I realized recently I’ve never written this kind of open letter. I figure if kids and Taco Bell got the benefit, maybe primary care physicians could as well. Kidding aside, there’s a genuine mismatch these days between standard medical advice and effective lifestyle practices. I think we can all do better. I’m not letting patients off the hook here either. (Maybe that’s fodder for another letter.) However, we naturally look to our physicians as our healers, as the experts, as our guides. Unfortunately, we’re not always well served by that kind of faith. I’m of course not talking about any one doctor or set of doctors. I happen to know a great many primary care doctors and other medical practitioners who are incredibly forward and critical thinking professionals. They balance their perspectives with the likes of medical logic, broad based study of existing research and close attention to real life results. While I think I’m not the only one who would have much to say to many specialists out there as well, let me specifically address primary care physicians here. They’re on the front lines – for all the good and ugly that goes with it. More than any specialist, they have the whole picture of our health (and a fair amount of our life stories to boot). It’s more their job (and billing categorization) to provide general health and lifestyle counseling to their patients. It’s with great respect that I offer these thoughts. As my readers can guess, this could easily be a tale of ninety-nine theses, but let me focus on a few central points.
The State of Weight Counseling
Can we talk about this for just a moment? Statistics vary, but generous numbers suggest two-thirds of physicians don’t counsel their patients about their weight – this at a time when approximately two-thirds (yup) of the adult population in our country is overweight or obese. I’m not pointing fingers at any specific people here, but this is disconcerting. It seems to be a downward aiming trend to boot. One study of primary care appointments, for instance, found doctors offer weight related counseling less often than they did twelve years ago. In fact, of the appointments researchers analyzed, doctors only discussed weight in a mere 6.2% of visits! In the year these statistics were gathered, 63.3% of adults were overweight or obese. Does this even make any sense? But there’s more. The same research found those with high blood pressure and/or diabetes were also less likely to receive weight counseling than they were twelve years ago – 46% and 59% less likely respectively. Any jaws dropping yet? Pardon me, but does this jive with some version of the Hippocratic Oath I don’t know about?
This utterly confounds me. Sure, I get it on an emotional level. It’s awkward. You don’t want to make anyone feel bad. But it’s your job to tell the truth – whether it’s convenient or not. It’s your job to steer folks in the right direction health-wise, to educate them in making better choices for their health. No one’s suggesting you call them at home to wake them up in the morning to encourage them to go workout. No one thinks it’s your job to write a personalized menu plan.
Nor is anyone saying you have to be a jerk about it. (Please don’t.) You really can have a conversation with a patient about his/her weight without shaming or blaming. The thing is, I’ll bet the person already knows he or she is overweight (just a wild guess). Mentioning it won’t dismantle any delusions of god-like svelteness or superhero health. I’d even venture to say they’re waiting for you to talk about it – as in, their weight and assorted related concerns/questions are already on their minds. Just be honest – and professional – and compassionate (without patronizing). Be down to earth about the real risks they face and the concrete strategies they can use. Bond as you would with any other patient. I say this because – guess what – research also shows physicians tend to bond less with overweight patients than they do with normal weight folks. As the researchers note, less engagement likely means less adherence to whatever good advice you do offer, and you might be wholly missing the patients who need you (and the care you provide) the most.
The Questioning of Conventional Wisdom and the Myth of the Magic Pill
With all of the above in mind, can we talk about the information itself? This is kind of big. In fact, it could be a book in and of itself. (I do have a few recommendations on that front….) I realize I’m not the first one to observe we’re living in a health care system that favors intense intervention and fails too often at basic prevention.
One of the things that troubles me most is the all-too-frequent, razor-focused commitment to conventional medical wisdom. I’m talking particularly about the red herrings and ridiculous claims like saturated fat is the bane of human existence, that dietary cholesterol is the culprit behind unhealthy lipid profiles, that 350-450 grams of carbohydrates are reasonable if not desirable each day, that whole grains (including GMO corn and gluten giant – wheat) are an essential part of a healthy diet. The research doesn’t line up – and never really did line up – behind these assumptions. The more our population follows these recommendations – eschewing whole foods like eggs, pastured butter, coconut oil and organic meats for the likes of whole wheat snack products and carb heavy dishes at every meal, the more unhealthy we get. Diabetes isn’t an organism that mutated. We’ve just never worked so miserably against our own physiology before in human history/pre-history.
The fact is, even studies published in some of the bigger name journals are beginning to demonstrate these truths and dismantle decades of erroneous conventional assumptions. To an extent, it’s a matter of reviewing the research, keeping up on what’s being said and shown. I know, I know. It’s difficult to impossible to stay abreast of the latest research – especially when you expand the scope beyond the most conventional sources. It’s tough for physicians to stay current on ALL the new research. It’s often fuzzy or contradictory, and much of it is still poorly conducted or biased in its funding, so even reading research can be a frustrating time expenditure. Even physicians agree that physicians regularly fall behind for various reasons. Some among them suggest more than anything “Continuing Medical Education” at the point of patient care – reports and summaries at hand of the latest thinking and evidence based findings. That sounds great. I have a more modest proposal, however.
Outside of accidents and serious genetic defects, 80-90% of conditions doctors treat are either prevented and/or cured…or at least mitigated…by lifestyle adjustments. And much of that is diet (although exercise, sleep, sun, stress control all play an added role). How about just investing in some nuts and bolts education on lifestyle interventions. Ideally, a physician would get 2-3 months of focused diet/exercise/lifestyle training in med school aimed at fixing various common health issues, rather than just relieving the symptoms.
Medicine in our country (as a culture), however, focuses on the symptoms more than the source. A stent, for example, offers relief of a symptom but doesn’t address the larger health issue or seek to remedy it. Gastric bypass isn’t a fix but a procedure that circumvents the bigger source of the problem. In some extreme cases, it might be an advisable course of action in the context of a bigger plan. Most of the time, however, psychological and lifestyle means are much safer and much more effective in the long run because they can address the root causes.
When it comes to the top selling pills, the same principle holds. Statins address the manufactured symptom of high cholesterol. When we put our faith in them, we lose sight of the real processes going on in the body – the processes we need to be addressing. The same goes for PPIs and SSRIs. Respectively speaking, heartburn is generally associated with too little acid rather than too much. Taking them might alleviate some short-term discomfort, but they’re contributing to long-term digestive issues and nutritional deficiencies. Likewise, SSRIs and other mental health meds often cover up underlying therapeutic needs for stress reduction and sleep improvement as well as physical conditions like dietary allergies/sensitivities, nutritional deficits, and drug interactions. Can we all back up for a minute and reconsider the conventional teachings and protocols?
Sure, you can’t redo your med school experience. Likewise, it’s probably not in the cards to take a leisurely sabbatical during which you get to delve into the sea of research that’s been published in the last year let alone decade. Still, you can forge your own commitment to the process of learning about lifestyle interventions, about recent findings and reviews. You can open your own mind to the less popularly cited studies, to the less front and center journal selections. Find a few that suit you, that you can believe in. Dabble for a while in the outer reaches of lifestyle research. Choose some publications that interest you. Commit to following them. Likewise, choose some less formal reading to fill in the gaps. Look for some books and blogs (I know of one.) you can feel comfortable with but that nonetheless challenge your way of thinking. Good Calories, Bad Calories or Why We Get Sick, for example, would be good places to start. They’re relatively easy and decent ways to digest a lot of info at once.
And while we’re on the subject of good resources, how about giving out the names of books and articles in lieu of many of these prescriptions? The fact is, we lean heavily on the latest pharmaceuticals rather than lifestyle measures. How often do we really exhaust the lifestyle intervention possibilities before handing out the magic pills? Can we give patients more credit? Can we challenge them more effectively to change their diets and daily regimens before getting out the prescription pad? Is it asking too much to go out on a limb and ask patients to educate themselves? Suggest accessible, engaging material on the blogs and books you see fit. Can I suggest The Primal Blueprint as one possibility? Many doctors already recommend it to their patients and – no surprise – their patients have seen the same kind of incredible results that we see here on Mark’s Daily Apple every week. If you’re an interested physician, contact me here and let’s see what we can do together.
Finally, can I just say a word about the later decades of life? You see, I have some expertise here. I’m turning sixty this week – yup, 6-0. The thing is, I don’t really fit the common image of a sixty-year-old that we’re given in our culture. Call me an outlier if you will, but the fact is I direct my lifestyle to live and feel the way I do. I don’t work as hard at it as you might imagine. I don’t train for hours a day. I eat amazing food. I play hard and sleep well. I live exactly the way I outline above. Nothing particularly special. Nonetheless, I think I demonstrate (along with some friends) that with a little effort and forethought, a modest portion of commitment and unconventionality, sixty doesn’t have to mean a life of aches, pains, prescriptions, and increasing impairment. Feel free to check out some photos of me to see what I mean.
Thank you, by the way, for reading. I appreciate your taking the time and thought to consider one humble guy’s opinion. If you’re ever up for some conversation, I’d love that. That’s where good things start. In fact, let’s make it lunch – Primal style of course.
Have a good end to the week, everybody, and share your “open letter” thoughts!