception, frequent visitors to physicians as
young adults. Most of them were still complaining about headaches and stomachaches
— now accompanied by symptoms of depression.
The most profound result of the follow up, hinted at in the original
study’s findings, was a significant association between frequent care as
children and academic problems as young adults. More than half of the frequent-care-users
in the original group had failed to complete high school, or had not attended
— or had dropped out of — college, compared with only 20 percent of their
infrequently using peers.
Lewis conducted a similar study with a low income population of children
at a Pomona, CA, elementary school from 1974 ’75 and found the same patterns.
During that study’s second year, however, the school employed a social
worker who began holding group therapy sessions in which the real concerns
of the frequent users were addressed. As a result, their numbers dropped
quickly.
Lewis would now like to do a second follow up with the original study’s
subjects, most of whom are now in their 30s. “We need more longitudinal
studies of kids from the pre formal cognitive stage all the way into young
adulthood,” he says. Unfortunately, he notes, financial support for such
long term work is hard to come by. For the 1986 follow up, funding came
out of the researchers’ own pockets.
Meanwhile, other studies conducted by Lewis have confirmed that the
vast majority of physicians continue to treat only their patients’ immediate
complaints, without promoting healthy behaviors or addressing underlying
factors — which may include grown up versions of the “new math headache.”
— D.G.
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