The picture of health
Lamplight glints off the stainless-steel coffee machine, one of those high-tech models that make a mug at a time. Beside it sits a basket of bagels and muffins, each tucked in a plastic bag tied with a silver bow. A bowl of organic pears and apples, perfect as a Renoir still life, snuggles up to the baked goods. Across the room are unruffled copies of today’s New York Times, Wall Street Journal and USA Today. A Bose Wave Radio murmurs nearby. A door at the back swings open, and Bobbie Wingate-Fisher presents herself. She’s wearing a clingy pink sweater and matching pumps. Her knee-length skirt reveals shapely calves. Flashing a toothpaste-ad smile, the brunette appraises the two 40-something guys slouched in soft chairs. Her gaze, friendly but firm, settles on one. She wiggles her fingers in a come-hither wave, says hi and beckons him to follow. “This is not good,” he thinks. “She’s come to take my vital signs, and my heart’s already racing.”
Yes, this is a doctor’s office, but, no, not a typical one. Duke Executive Health Program, a division of the university’s nationally esteemed hospital, offers a level of convenience and coddling rare in today’s health-care industry. The waiting room, like nearly everything about the program, underscores a message that’s straightforward but, in medicine, startling: We care about your business, and we’re here to serve you. In a typical doctor’s office, that notion would be shocking enough to send you into cardiac arrest. If it does so here, the folks at Executive Health want you to know you’ll be whisked up the hill to Duke University Hospital, ranked eighth in the nation in cardiac care by U.S. News & World Report. “It’s a way for them to practice concierge medicine,” says Curtis McLaughlin, an expert in the business of medicine and emeritus professor at UNC Chapel Hill. “It’s a way of maintaining relationships with a well-heeled population who’ll pay a premium to see a physician who gives them lots of time.”
Programs like this once were common, with the Mayo Clinic leading the way. “When my father-in-law was with Arthur Andersen, it used to be a big perk to send somebody to Mayo for a day at company expense,” McLaughlin says. They lost popularity as employer-provided health insurance expanded, but now with medical centers scrapping for every dollar in their ongoing smack down with managed-care insurers, they’re resurging. “If you bring in executives and they’ve got a leaky heart valve, where do they send them? Chances are to Duke. Imaging, orthopedic replacements and heart surgery are the most profitable things in health care. So this is another way of capturing and servicing profitable market segments.” With a full-time staff of nine, the Executive Health Program operates profitably, an unusual enough distinction in a major academic medical center, but its contribution is a pittance to an enormous operation such as Duke University Health System, with its $1.8 billion annual revenue and more than 20,000 employees.
The program’s other benefits might outweigh its financial contribution, says Charles Sanders, former CEO of Glaxo Wellcome and a cardiologist by training. Sanders, who has used the service himself, points out that clients may become donors. “That’s been proven at Duke with Roger Milliken and Dave Thomas.” The chairman of Spartanburg, S.C.-based Milliken & Co. provided one of the testimonials on the Executive Health Web site and contributed to Duke Eye Center. The late founder of the Wendy’s fast-food chain’s name is found on the R. David Thomas Executive Conference Center.
I’ve come to Durham to learn firsthand what could make a tough textile baron like Milliken go gaga over Duke doctors. I’m the guy Wingate-Fisher summoned from the waiting room, and I’m here to find out what executives get for their money. The typical client — a man between the ages of 45 and 60 — pays $2,765 for his visit. The program doesn’t take insurance, though some who come submit the bill on their own and often see some reimbursement. Others have the fee paid by their companies as a fringe benefit. Each typically gets a physical, separate diet, fitness and stress assessments and a raft of chemical and digital evaluations, including an electrocardiogram, body-fat scan, chest X-ray and multiple blood and urine tests. Like the executives, I’ll devote a full day to meeting with a retinue of specialists who will assess everything from the rhythms of my heart to the soundness of my psyche. (Unlike some of them, I won’t spend the night at the luxurious Washington Duke Inn, just up the road, nor squeeze in a round of golf at its Robert Trent Jones-designed course.) I’ll be poked, prodded, measured and scoped to create the most complete picture of my health and physique I’ve ever had.
I’ve already had seven vials of blood drawn, and as Wingate-Fisher and I pad down the hall to the nursing station, a courier is shuttling them to a Duke lab so that I’ll get the results by that afternoon. Later, he and the program’s shiny silver SUV will be available in case I need a lift to the hospital to see a specialist. Even at the main hospital, Executive Health customers get VIP treatment. They often get to jump to the front of the line, instead of camping out with the common folk amid the blaring TVs and dog-eared copies of Car and Driver and Good Housekeeping. After Wingate-Fisher checks my vitals, she drops me off for an introductory chat with Kevin Waters, the program’s director and one of two physicians on its staff. He gives me the rundown of the day ahead and a piece of advice: “Don’t try to beat the treadmill,” he says, referring to the stress test. “We get a lot of competitive guys here, and sometimes they overdo it. The treadmill always wins.”
A few minutes later, I’m facing the treadmill and its imposing operator, exercise physiologist Rob Gray, who sports a nearly shaved head and the thick shoulders and broad back of a football player, which he once was. After explaining the test, he tells me to remove my shirt because he’s going to shave patches of hair off my legs, stomach and chest to attach the leads for the EKG’s wires. Soon my torso looks like a crazy quilt of farmland and forest as seen from an airplane. “A stress test can get you with in- cline or get you with speed,” Gray says as he does my resting EKG. “We choose to get you with incline. This thing tilts up to 23 degrees.” A smile flickers across his face, and I can’t help but think that he’s going to enjoy humbling me. He fires up the machine. Its wide belt starts to whir. Soon enough, I’m panting and he declares my test done. I say, sheepishly, that I believe that I could’ve gone longer. “Don’t worry,” he responds. “Everybody thinks that.”
Wingate-Fisher ushers me into an examination room. She pauses for a little friendly banter, then tells me that the doctor will be with me in a couple of minutes. He soon arrives, settles into a chair and starts to quiz me on my medical and family history. I regale him with the whole sorry tale — the litany of clogged arteries, weak hearts and remorseless cancers. I’m relieved when he skips the mental-health questions — one side of the family alone could keep a psychiatrist busy for months. Lanky and loquacious, Waters has a bartender’s knack for knowing when to talk and when to listen. A natural storyteller, he riffs at length — about his stint as an Air Force medic, about his former life as a primary-care physician in New Mexico, about his family’s history of esophageal cancer. But he also waits patiently as I answer his questions. Seldom have I met with a doctor who seemed so unrushed.
“If you ask all the doctors what would make their lives better, they’ll say, ‘If I could spend more time with my patients,’” he says. “And if you ask the consumers, they’ll say, ‘If I could spend more time with my doctor.’” Working at Executive Health, he says, gives him the professional satisfaction of spending that time and really getting to know his patients. He even hands out his phone number and e-mail address. If his clients become patients of other medical departments at Duke, he coordinates their care, checking in with them and their specialists.
As the physical exam begins, he mentions that Wingate-Fisher had noted a slightly higher blood pressure — 130 over 70 — than is ideal for my age. He gets the same reading. “You look pretty healthy — your weight’s good. We’ll talk about this later, once I’ve seen all your test results. Meantime, talk about it with Gene, our nutritionist. He can tell you about the DASH diet.” DASH stands for Dietary Approaches to Stopping Hypertension. Next come the usual body thumping and stethoscope listening. Waters checks my reflexes, eyes and ears, then he tells me to drop my drawers. “Do you know where your prostate is?” Unfortunately, I do. “They put it in a weird place,” he says. “I didn’t pick where they put it.” I hear his rubber glove snap into place and wonder if he’s pulled it on with just a tad too much glee. I know how many folks feel about journalists.
Dressed again, I soon find myself across the desk from nutritionist Gene Erb. He’s running down the food diary I completed online, tracking three days’ worth of what I shoved into my mouth. (Before coming to Duke, clients fill out lengthy questionnaires on their diet, stress levels and exercise routines.) He’s tallying calories, fat and food groups. Undoubtedly, he’ll chastise me for my affection for pale ales and dark chocolate. While he calculates, my eyes stray to the long blue case sitting atop his desk. It’s shaped like a carrier for a clarinet or soprano saxophone. He reaches over, pops the latches and lifts the lid, revealing dozens of rubber models of food, everything from a hamburger to hunks of rice, beans and spinach. “You say that you had some chocolate. Was the portion this big?” he asks, waving a fake candy bar before my face like a parent’s scolding finger.
“You’re not getting enough vegetables and low-fat dairy. And I saw that your blood pressure’s a little high, so you’ll want to be careful about sodium.” He asks if I’m familiar with DASH, adding, “I’m a big advocate of that. Some of the early work on it was done here at Duke, in the building next door. The keys are getting two to three cups of low-fat milk or yogurt a day along with plenty of fruits, vegetables and seeds. I’m a client of it myself.” Erb’s blood pressure popped up when he was around my age, 43, and he started taking medication. After adopting DASH, he was able to reduce his dosage.
The meeting with the dietician turns out to be deviously timed. Wingate-Fisher shepherds me back to the waiting room, takes time for another chat — maybe that’s why my blood pressure is up — and presents my lunch. It’s a grilled-salmon sandwich on whole-grain bread with lettuce and tomato, a mixed-greens salad with a splash of vinaigrette and a glass of water. After listening to Erb, I’m not expecting chips or pretzels. The food is surprisingly tasty, but the portions are meager. When Wingate-Fisher leaves, I sneak a big pear and a box of raisins from the snack bar. While munching, I check my e-mail on the PC provided for clients’ use. Across the waiting room, another guy pokes away furiously at his BlackBerry, then starts making rapid-fire cell-phone calls. He must not have gotten the stress lecture yet.
My stress lecture turns out to be, well, stressful. The therapist, social worker Eric Garland, first asks me to enumerate the stresses in my life, then whips out a multipage report based on the questionnaires that I filled out. “We use the gold-standard instruments for diagnosing stress, and what you’re saying is what we found with your surveys. We’re trying to connect stress with health. Some of the pioneering research on these connections was done here at Duke.” He zeroes in on one section of my report. “You seem to have a Type A personality with moderate levels for hostility and cynicism.” I try to laugh this off, pointing out that journalists are notorious cynics. But Garland, whose locked-on stare reminds me of Robert De Niro, won’t be deterred. “You need to keep an eye on these tendencies. They can contribute to heart disease.” He quizzes me on my “techniques for managing stress.” I play along without pointing out that the words techniques and managing imply a level of self-control that often eludes me when my temper crackles. I tell him that I try to hit the gym when stressed. I fail to mention that I’ve been known to yell and slam doors. He recommends a book: Anger Kills. As he concludes our chat, I’m ashamed to realize that I’m starting to get annoyed.
My next session, with fitness counselor Stacey Herrera, comes as a relief. As a bike rider and gym rat, I figure I’m going to glide through the hour with her. But she, too, manages to zing me for a shortcoming: I never stretch. “Flexibility is increasingly important as we age,” she says. “I highly recommend yoga.” Herrera has a cheerleader’s enthusiasm but an athlete’s build. She tells me that she’s going to show me a stability-ball workout. “It’s a really great way for someone with time constraints to work out. You can do it at home. It combines strength and balance.” She then peels off her navy blue Duke sweatshirt to reveal a white Duke Executive Health golf shirt and biceps bigger and tauter than mine. To demonstrate the routine, she pulls what looks like a giant beach ball from beneath her desk, drops onto her hands, props her feet on the ball and starts pumping out pushups at boot-camp speed. Soon enough, she has me atop the ball doing a series of moves that make me feel like a trained circus animal — or would if I had any coordination. With each, she tries to ensure that my positioning is just right. “I want your pelvis here,” she announces, firmly but sweetly, as I teeter atop the ball. “A little lower, no, just a little lower. Here, let me show you with my hands. Yes, yes, that’s it. Good, goood!” I begin to worry what someone who happens by in the hallway might think is happening in here.
My workout done, Herrera hands me a sheaf of guidelines, including a long list of instructional programs on TV and DVD so that I can try yoga on my own time. “Now you don’t need to go to the gym,” she notes brightly, having heard me complain that I’m pressed for workout time. As I slip the papers into my Executive Health folder, I realize that each counselor I’ve met has given me pamphlets and tip sheets on improving my health. I amble back to Waters’ exam room for my day’s wrap-up. He’s jovial, as usual, but has a stern message to deliver: Heart disease is by far the No. 1 killer of men over 40, and few of us take the simple steps needed to prevent it. As a result, we pay dearly. “Fifty percent of the people who have this disease, their first symptom is a bad symptom. Twenty percent, their first symptom ever is that they die. Thirty percent, their first symptom is that they have a heart attack. The best treatment for this disease is to prevent it.”
He then runs through the top risk factors, pointing out that only two of them — family history and age — can’t be controlled. Everything else — including cholesterol level, weight, physical activity, diet, even blood pressure and stress — remains, to a great extent, within the power of the patient. With this as the backdrop, he reviews my test results — the lab work, the stress test, the body-fat measurement — and, except for my blood pressure, pronounces himself satisfied. He suggests that I buy a home blood-pressure monitor and take measurements throughout the day to get an understanding of what influences my number. If, for example, it rises after I’ve had a couple of mugs of the high-octane coffee I favor, I might consider cutting back on caffeine. That works for some people, he says. Likewise, I might find that everything’s fine — seeing a doctor stresses out some people. Even if that proves to be the case, knowing your blood pressure and what influences it empowers you to manage your own health, he says.
“The most important person in your health-care plan isn’t me. Don’t tell Duke that I said this, but it’s not Duke, either. It’s you. You’re the one who has to do this stuff. What we try to do is motivate people with the team we have here. If they don’t know how, we want to make sure they know how.”
As he finishes, I’m chastened — that blood-pressure number has me down — but impressed. I’d assumed I was healthier than most — though I drink moderately, I’m thin, active and avoid junk food — and I had figured that, unless the folks at Executive Health managed to unearth some rare disorder, they’d tell me that. Instead, I’m leaving with a hefty list of stuff to improve — my blood pressure, my eating, my workout routine, even the way I respond to stress. On top of that, I have a bunch of numbers and test results that Waters encourages me to share with my physician. I run into Herrera on my way out of the building, and she shares a few final tips for integrating stretching into my life: “Stretch at your desk, stretch in the shower, stretch for two minutes at the end of every workout. Promise me you’ll do that.” If I weren’t trying to manage my hostile tendencies, I’d probably strangle her.
As my day at Duke attests, the Executive Health Program’s clients are treated well — they receive a high level of service and an exhaustive exam. Perhaps most remarkable in today’s health-care industry, they’re accorded basic respect and courtesy — they’re not barked at by the receptionist nor made to wait for an hour by the doctor. The convenience of the service alone would recommend it to many executives, says Sanders, the former Glaxo chief. “It’s one-stop shopping. It’s all done during the course of a day. It guarantees minimum waits. So for a busy executive, it’s exactly what you want. Companies want to ensure that their executives are in good health but don’t want to waste a lot of time with them away from the jobs.”
What Sanders wouldn’t offer an opinion on is whether the program’s clients are overtreated, that is, whether they’re receiving services they don’t really need. Does a healthy nonsmoker need a chest X-ray? Does a slim person need a digital body scan to determine his fat percentage? When pressed about his program’s multitude of tests and digital measurements, Waters cheerfully admits that several aren’t strictly necessary. Occasionally, a chest X-ray of a seemingly healthy person identifies a spot deserving additional exploration, he points out. And body-fat scans can give his figures-obsessed, driven clientele a number to strive for; Waters shows them how their measurement compares with the ideal range.
“I had this one guy who was about 40 pounds overweight, and his blood pressure was scary. He completely rechanneled everything in his life and got into this hobby of being a power lifter. He’s just won some big national contest in his age group.” Besides, Waters adds, the program’s core is low-tech — it’s the meetings with him and the diet, fitness and nutrition counselors. The main mission, he says, is education, and if some of the tests help in that, so much the better. “The philosophy is to teach. That’s what we did today. We measure things and check them, but we teach.”