Abstract
Interview with Dean Ornish, MD
Out of all of your accomplishments, which are you most proud of?
I guess probably being a good husband and father.
Now, specifically with regard to your career, out of all of your accomplishments, which are you most proud?
I would not limit it to one thing. First, I would mention the scientific research that I have completed with my colleagues. Our ability to use the latest high-tech, state-of-the-art scientific measures to prove the power of very simple low-tech and low-cost interventions, in not only preventing, but even reversing the progression of the most common chronic diseases, beginning with coronary heart disease, and type 2 diabetes, early stage prostate cancer, gene expression, the aging process itself as reflected in telomeres, really became the foundation for lifestyle medicine as a new discipline and helped provide the credibility and the scientific basis for it.
Equally important was ultimately being successful in getting Medicare to pay for our program, which was a 16-year journey in itself.
Through a 501(c)3 nonprofit institute that I started in 1984 when I moved here from Boston, called the Preventive Medicine Research Institute, we were able to conduct our randomized trials and demonstration projects showing that our lifestyle medicine approach worked to treat and to reverse cardiovascular disease. And then the next research question really became, “How practical is this? How scalable is this? Will it play in Peoria?” and so on. People often said to me, “Well, you live in California. It’s an altered state. They’ll do anything there.” So we wanted to see if people in other places would follow the program and benefit from it in the same way.
So we began training a total of 53 hospitals and clinics around the country. And we showed bigger clinical improvements, better adherence, and even larger cost savings than anyone had ever shown before. We had 85% to 90% adherence. We also showed impressive savings. Mutual of Omaha in the first demonstration project found they saved almost $30 000 per patient. In the second demonstration project, Highmark Blue Cross/Blue Shield found that they cut their overall health care costs in half in the first year and by 400% in the subgroup of people that they had spent at least $25 000 dollars on in the preceding year.
And yet, with all of that success, a number of the sites closed down. And they all said the same thing, “This is the best program we’ve ever had. And we have to close it down, because you don’t have reimbursement, you don’t have Medicare, you have some insurance companies, but not most.” And the painful lesson was that, if it’s not reimbursable, it’s not sustainable. So that set me off on the journey to see if we could achieve Medicare coverage for the program, which, after 16 years, we did, for which I remain deeply grateful.
That was a real game-changer, because if it’s reimbursable, not only is it sustainable, but we doctors do what we’ve been trained to do, and we get trained to do what we get paid to do. So if you change reimbursement, you change not only medical practice but even medical education. And then it becomes sustainable. And now that Medicare is paying for these lifestyle medicine programs, many of the other commercial insurance companies like Blue Cross/Blue Shield and Anthem and Aetna and HMSA and others are paying for it.
We’re really creating a new paradigm of health care that’s a lot more fun for doctors and other health care professionals to practice. With the current system in a managed care environment, if you have to see a new patient every 8 to 10 minutes, you really don’t have time to talk about the things that matter most. You listen to the heart, lungs, talk to the patient for a moment, get their chief complaint, write a progress note, write a prescription, and you’re off to the next patient. It’s profoundly unsatisfying for both doctors and patients. That’s why most doctors wouldn’t recommend medicine as a career for their kids, why they’re trying to get out of the field. They’re selling their practices to hospitals. We have among the highest rates of divorce, drug addiction, and suicide of any identifiable groups.
Now, we have a new paradigm, where Medicare is paying for 72 hours of training as opposed to 8 or 10 minutes, and the doctor’s the quarterback. We work with a team consisting of the doctor, the nurse, the stress management instructor, which is a certified yoga meditation teacher, exercise physiologist, registered dietician, and clinical psychologist. Medicare will pay for 72 hours, which we divide into 18 four-hour sessions. This way, patients get an hour of supervised exercise, an hour of yoga and meditation, an hour of a group meal with a lecture, and an hour of a support group, which is really more than a support group because it’s creating a safe environment where people can bond very deeply by being open and authentic with each other.
The doctor is ultimately responsible for everything, but it doesn’t take an inordinate amount of their time. And since doctors receive very little, if any, training during medical school in nutrition, meditation, or emotional support, they can use their time wisely to do what they were trained to do in medical school and delegate the other aspects to the rest of their team. It’s a profoundly satisfying and rewarding way, both economically and emotionally, and even spiritually, to practice medicine this way. With this lifestyle medicine intervention model, now we can go back to the spiritual roots of why people went into medicine. Most people went into this field to help people deal with the underlying causes of why they get sick, and to transform suffering into healing and joy, which is incredible.
What’s your next step in your career?
Well, professionally there are several things we’re doing. Now that Medicare and other insurance companies as well as commercial carriers are paying for the program, it enables us to perform large-scale studies at a fraction of the cost and the time that it would otherwise take.
Now, we can measure outcomes in much larger groups of people who make these lifestyle changes. We can take a closer look at cost savings and adherence.
Most of these large-scale studies can be extremely expensive. The Women’s Health Initiative was at least a billion dollars, and maybe as much as two. And yet it didn’t really show that much, because they had a hard time getting the women in the experimental group to change their lifestyle as much as they wanted them to. Also, people in the control group changed more than the experimenters wanted. They couldn’t tell them not to, because there’s so much information out there. So that really diluted the differences between the groups. And they really weren’t able to show much at the end.
Whereas what we’re doing is we—because the expensive part of any of these studies is the intervention, which is now paid for by Medicare or commercial carriers, we—can piggyback onto that and look at interesting research questions in large numbers of people at very low cost and very quickly. And because we have 72 hours to train and support them, we can achieve much bigger changes in lifestyle than in the Women’s Health Initiative or similar studies.
So, for example, we’re collaborating with Stan Hazen at the Cleveland Clinic to measure TMAO levels in the people who go through our program. And so, from our standpoint, we can work with the best person in the country to do these studies, and we can publish them together. From his standpoint, he gets access to people who are making much more intensive lifestyle changes than they did in the Women’s Health Initiative, for example. So we’re likely to see much bigger differences in outcomes. We’re working with Dr Elizabeth Blackburn, who got the Nobel Prize for her pioneering work with telomeres. We did a study earlier with her. And it is still the only controlled study showing that any intervention can actually lengthen telomeres, in a sense reversing aging in a cellular level, which we published in The Lancet Oncology. Now, we can measure changes in telomeres in much larger groups of people.
We can measure results in much larger groups of people who make these lifestyle changes, and then we can look at cost savings and adherence. We’re still getting 87% to 90% adherence in all of the various sites we’ve trained.
Another goal I have is to continue to iterate on this new paradigm of clinical medicine—lifestyle medicine—that we’re developing, and make that better and better based on more and more experience doing this.
Third, I’m interested in doing additional randomized trials, for example, to look at Alzheimer’s disease. Dale Bredesen at UCLA did a pilot study of a version of our program with 10 men and women who had early to moderate dementia. Nine of the 10 people showed significant improvement in cognitive function in just 60 to 90 days. I’d love to do a randomized trial to see if we could stop or reverse the progression of men and women with early Alzheimer’s disease.
Fourth, I plan to write another book. I enjoy trying to find new ways to make it easier for people to make and maintain lifestyle choices that it can be so transformative. I’m medical editor of the Huffington Post. They had over 100 million unique visitors last month. So it’s a great platform. I write a periodic column for Time Magazine. I’m a LinkedIn influencer. So that provides different formats and forums to reach large numbers of people with information that can really empower and transform their lives for the better. Having seen what a powerful difference these lifestyle changes can make, I’m always looking for leverage points where we can influence things for the better, as well as empowering people and making it easier for them to make, maintain, and incorporate these changes into their own lives.
My wife and partner, Anne Ornish, created and produces our website—Ornish.com—which includes a lot of valuable resources, including instructional videos on cooking, yoga, meditation, and exercise, as well as pdf reprints of our research, an online community, recipes, menus, and more that can make it easier for people to make and maintain these changes. Everything on there is free.
Who is your hero?
I have many heroes. My wife, Anne, is my hero right now. She has this amazing quality of making everyone and everything that she comes into contact with feel and look beautiful. She embodies extraordinary grace in everything that she does. We’ve worked together for almost 20 years, and I still learn something new from her almost every day. She’s as brilliant and loving as she is beautiful.
What words of advice would you give to lifestyle medicine practitioners trying to make a living with their practicing of lifestyle medicine?
Well, again, that’s part of the reason that I spent 16 years working with Medicare, and a lot of time with the commercial insurance companies, to get reimbursement, because I didn’t want this just to be concierge medicine or medicine for the affluent, I wanted this lifestyle medicine to be for everyone. The components of the lifestyle program don’t really cost anything. I designed it that way, so you don’t need any special equipment. You just need a pair of walking shoes and a yoga mat (or a carpeted floor). The diet is inexpensive as well as it is essentially a third world diet.
Government subsidies of unhealthy foods are part of the nutrition and poor diet problem in our country. When I consulted with the CEO of McDonalds in 1999 and 2000, I was able to persuade them to put salads on the menu. But, because the burgers were subsidized and the salads were not, the burger was 99 cents, and the salad was $5.95. So if you’re on a fixed income, you get a lot more calories for your dollar by eating junk food, because (a) the unhealthy foods are subsidized and (b) it doesn’t really price into it the real cost to your health and to society.
Working on a legislative level is something that I’m also trying to do, to see if we can change these things. But for me, the opportunities are worth it.
To the extent we can train lifestyle medicine practitioners and certify them, then they get the Medicare coverage and can make a living by practicing the medicine they want to practice. But also, as we move to the era of accountable care organizations, integrated delivery networks, Obamacare in general, whatever people think about it, it’s turning all of the incentives on their ear. In a fee-for-service environment, the more operations, the more stents, the more angioplasties, and the more hospitalizations, the more money is generated for the doctor or for the hospital or both.
Now we move into the era of bundled payments: here is X amount of dollars to take care of a group of patients, and the doctor, the hospital, or the clinic can keep what’s left over. In this new model, the fewer procedures you do, the more revenue is generated. Although I’ve been doing this work for almost 40 years, I’m encouraged because there’s a convergence of forces that’s really like a tipping point. It’s the right idea at the right time.
On one hand, the limitations of drugs and surgery are becoming increasingly clear. For example, a series of randomized controlled trials has shown that angioplasties and stents don’t work in most stable patients. Getting your blood sugar down with drugs if you have metabolic syndrome or type 2 diabetes doesn’t work nearly as well as getting it down with diet and lifestyle, in terms of preventing the complications and premature death from type 2 diabetes. Studies have shown that only about 1 of 49 men who have early stage prostate cancer benefit from surgery or radiation. The other 48 who undergo radical prostatectomy or radiation often get maimed in the most personal ways if they become impotent or incontinent, or both, for no benefit and huge economic cost. We can provide a third alternative. We conducted a randomized controlled trial showing that this comprehensive lifestyle medicine intervention may slow, stop, or even reverse the progression of early stage prostate cancer.
In summary, my advice is to consider getting trained in a lifestyle medicine program that works, has been proven in multiple randomized controlled trials, and has reimbursement.
Is there someone in your professional life that influenced the trajectory of your career?
Two people had a major influence in my life. The first was Swami Satchidananda, who I first met in 1972. Much of what I’m doing professionally and personally is based on things that I learned from him. This idea of lifestyle as treatment really came from him, and the idea of addressing the underlying cause of the problem also came from him. The components of my program, including a whole foods plan-based diet, exercise, yoga, and meditation, as well love and support, all derive from what I learned from him. I also learned a lot from my own suffering when I was in college. That suffering helped me learn how, when someone’s in pain, there’s an opportunity for transformation. Because change is hard, but if you’re hurting bad enough, you say, “Well gosh, that may be kind of weird or different or hard. But since I’m hurting so badly, let me try this stuff.” And because the underlying biological mechanisms are so dynamic, most people feel so much better, so quickly, it reframes the reason for changing from fear of dying to joy of living. People often look back on their crisis or their suffering as something that was a blessing in disguise in many respects because it got their attention and motivated them to make these changes that they might not otherwise have done.
Dr Alexander Leaf also had a major influence on my life. He was chief of medicine at Harvard and at the Massachusetts General Hospital when I trained there, and he became a mentor and a lifelong friend until he passed away last year.
Who do you consider the best teacher?
I think the best teacher is a good example. And if we can embody the core values that we teach others, and people see that, they learn. I studied with Swami Satchidananda for so many years, and we talked once a week for decades. He embodied his teachings. He used to tell a story about a convention of unlit candles, arguing about whether or not light exists. There were big candles, small candles, and expensive candles holding heated debates about whether or not light exists. And then, this tiny little birthday candle walks in. It’s lit. Then, the whole room turned around and looked toward the light. That’s all it takes. So, to the extent that we can really let our light shine and embody the principles we are teaching, people can feel our light when they’re around us. Then, they want to learn. They will ask, “So what did you do? And how come you look so good? And how come you feel so good? And how can I get some of that?” That opens the door to them. But otherwise, we become like a room full of unlit candles, you know, preaching about why light is such a good thing. Obviously, I don’t embody every principle of lifestyle nearly as well as I would like to, but it becomes aspirational and becomes a guiding principle. To the degree we change our lifestyle, there is a corresponding benefit. It’s a process. And, unlike so much of what we’re trained to do as doctors, the only side effects are good ones.
Footnotes
These articles are based on The Annual Conference of the American College of Lifestyle Medicine (ACLM) held November 1-4, 2015, in Nashville, Tennessee—Lifestyle Medicine 2015: Integrating Evidence into Practice.