Practice Spotlight: Liana Lianov, MD, MPH

 ACLM President-Elect

Dr. Lianov’s career in medicine started like many physicians, with her wanting to be of significant help to people. She grew up in a medical family with encouragement from her father who was a physician. She completed her medical degree at the University of Nevada, Reno.

During her time in medical school, an epidemiologist’s presentation intrigued her with the concept of impacting large numbers of people to improve their health. She took this interest in public health to her medical advisor in medical school, who counseled her to engage in a career in primary care, and if she still had interest in public health down the road, she could pursue those in addition.  Her counselor discredited public health endeavors as not being worthy of her energy.  Looking back, she feels this was a jaded perspective, but she understands where it was coming from.

During medical school she was awarded the Internal Medicine Award.  This influenced her decision to pursue a residency in Internal Medicine at Baylor Medical Center in Dallas, Texas. She says that, to be honest, she was miserable in this residency; she knew clearly that she did not want to do intensive care unit work or palliative care. She saw a lot of money being spent doing invasive and intensive kinds of therapy that did not help patients much, and often even added to their suffering.

While finishing residency, her desire to help large numbers of people drove her to attain an MPH at the University of California, Berkeley, where she became engaged in aging, chronic disease management and related issues.

She eventually completed a preventive medicine residency through the California Department of Health Services. During this time of working on chronic disease and geriatric programs issues, she submitted a successful grant application to the CDC for a breast and cervical cancer screening program for the State of California. She then spent ten years with leading the breast and cervical cancer program at the department.

She was aware that the number one killer was not breast cancer, but heart disease, and yet the program within the state system was very small, much smaller than the breast cancer program. She saw this as a challenge, and switched focus to lead the heart disease and stroke prevention program at the state level. She discovered that because heart disease and stroke were not popular or “sexy” issues, funding was much harder to obtain.

During the three years heading up the heart disease program, she delved into the research surrounding “what makes people tick”: why they do what they do. She read extensively on this topic and eventually decided to pursue a psychiatry fellowship program at the University of California San Francisco for a formal education on human behavior. The fellowship was targeted to serving patients with medical issues that also had psychiatric issues. This provided additional training and experience in the mix of medical and mental health dynamics, including cognitive behavioral therapy.

While continuing the fellowship part-time, she began working with the MediCal Managed Care Program focused on chronic disease management. This gave her experience in Federally Qualified Health Centers, the National Committee on Quality Assurance, the Healthcare Effectiveness and Data Information Set, and insurance and health plan systems, proving quite valuable for her next professional adventure.

Even after these experiences, Dr. Lianov was still searching for the area of medicine she considers her primary passion. She discovered a new position opening at the AMA for the Director of a new Healthy Lifestyles Division. Even though she had just recently gotten married, and her husband was living in the state of California, she decided to seize this opportunity, and from 2006-2008 she worked in Chicago for the AMA while commuting from California.

She loved this job because she was helping physicians address healthy lifestyle issues clinically.  The division at the AMA under her leadership pursued grants and developed clinical practice tools, with guidance from physician focus groups and a multi-organization advisory council. Feedback that she got from physicians brought to light that physicians were not addressing lifestyle because they were not reimbursed to do so, and many physicians felt that patients were not motivated to make changes.  Dr. Lianov’s team discovered that the typical physician needs to offer lifestyle interventions that are simple and take very little time. Physicians need to be able to quickly identify issues and refer the patient for other services as needed.

Dr. Lianov states that in their focus groups of six physicians, typically one of them really “got it” and would do whatever it took to adequately address health behaviors for patients despite the challenges of time and other issues. This led her to conclude that a sub-segment of physicians engages more effectively than the majority of physicians in addressing lifestyle medicine. One successful project completed by her team that continues to be a focus of lifestyle medicine-related activities at the AMA is the Healthier Life Steps Program.

Dr. Lianov considers this time at the AMA the real “birth” of her Lifestyle Medicine career and the basis for future engagement in this new field. Her time at the AMA also gave her exposure to a wide spectrum of professional societies and associations, and what they were doing to try to address lifestyle issues clinically. They found that obesity was often the focus condition for which physician groups were seeking to develop better tools for clinical practice.

Her time at the AMA also gave her experience in policy and advocacy issues. She recalls one of the interesting highlights being a high level meeting at the McDonald’s headquarters addressing the nutritional issues. She was also involved in efforts to address menu labeling, regulating trans fats, limiting marketing to children, negotiations with the food and restaurant industries on salt restrictions, curtailing alcohol promotions at college sporting events, and improving smoking cessation clinical and environmental programs.

After almost two years of commuting between California and Chicago, she left her role at the AMA in order to spend more time with her husband, and accepted a position at the California Department of Corrections as their Chief Medical Officer for Quality Improvement. In this role she focused on chronic disease issues and developed a mini- medical home model. Unfortunately there was a very heavy dynamic of politics that made progress and productivity challenging.

For the past year Dr. Lianov has been the Vice-President of Clinical Operations for Berkley HeartLab. One of her primary roles has been developing and managing the  4myheart Program--a lifestyle management program. A significant part of this role has been to work with a group of clinical educators, teaching them the stages of change and stage matched interventions. The 4myheart Program is offered at no additional charge to patients who have laboratory testing done through the Berkley Heart Lab, and includes nutrition, physical activity, medication adherence, and stress management. Any patient can access their services within nine months of having laboratory work done. Health educators are available in-person in some areas and by telephone, and they have a wealth of resources on their website, including recipes and other aids.

Dr. Lianov says that the typical patient who takes advantage of this program will have between 6 to 12 visits with a clinical educator. Berkeley HeartLab still has ten physical centers around the country where patients can do face-to-face interaction with the clinical educators. But they have been phasing these centers down, since phone counseling produces similar outcomes and is more cost-effective. Overall, only about 20% of those tested are taking advantage of the health educator services. Possible reasons may include lack of awareness about these services on the part of both providers and patients, and choosing to take advantage of the website or group classes.

On a voluntary basis, Dr. Lianov teaches at the Departments of Public Health sciences and Internal Medicine and works with the women’s cardiovascular disease program at the University of California Davis. She takes every possible opportunity to highlight lifestyle medicine and is advocating for a focused program on the topic to be integrated into the primary care residency programs and the outpatient Primary Care Network.

The Future of Lifestyle Medicine

In looking at the big picture and the future of lifestyle medicine, Dr. Lianov sees the whole areas of lifestyle, health, and wellness are taking off.  “The traditional healthcare community seems slower to grasp this than the rest of society,” Dr. Lianov says. “There are many business elements and non-traditional healthcare providers that have taken this idea and are running with it. There are elements of the recent healthcare reform package that do provide opportunity for the medical professional community to catch up, as imperfect as some of the reform legislation may be. There have been substantial amounts of funding set aside for wellness programs and preventive services.”

Dr. Lianov sees lifestyle and the use of Lifestyle As Medicine being an increasing issue. The trajectory of our healthcare system and the cost issues are forcing the focus to come back to the causation of disease - lifestyle. She’s very hopeful that persons in positions of power and responsibility will engage with experts in lifestyle medicine and behavior change to emphasize this crucial aspect of medicine.

Dr. Lianov sees ACLM’s role going forward as increasing awareness and implementation of lifestyle medicine clinically and as a fundamental part of healthcare. She sees ACLM continuing its current process of building substantial collaborations with other professional societies and organizations. She believes that there is room for all parties that are interested in lifestyle medicine.  “Lifestyle Medicine should increase throughout all of healthcare, including primary care and specialists. But the typical physician will not be able to provide all services and there will be a need for those providers who can do more intensive or specialized work in lifestyle medicine.”

Dr. Lianov has a particular interest in assisting the younger generation of healthcare providers: both physicians and non-physicians of all types. “In that lifestyle is such a fundamental issue, all healthcare providers really need to be trained on the same fundamental platform.” Physicians need to also pursue their own healthy lifestyles to achieve better health and serve as role models for their patients and their communities.

She also believes that there is a significant interest on the part of younger healthcare professionals in this evidence-based, lifestyle approach to a better type of healthcare.

We at the American College of Lifestyle Medicine would like to thank Dr. Lianov for her continued passion and efforts in developing and furthering the field of lifestyle medicine. Her work with the American College of Preventive Medicine’s Lifestyle Medicine Task Force, and role in the JAMA publication of recommended Lifestyle Medicine competencies is helping us move the field forward in very tangible and substantial ways.

 

Thank you Dr. Lianov.