Medicine and Health
A common social media wellness post:
If your doctor prescribes you medication without asking about
-your diet
-your sleep
-your exercise
-your stress
Then you don’t have a doctor, you have a drug dealer
Interest in health and wellness is growing rapidly, and the internet and social media are now filled with ideas on how to be healthier. Whole industries have popped up dedicated to making the population healthy. As people declare themselves experts in areas such as nutrition and exercise, they will often criticize the medical establishment for not doing enough to improve the population's health and wellness. Physicians always have room for improvement, but I’d like to give the reader a little insight into why this is often easier said than done. In other words, it is easier to put it into a short social media post than into a doctor's appointment.
It is commonly criticized that nutrition and exercise are not a priority in medical school education. When I graduated medical school in 1996, I did not get one lecture on exercise, sleep, or nutrition. I do not remember any connection made between mental health issues such as stress and a patient’s clinical diagnosis. I do not think things have improved much in the last 27 years. Most medical schools only dedicate a few hours of training to teaching about nutrition and exercise. I would prefer if medical schools dedicated some more time to these subjects, but I do not believe exercise and nutrition are as much of an obstacle that some health experts want us to believe it is. The reason it is not a huge problem is because the subjects are not that complicated. I do not believe there is a significant number of physicians who do not understand the importance of nutrition, fitness, and wellness to overall health. Whatever knowledge they may lack can quickly be made up by reading a book, watching a lecture, or listening to a podcast on the matter. The issue has nothing to do with lack of scientific knowledge. The real issue is passing this knowledge along to patients and getting them to comply. I am sure there are physicians out there who give nutritional advice with which you disagree. For instance, one doctor may tell a patient to cut red meat out of their diet, and another may say grass fed beef is perfectly healthy. Reasonable people can disagree. We discuss, and even argue about the best treatment options all the time in medicine. In either case, both doctors would likely agree on the basics of nutrition such as eliminating sugar, processed carbs, and junk food while disagreeing on the recommended ratios and types of meats, fruits, vegetables, and nuts.
The science of determining the best human diet, or the best diet for certain diseases can be incredibly complicated, but advising one single patient on how to improve their diet is easy. Designing studies to determine which diet such as a vegan diet versus a carnivore diet is healthier is difficult. You would need large groups of patients and study them over decades while eliminating other cofactors or variables. The medical study gold standard of a double blind case versus control study is virtually impossible in nutritional or exercise science. On the other hand, telling your 50 year old pre-diabetic patient to quit eating junk food is pretty easy. In reality, a medical school exercise and nutrition class would only serve to keep this information in the students mind and possibly spark an interest in continuing to learn as the science of nutrition advances. Nutrition and exercise can be as complicated or as simple as you want. A nutrition class could take years to compare and contrast all the various diets around the world, how they developed, how they prevent or lead to disease, how they affect the economy, and how they affect the environment. I am sure the right professor could make the class fascinating. Or a professor could just walk to the front of the class and say “eat whole foods and drink water, class dismissed''. If you're eating whole foods such as fruits, vegetables, nuts, and lean meats it is hard to be unhealthy. We can argue forever about the best timing and combination of these foods, but the basics are simple. Exercise class could be just as quick, “Lift heavy things and get your heart rate up every day, class dismissed”.
“You can send them to school, buy them the books, and all they do is eat the covers”
- Homer C House M.D.
The bigger issue in healthcare is patient compliance. It is easy to tell all your patients to eat healthy and exercise, but you can not make them do it. Ultimately, it becomes necessary to treat the disease that results from unhealthy lifestyle choices. If someone has high blood pressure, the physician needs to bring the pressure down to prevent things like stroke, heart attacks, and kidney failure. They can not usually wait to see if the patient is willing to change their lifestyle. In reality, most patients will choose a pill over changing their lifestyle anyway, and getting the blood pressure down is a victory regardless of how it is accomplished. The vast majority of physicians would love for their patients to accomplish this with diet and exercise, but if a pill is required then so be it.
“There is a fine line between honesty and cruelty”
Truthfully, it can be difficult to discuss a healthy lifestyle with patients. In my field, most people come to the orthopedist in pain with a desire to improve their pain level. A lecture on how their poor lifestyle has contributed to their pain will likely not be well recieved. Physicians will rarely be surprised when overweight patients have back and knee pain. The patient may not expect this if they never had pain before, but to the doctor it makes perfect sense. With the extra weight and pressure on the joints, muscles, tendons, and ligaments it would be more surprising if the patient did not have pain. The extra weight may be a huge factor in the patients current situation, but it is not something that can be immediately addressed. Can you imagine going to the surgeon to get your broken arm or ankle fixed and being lectured on how some agility and balance work may have prevented the injury? Or being told the bad news that you have arthritis and then being lectured to quit all sugar? In the end, the physician will direct their attention to the ailment and only discuss lifestyle changes if the appropriate time arises. However, this is slowly changing. Most morbidly obese patients can not get joint replacement surgeries due to the unacceptable complication level. As a result, most surgeons are discussing weight, nutrition, and fitness with patients in the earlier phases of arthritis more. In addition, many patients are no longer able to take NSAIDs due to stomach, kidney, or blood pressure issues. They are still searching for ways to decrease inflammation and physicians will often explain that lifestyle changes are the best option.
The best time to treat unhealthy lifestyles is when people are young, but this is often the hardest group to make understand their lifestyle will be detrimental in the decades to come. Ultimately, physicians need to be honest, and tell the patient the truth so they can make informed health choices. Many health experts criticize doctors for not doing what seems so simple, but let's look at an example. My friend was told as a teenager to watch her weight. Let’s assume the doctor was just encouraging her to eat healthy and exercise while she was about to enter young adulthood which can be a challenging time for many. Kids are often leaving home and making their own food choices and purchases for the first time. They are often ending their athletic careers and will either become inactive or continue a fit lifestyle. My friend listened to her doctor, but only heard “you are getting fat”. She has eaten healthy and exercised regularly since that day. This is a victory, but her doctor took a risk. Some teenagers would have ignored the advice and made no lifestyle changes. In one ear and out the other. For another teenager, this could increase anxiety and depression along with body image issues that could be detrimental to long term health. In a small group of patients, this could even lead to a dangerous eating disorder. Tough love is not always the answer. Often a physician is a health teacher or a health coach. My son had a sports coach who would give the same speech at the beginning of every season. He would tell the parents that some kids need an arm on their shoulder to be encouraged and others need a kick in the ass. He would ask parents to openly communicate with him because he was not always aware what player needed which approach. This is the physician's dilemma. In brief office visits, it is virtually impossible to know who needs the gentle touch versus the kick in the butt. This same coach made it a habit to always discuss two positives for every negative. This approach can work in medicine as well. It is usually possible to put a positive spin on most lifestyle recommendations.
It is important for both patients and doctors to realize that physicians face the same issues as their patients. Many physicians struggle with lifestyle choices. Regardless of a physician's current health status, they still need to guide their patients towards a healthy lifestyle. Whether or not a physician “practices what they preach” does not mean they can or can not have valuable advice. Think of the world of sports. Some of the greatest coaches were not great players. Patrick Mahomes does not ignore the advice of Andy Reid because Coach Reid has never thrown an NFL pass. Ideally all physicians should be role models but do not shoot the messenger because the messenger is not a perfect specimen of health.
There may be bigger issues at play regarding why patients do not comply with a nutrition and fitness plan. First, is the “Standard American Diet” of sugar, processed carbs, and junk food has become so normalized many people do not have the ability to avoid it. A doctor discussing healthy eating, handing a patient a pamphlet or referring them to a nutritionist is still up against the army of fast food restaurants, convenience stores, advertisers, and temptation. Secondly, for some patients the link between their illness and their lifestyle is a lot to process mentally. We have been brought up to believe illnesses are just bad luck or bad genetics rather than accumulation of lifestyle choices over the years.
“Diabetes, obesity, and heart disease run in your family because no one runs in your family.”
Again, a catchy phrase, but many patients have never considered their families’ habits may be the problem and not their genetics. They may not even know their habits are unhealthy, so the doctor may help chip away at these beliefs, but that may be a lot to change in a single visit to the doctors office. Third, and perhaps the biggest issue of all, is underlying psychological issues that prevent patients from being healthy. Some patients know exactly what to do, have access to all the tools they need and still make poor lifestyle choices. Food may be the coping mechanism for other mental health issues. After dealing with everyday stress they do not have the physical or mental energy left for exercising. A physician who is always harassing them to get their act together may only make matters worse. Finally, some patients just do not have access to anything but “Standard American Diet” food options due to socioeconomic issues. This is a national issue and not something easily addressed in a doctor's office visit.
Many health experts blame the current physician fee schedule as a major part of the issue. Doctors are currently paid based on the complexity of the office visit. If you come in with a bruise and I assure you that everything will be OK, this is considered a lower complexity visit which equates to a smaller fee paid . If the problem is more complex and requires medicines to be prescribed, further tests, or physical therapy to be ordered then a larger fee is paid.. If I do a procedure such as placing a cast, giving an injection, or performing a surgery I get another fee. Discussing the importance of exercise, nutrition, sleep, and stress control, will not significantly raise the complexity of the visit. Judging my success in getting patients to comply is virtually impossible. I could save the healthcare system hundreds of thousands of dollars if I could motivate one patient who is inactive, and lives on junk food to convert to a healthy lifestyle. It would still be difficult to see any financial reward from this success. In reality, the patient is the one who actually did all the work when the treatment is lifestyle changes. We do not currently have adequate reward systems for patients who remain healthy and therefore do not need the healthcare system regularly, or for the doctor who encouraged them on their journey. This website is really just a tool to help patients become healthier that my assistant/editor and I have created out of our own interests in health and wellness. Our only financial goal at this point is to get our Chief Executive Editor, Nick, a free year supply of his preferred nutritional supplement, AG1, and a cold plunge tub, so we can blog about the benefits of a daily ice bath.
So, what are health conscious physicians to do moving forward? To start, we can always mention lifestyle changes as a potential treatment option. Even when a medicine or surgery is needed, we can encourage patients in areas of lifestyle to eventually get off the medicine or avoid the next surgery. We can also try our best to make sure patients understand the link between their disease and lifestyle, so they understand the choices they have before them. Examples of people enjoying a healthy lifestyle are everywhere. Physicians can point out that these people are not just lucky, but have built healthy habits over time. We can try to avoid always focusing on weight, and instead focus on how a healthy diet can improve energy and chronic inflammation. We can emphasize exercise as both a physical health and mental health tool. Finally, we can be compassionate that many patients will be unable to make significant changes.
These are issues I’ve had to confront in my own practice. I walk the line of wanting my patients to be informed about their health while not wanting to alienate anyone. Ultimately, the goal is to treat all patients, but get a few to start treating themselves along the way. One at a time.
Flash- It’s really cool you guys seem ready to do battle and stuff but I’ve never done battle
Batman- Save one
Flash - What?
Batman- Save one person.
Flash- And then?
Batman - And then you’ll know.