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Friday, June 22, 2012



LIFESTYLE RISK FACTORS PREDICT DISABILITY AND DEATH IN HEALTHY AGING ADULTS [THE 15TH MAJOR LIFESTYLE STUDY]For the development of my "Formula for Health" I had collected 13 major observational studies and 1 RCT to support the synthesis of lifestyle essentials into just 5 lifestyle factors. These were cited in my Editorial in American Family Physician in 2010. Now it is time to add a new observational study to the list.(1)
        "[The] [p]ositive health effects of maintenance of normal weight, routine exercise, and nonsmoking are known for the short and intermediate term." These investigators studied the effects of these risk factors into advanced age. They collected data from 2,327 college alumnae aged 60 years of more who were followed annually (1986-2005) by questionnaires addressing health risk factors, history, and Health Assessment Questionnaire disability. Mortality data were ascertained from the National Death Index. Low-, medium-, and high-risk groups were created on the basis of the number (0, 1, > 2) of health risk factors (overweight, smoking, inactivity) at baseline. The medium- and high-risk groups had higher disability than the low-risk group throughout the study (P , 0.001). Low-risk subjects had onset of moderate disability delayed 8.3 years compared with high-risk subjects. Mortality rates were higher in the high-risk group (384 vs 247 per 10,000 person-years). The authors conclude: "Seniors with fewer behavioral risk factors during middle age have lower disability and improved survival. These data document that the associations of lifestyle risk factors on health continue into the ninth decade."
COMMENT: We already knew this, at least for elderly Europeans (aged 70-95 years) from the HALE Study which looked at 4 factors (not smoking, Mediterranean diet, exercise, and some consumption of alcohol. The benefits observed in the HALE study were truly dramatic-- 61-64% reductions in coronary and peripheral vascular mortality, 36% reductions in cancer (of all causes), and a 60% reduction in all-cause mortality. [It's OK to gasp.]
        So how much more data will it take before something like the "Formula for Health" becomes the cornerstone of all primary care--from cradle to grave? (Of course, it is NOT a data problem. Those who could be persuaded by data WERE persuaded a long time ago. For the rest, the data are irrelevant. It will probably take until ALL of the MONEY runs out to pay for procedures, tests, and medications before we give primary prevention a chance.
REVIEWING THE "FORMULA FOR HEALTH": DOES ADVICE TO EXERCISE WORK?  Of course, it does, but it's hard to prove. For this reason the USPSTF has dismissed physician counseling for exercise to the trash bin of "insufficient evidence," which I have always considered unfair. "The USPSTF found insufficient evidence to determine whether counseling patients in primary care settings to promote physical activity leads to sustained increases in physical activity among adult patients. Controlled trials of physical activity counseling in adult primary care patients were of variable quality and had mixed results. There were no completed trials with children or adolescents that compared counseling with usual care practices." [Not updated since 2002]  While we have to make concessions to the fact that the studies are few, small, often uncontrolled, and generally use suspicious "self-reported" amounts of exercise as outcomes, the remarkable thing is that a few minutes of physician or practice time, whether face-to-face or by phone or by class, makes a difference; the trend among studies is phenomenal. And, all of the lifestyle studies with their more global perspective identify exercise as a key component of a healthy lifestyle that is associated with the dramatic improvements in outcomes as mentioned above.
        The British are far more pragmatic and ultimately more fair, and with good reason. The BMJ has just published a systematic review of physical activity promotion based in primary care and found that it significantly increases physical activity levels at 12 months.(2) A prior meta-analysis of cohort studies found that self reported achievement of the official UK exercise goal (150 minutes of moderate intensity activity each week) was associated with a 19% reduction in the rate of all cause mortality, compared with sedentary behavior.(3) In the UK only 39% of men and 29% of women achieve this goal (2008).  A Cochrane review of interventions to promote physical activity in community dwelling adults showed a moderate effect on self reported physical activity and cardiorespiratory fitness at a minimum of 6 months of follow-up.  In addition, similar brief interventions have previously been shown to reduce smoking and alcohol use. One of the major problems with previous studies on exercise are that reviews included non-randomized trials and trials with short follow-up duration. Since the USPSTF recommendation (2002), however, there have been several large trials of physical activity promotion based in primary care with outcomes data after at least 12 months. It is time to take a fresh look. [Shame on you, USPSTF!]
        These investigators found a total of 15 relevant randomized controlled trials with 8745 subjects. Most interventions took place in primary care, included health professionals in delivery, and involved advice or counseling given fact to face or by phone (or both) on multiple occasions. In the 13 trials presenting self-reported physical activity, there were small to medium positive intervention effects as 12 months (OR, 1.42). The number-needed-to treat for one additional sedentary adult to meet internationally recommended levels of activity as only 12 (7-33). These are very positive results.
        Here are some other noteworthy aspects of the data to consider:
  1. The authors could find no unpublished studies on brief interventions to promote exercise. Funnel plots of their pooled data did not suggest any publication bias.
  2. A planned subgroup analysis showed significantly larger intervention effects on self reported activity in studies where control participants received no intervention than where they received a lesser comparator intervention. This analysis suggests that the observed positive effect on exercise levels may be underestimated as it appears that the comparator interventions themselves had positive effects. "The additional percentage of participants who reported meeting international activity recommendations at 12 months, compared with baseline, was 11-47% in participants allocated to receive an intervention, and 8-47% in those allocated to receive a comparator intervention. The corresponding range for those allocated to receive no intervention was from -2% to +19%. These findings suggest that briefer interventions, as used in the comparator groups, might achieve effects that are similar to those of more intensive interventions." 
  3. Only one study reported an objective measure of physical activity level as an outcome, and in this study it was not significantly different. The authors call for more studies with an objective measure of outcome.
  4. Only one study found a significant intervention effect on adverse events, reporting a relative 11% increase in falls and a 6% increase in injuries among intervention participants.
  5. Since follow-up was limited to only 12 months in most trials, the effect of the exercise intervention of diabetes, cardiovascular events, or mortality could not be assessed.   
COMMENT: The USPSTF has been way too timid. They are missing the forest for the trees. Promoting exercise should be consider one of the absolute core activities of primary care practice. It's not. The USPSTF could be helping. It is not.
WALKING TO SAVE YOUR MINDThe Japanese have conducted a trial to evaluate the efficacy of a municipality-led walking program under the Japanese public Long-Term Care Insurance Act to prevent mental decline.(4) These data are from the program in the city of Takasaki. One hundred fifty community members aged 72.0 =/- 4 were randomly divided into intervention and control groups. A walking program was conducted once a week for 90 minutes for 3 months. The program encouraged participants to walk on a regular basis and to increase their steps per day gradually. The intervention was conducted in small groups of approximately six in order to obtain possible benefits in both exercise and social interaction. Cognitive function was measured using 9 tests in 5 domains: memory, executive function, word fluency, visuospatial abilities, and sustained attention. Quality of life, depressive state, functional capacity, range of activities, and social network were also assessed as well as motor function. There were significant differences between the intervention and control group in word fluency related to frontal lobe function (P=0.01), quality of life (P=0.002), functional capacity including social interaction (P < 0.001), and motor function (Timed Up and Go Test; P=0.002). COMMENT: As opposed to the "do nothing" attitude of the USPSTF, this is the kind of program we should be starting in our practices. Get every staff member (including a stint for yourself!) to lead a group at different hours during the day. I had a resident a few years ago (my esteemed Chief Resident at Santa Rosa, Dr. Serena Brewer, Touro graduate) who designed a project to do just this in a residency clinic setting. It would even reimburse well (if a provider spent some face-to-face time with each patient). You know what doomed it in this setting? The supporting hospital's fears of potential legal liability in the case that a patient might slip and fall. Sigh. We have to do better than this.
HOW OFTEN SHOULD I EXERCISE, DOC? The answer from Joseph Alpert, MD [Editor-in-Chief of American Journal of Medicine] is "Only on the days you eat."(8) His full answer is: "Our DNA heritage with its highly complex biochemical and physicological processes is appropriate to a very active lifestyle, not a modern 21st centruy couch potato, fast-food existence. Consdequently, we should make every effort to include elements that resemble the Paleolithic lifestyle [of our ancestors] in our modern daily existence. My lifestyle includes daily exercise, lots of fruits and vegetables in the diet, and avoidance of heavily engineered snack food. Of course, I also do not smoke tobacco nor do I consume large quantities of alcohol. I recommend these liefstyle elements to all my patients. When friends or family ask, 'How often should I exercise?' my answer is always 'Only on the days you eat.' That seems to get the message across." COMMENT: It's a shame that he didn't mention relaxation or stress reduction. But perhaps that is not an option for the Editor in Chief of American Journal of Medicine. 
ANOTHER ASIAN STUDY: AS LITTLE AS 15 MINUTES OF EXERCISE EACH DAY MAY PROLONG LIFEA prospective cohort study from Taiwan examined the association between physical activity and mortality.(5) In this study, people who did as little as 90 minutes of exercise each week (who would ordinarily be considered physically inactive) were analyzed as a separate group. Around 12.5% (28,311 of 226,493 subjects) of those who exercised at all did so for about 15 minutes of 6 days a week. The study followed up for an average of 8 years more than 400,000 people who underwent regular health check-ups. Compared with people who exercised very little, those who did not exercise at all had a 17% higher risk of dying from any causes, and an 11% higher risk of dying from cancer. Each extra 15 minutes of daily exercise was linked with a 4% reduction in the risk of dying from any cause, and a 1% lower risk of cancer related death. The results held in both sexes, regardless of age, smoking and drinking habits, and overall risk of cardiovascular disease. The authors conclude that, at age 30, men who exercised for 15 minutes each day on average could expect to live 2.6 years longer than their peers who did not exercise at all; women could expect 3.1 years of extra life. Among 30 year olds who met the recommendations for physical activity--30 minutes exercise on 5 days a week--men could expect to live 4.2 years longer and women 3.7 years longer, compared with their physically inactive peers.

1.  Chakravarty EF et al. Lifestyle risk factors predict disability and death in healthy aging adults. Am J Med 2012; 125: 190-197.
2. Orrow G. et al. Effectiveness of physical activity promotion based in primary care: systematic review and meta-analysis of randomised controlled trials. BMJ 2012; 344:e1389 doi: 10.1136/bmj.e1389 (March 26, 2012).
3. Woodcock J et al. Non-vigorous physical activity and all-cause mortality: systematic review and meta-analysis of cohort studies. Int J Epidemiol 2011; 40: 121-38.
4. Maki Y et al. Effects of an intervention using a community-based walking program for prevention of mental decline: a randomized controlled trial. J Am Geriatr Soc 2012 Mar; 60(3): 505-10. doi: 10.1111/j.15
5. Wen CP et al. Minimum amount of physical activity for reduced mortality and extended life expectancy: a prospective cohort study. Lancet 2011; 378: 1244-53.

Tuesday, June 12, 2012



GLASSES UP! A COCKTAIL TO ROUND UP YOUR LIFE:  As you know (perhaps ad nauseam) my approach to maximizing the lifespan (i.e., reducing all-cause mortality) is to follow The Formula for Health: 0 cigarettes, 5 servings of fruits & vegetables a day, 10 minutes of relaxation a day, maintaining a BMI < 30, and getting 150 minutes of exercise each week. Now these researchers have done me one better. They offer a cocktail of 30 ingredients to delay aging and extend the life span.(1) The data are preliminary but very positive (i.e., in mice). The thesis makes perfect sense. We have learned that health is always multifactorial and never attributable to a single factor. The reason that the Okinawans live so long is that there diet has little meat but contains more than 15 different kinds of fruits and vegetables each day. These investigators have further refined the nutrition essentials to go beyond a simple one-a-day multivitamin (which, prior to this I enthusiastically supported).
        This nutrient cocktail was developed by Dr. C. David Rollo and colleagues at the McMaster University in Canada. It was not a simple ad hoc formulation, but was strategically selected to address the five key mechanisms of aging. 
oxidative stress
mitochondrial dysfunction
insulin resistance
loss of membrane integrity
"No single mechanism alone accounts for any one specific disease process. Instead, all five mechanisms interact with one another to produce both general aging and specific conditions that limit activity, cognitive function, and ultimately lifespan...All animals, from worms to insects to humans, change in very similar fashions as they succumb to the five key mechanisms of aging."  Dr. Rollo and colleagues studied the impact of these nutrients on laboratory mice because of their short normal life span." (A mouse is considered 'old' by age 2 years.) They sought to study measures that would apply equally to mice and humans. They chose to focus on how much the aging animals moved and how their cognitive function changed with time. 
        "As they grow older, all animal species move about less and less each day, spending more and more time at rest or in sleep. Reduced mobility is an excellent marker of aging, because it is closely linked to overall metabolic rate, feeding, fat storage, brain neurotransmitter levels, mitochondrial function, and cardiovascular and skeletal muscle systems...[L]loss of mobility in humans is associated with muscle wasting, bone thinning, and other changes that increase the risk of other negative outcomes such as fractures, pneumonia, and skin infections. Cognitive function also declines with age in all animal populations. Younger animals typically learn faster, requiring fewer repetitions to master a task. They can also bring up important memories faster and more accurately, allowing them to find food, escape threats, and protect other members of their species. Studies show that preserving cognitive function into older ages is associated with longer life spans."
       In the study, the 30-ingredient cocktail was soaked into small pieces of bagel. For the longevity study they used both normal mice and a special strain that demonstrates accelerated aging as a result of excessive sensitivity to all five aging mechanisms. Compared with control animals, the supplemented mice of the accelerated aging strain lived 28% longer. Supplemented normal mice survived 11% longer than controls. For the mobility component of the study the investigators placed the mice in a system of transparent chambers, where they were given food, water, and an exercise wheel; they recorded the amount of time each animal spent moving about the enclosure over a 24-hour period. "Normal, unsupplemented mice showed a progressive decline in activity; by 24 months their mobility was roughly half that of younger normal animals. By 24 months of age, supplemented normal mice were moving roughly three hours more per day than were unsupplemented animals. No other treatment has ever been found that ameliorates declining mobility to this extent."
        Dr. Rollo's group also measured biochemical markers that might explain the difference in mobility. Supplemented older mice had increased activity of the neurotransmitter dopamine (decreased dopamine levels are associated with loss of movement in aging humans and in Parkinson's disease). They also had increased measures of mitochondrial activity, "suggesting that supplemented animals simply had more energy as they aged." Finally, they measured decreased levels of protein corbonyls--altered molecules that reflect the impact of glycation and oxidation on cells and tissues.
        To assess cognitive outcomes they  tested the mice on a water maze that required the animals to find and remember the location of a platform submerged just below the surface of a pool filled with waters. This test is an indicator of both learning skills and memory. They repeated this test each day for 5 days. At first all of the animals had difficulty finding the platform taking an average of 81 seconds. By day 5 young mice had learned and remembered enough to find the platform 43% faster than on day 1. "Older unsupplemented mice, however, showed no significant improvement in the time it took them to find the platform, indicating age-related impairments in learning and memory. But with supplementation, old mice showed a level of learning almost identical to that of young mice; in fact on day 5 they took an average of 46% less time to find the platform than they did on day 1. In other words, supplemented old mice showed the same ability to learn and remember new tasks as did young animals." In the related biochemical observations they noted that brain mitochondrial activity fell steadily with age in the untreated mice, while supplemented animals showed a steady increase in this measure of brain energy supply; mice with higher brain mitochondrial activity proved to be significantly better learners than those with lower mitochondrial activity; and brain weights, which normal decrease with age, were higher in supplemented male mice by 7%, and in females by 11%, compared with brain weights of control animals.
        The editors of Life Extension Magazine (free 3 month trial subscription available at this link: summarize the article as follows:
  1. "Aging is a complex, multifactorial process, but five major mechanisms are now known to account entirely or in part for most human age-related diseases.
  2. Dr. Rollo and colleagues have developed and tested successfully in mice a 30-nutrient supplement mixture designed to attack all 5 mechanisms of aging.
  3. Tested in mice, the supplement mix extends life span by up to 28% while improving the aging animals' mobility and cognitive function.
  4. All 30 ingredients are known to be safe and effective in human beings.If this mixture, or one like it, has similar effectiveness in humans, one could expect an 80-year-old to add nearly 9 years of life with youthful levels of activity and cognition."
Anyone interested?
And, of course, here is the prize. The 30 ingredients of the cocktail are:

Oxidant stressInflammationMitochondrial functionInsulin resistancemembrane integrity
B vitamins (B1, B3 (niacin), B6, B12,and folate.x
Vitamin Cx

Vitamin D

Alpha-lipoic acidxxxx



Chromium picolinate

Ginger root extractxxxxx
Ginkgo bilobax

Green tea extractxx




N-acetyl cysteinex

Potassium    x


Vitamin Ex

Cod liver oil (omega-3)

Coenzyme Q10xxx

Flax seed oil

COMMENT:  In my opinion this list makes complete sense. Over the years in my newsletters I have reviewed favorably 28 of the 30 ingredients as having important preventive benefits; the only ones that are new to me are rutin and manganese. The table above suggests particularly potent health benefits from garlic, ginger, selenium, and ginseng
        One of the important trends in medicine is the evolution of the 'polypill' principal. The original 'polypill' published by Wald & Law in the British Medical Journal 2004 consisted of a recommendation for universal consumption, starting at age 50, of an aspirin, folic acid, a statin, and 3 antihypertensive agents (regardless of baseline blood pressure) in half their usual starting doses. The imputed benefits were a greater than 80% reduction in heart disease and stroke. Then came the healthy lifestyle literature starting with the Hale Study focusing on a recipe of no smoking, regular exercise, a Mediterranean diet (which contains a lot of the ingredients above), and any intake of alcohol; the reported benefits for these elderly subjects over 10 years were a 60% reduction in mortality over, a 64% reduction in coronary heart disease, a 61% reduction in cardiovascular disease, and a 60% reduction in cancer. On the lifestyle front, I further refined a healthy lifestyle to my "Formula for Health" with the imputed benefits listed below:
This article takes the evolution of this concept yet one more step farther. Expect to see much more of this in the future.
WHAT IS THE BEST WAY TO DISPOSE OF OLD MEDICATIONS?  This is an important and very practical concern. The 'experts' have previously led us to believe that to dispose of medications with minimal damage to health and the environment, they should all be dropped off somewhere (like your local pharmacy) to be incinerated. The exception to this was a previous FDA recommendation that the following medications could be flushed down the toilet:
Abstral, tablets (sublingual)Fentanyl
Actiq, oral transmucosal lozenge *Fentanyl Citrate
Avinza, capsules (extended release)Morphine Sulfate
Daytrana, transdermal patch systemMethylphenidate
Demerol, tablets *Meperidine Hydrochloride
Demerol, oral solution *Meperidine Hydrochloride
Diastat/Diastat AcuDial, rectal gelDiazepam
Dilaudid, tablets *Hydromorphone Hydrochloride
Dilaudid, oral liquid *Hydromorphone Hydrochloride
Dolophine Hydrochloride, tablets *Methadone Hydrochloride
Duragesic, patch (extended release) *Fentanyl
Embeda, capsules (extended release)Morphine Sulfate; Naltrexone Hydrochloride
Exalgo, tablets (extended release)Hydromorphone Hydrochloride
Fentora, tablets (buccal)Fentanyl Citrate
Kadian, capsules (extended release)Morphine Sulfate
Methadone Hydrochloride, oral solution *Methadone Hydrochloride
Methadose, tablets *Methadone Hydrochloride
Morphine Sulfate, tablets (immediate release) *Morphine Sulfate
Morphine Sulfate, oral solution *Morphine Sulfate
MS Contin, tablets (extended release) *Morphine Sulfate
Nucynta ER, tablets (extended release)Tapentadol
Onsolis, soluble film (buccal)Fentanyl Citrate
Opana, tablets (immediate release)Oxymorphone Hydrochloride
Opana ER, tablets (extended release)Oxymorphone Hydrochloride
Oramorph SR, tablets (sustained release)Morphine Sulfate
Oxecta, tablets (immediate release)Oxycodone Hydrochloride
Oxycodone Hydrochloride, capsulesOxycodone Hydrochloride
Oxycodone Hydrochloride, oral solutionOxycodone Hydrochloride
Oxycontin, tablets (extended release) *Oxycodone Hydrochloride
Percocet, tablets *Acetaminophen; Oxycodone Hydrochloride
Percodan, tablets *Aspirin; Oxycodone Hydrochloride
Xyrem, oral solutionSodium Oxybate
        By this time, fortunately, we have the benefit of a little experience with such guidelines and thoughtful review.(2)  The problem remains that American homes are filled with unused prescription drugs. "Each year we squirrel away 200 million pounds of pharmaceuticals we don't need anymore." Flushing or trashing drugs was the traditional means of disposal for decades, but in recent years take-back programs have been encouraged. The DEA has organized four nationwide take-back events since 2010. The most recent, in late April, collected more than 500,000 pounds of unwanted medications.        Flushing has fallen out of favor for all but a handful of drugs (see above) because of concerns about water contamination. Also we have data from Sweden that participation in take-back programs tends to stagnate at around 40%. New research, however, from the University of Michigan concludes that trashing drugs may be the most environmentally-friendly option. The researchers looked at the overall environmental impact of 3 disposal methods--flushing, trashing, and incineration. They analyzed how much of the drugs would enter the environment, emissions impacts from transportation, water treatment, and burning of waste materials. Their results show that flushing allows the highest levels of drugs to enter the environment by far, and creates more pollution than trashing. Drugs collected by take-back programs are incinerated, which means that none of the medicines themselves enter the environment, but these programs produce much greater emissions of green house gases and other pollutants than either flushing or trashing. This is mostly because consumers have to travel to a drop-off point and then the collected drugs are shipped somewhere else for incineration. The investigators suggest that home disposal is beneficial because we already have an infrastructure for collecting household trash. If our take-back programs are no more efficient than the Swedish programs, then our take-back program produces three times as much pollution while allowing about the same amount of drugs ultimately to reach the environment as home disposal in the trash. COMMENT: This suggestion makes a lot of sense. While the intention of take-back programs was to spare the environment, unless you take a more global perspective, you may be doing more harm than good. I, for one, appreciate being able to put my drugs back in the trash.

1.  Life Extension Magazine. May 2012. Nutrient 'Cocktail' Delays Aging and Extends Life Span.
 This article was brought to my attention by reader Phawda Moore.
2. Trash can may be greenest option for unused drugs. accessed 9:53 am, May 18, 2012.

Wednesday, June 6, 2012




     Almost all health care organizations are obsessed by patient satisfaction as an outcome measure. But think about it. Does a satisfied patient necessarily mean that the care was either good or effective? Patient satisfaction is well known to reduce law suits (if they like the doctor they are less likely to sue him/her), but it is also well known that patients who have liked their doctor over time are less likely to sue even if an egregious mistake was made. Patient satisfaction is really just a subjective measure of a brief interaction. It is more sensitive to process problems like long waits, rude staff, doctor in a hurry, etc., which cumulatively can undermine the quality of care. But actually there is very little a patient can discern about whether his/her doctor was right, efficient, or cost-effective in his/her care. So is it enough just to measure the subjective quality of the experience? Do we have to give up on trying to understand anything about the 'quality' of the care?  These questions are worth much further thought. This recent article provides that and comes to a surprising conclusion.(1)
    These authors conducted a prospective cohort study of 51,946 adult respondents to the 2000-2007 national Medical Expenditure Panel Survey. Patient satisfaction was assessed using 5 items from the Consumer Assessment of Health Plans Survey. The positive correlate of patient satisfaction (in the highest quartile group) was a lower odds of any emergency department visit (OR 0.92; 95% CI, 0.84-1.00), which is a good thing. On the other hand, however, this group had higher odds of an inpatient admission (OR 1.12), 8.8% higher total health expenditures, 9.1% higher prescription drug expenses, and higher mortality (OR 1.26, 95% CI, 1.05-1.53).
    These findings are not completely out of line with limited prior research. Among a vulnerable older population, patient satisfaction had no association with the technical quality of geriatric care;(4) other evidence suggests that satisfaction has little or no correlation with Health Plan Employer Data and Information Set (HEDIS) quality metrics.(2,3) [Original References 3, 7, and 8] There are other data to suggest that physicians whose compensation is more strongly linked with patient satisfaction are more likely to deliver discretionary services (e.g. advanced imaging for acute low back pain).(5)
     It is not certain what is going on here. Physicians may be just trying to keep patients happy by ordering tests, medications, and hospitalizations that are not really necessary. On the other hand, sicker patients may develop closer long-term, more satisfied, relationships with physicians who order appropriate tests and services. But the 26% greater mortality in this study strongly suggests that this is not an idle or trivial question to pursue. We don't want to kill our patients with kindness.
   The authors comment: "In the ideal vision of patient-centered care, physicians deliver evidence-based care in accord with the preferences of informed patients, thereby improving satisfaction and health outcomes, while using health resources efficiently. However, patient-centered communication requires longer visits and may be challenging for many physicians to implement...Relaxing patient satisfaction incentives may encourage physician to prioritize the benefits of truthful therapeutic discourse, despite the risks of dissatisfying some patients."