Marks Daily Apple
Serving up health and fitness insights (daily, of course) with a side of irreverence.
11 Jul

An Open Letter to Doctors

DoctorI 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 exercisesleep, 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!

You want comments? We got comments:

Imagine you’re George Clooney. Take a moment to admire your grooming and wit. Okay, now imagine someone walks up to you and asks, “What’s your name?” You say, “I’m George Clooney.” Or maybe you say, “I’m the Clooninator!” You don’t say “I’m George of George Clooney Sells Movies Blog” and you certainly don’t say, “I’m Clooney Weight Loss Plan”. So while spam is technically meat, it ain’t anywhere near Primal. Please nickname yourself something your friends would call you.

  1. Hi Mark,

    Dr Mark Hyman shares many of your views as do I:

    http://drhyman.com/about-2/about-functional-medicine/

    Functional Medicine is the future of conventiinal medicine and perfectly complements the Primal ethos.

    You should reach out to this guy.

    Best regards,

    Damian

    Damian wrote on July 20th, 2013
  2. I have to say I am glad doctors aren’t imposing “obesity counseling” as much anymore. Before anyone yells at me, I have three reasons for this.

    Reason one: A doctor who’s willing to offer an unsolicited opinion about a patient’s weight will do so in *any* circumstance. Break a leg? “You need to lose weight.” Caught the flu? “You need to lose weight.” This gets irritating after a while–we’re fat, not stupid, and we can see the mirror just fine, thank you. And can you imagine going through this with a new doctor after losing 75 pounds but you’re still not at goal weight? Can you just picture how frustrating that is?

    Reason two, relatedly: A doctor who will yell at me about my weight without first checking my labs is not a doctor I trust to be right for me. If my labs say I’m healthy, that’s the end of it. Especially when they refuse to test your hormone levels or anything else other than the standard bloodwork unless you threaten their next of kin, and usually at that point you just go to jail instead.

    (Yes, I’m being facetious. You laughed.)

    Reason three: Chronic disease IS NOT CAUSED BY OBESITY. There are people out there with metabolic syndrome who are not fat. I knew of one guy who drank lots of Mountain Dew and ate lots of PB&Js and was skinny as a rail but he’s got mental illness and high BP. Yes, mental illness can be caused by metabolic issues (*raises hand* I have BEEN THERE…) but aside from that, of course high BP is a symptom of metabolic syndrome. What did he think? Well, he got lots of exercise on his bicycle so it must be hereditary. Right, whatever. Then there was the slender guy in Men’s Health some years ago whose slender dad died of type 2 after an amputation, and who wound up with type 2 himself. And these are not aberrations. How many success stories have you had here from people who didn’t have weight problems but who had other diet-related physical issues? I know you’ve had at least one; I read it in the past 24 hours. Anyway. Obesity is a *symptom* of metabolic disorder. Duh… if your metabolism were working right, you wouldn’t get fat! But you can get other problems as a result of it not working right as well. Hell, you can have fatty liver disease without having a beer belly. It does happen. Be vigilant.

    So whatever reason these docs have for not lecturing… I’m *glad* they don’t lecture. If all they’re going to give is verbal abuse and bad advice (like “eat less meat” or “avoid fat” or “eat hearthealthywholegrains”), it’s not going to do anyone any good. And really, I am over slender people thinking that the only reason fat people have a weight problem is because no one told us we were fat. We’re already contending with losing our looks and losing our health and being treated differently by society. The verbal abuse on top of that is going to be more than some of us can take. And I thought you wanted us to get healthy, not depressed or dead.

    Something to think about anyway. Feels like I’m going blue in the face sometimes.

    Dana wrote on July 20th, 2013
  3. I read through as many of these as I could stomach (not all of them) before I decided to reply. I am probably too late to the show for anyone to actually read this but, it makes my heart ache so I am responding for my own mental health at this point. I am a primary care physician who understands firsthand the broken medical system we face in the United States. And, there is so much physician-bashing on this blog that it is no surprise to me that the bright-eyed medical students I currently teach at one of the finest medical institutions in this world have a greater chance of burnout and career dissatisfaction than thriving in the career they entered with the self-proclaimed purpose of “helping people.” You bloggers are not alone in your distrust and adversarialism toward your physicians. But, it astounds me to no end that you all think that we (I and other physicians) somehow have an alterior motive to offering you “our drugs” or pushing “our treatments” on you or refusing treatments that you are positively sure you need (like antibiotics for a viral illness). Do you think I am offering you the professional advice YOU actually solicited from me for my own edification? Well, I’m not (and neither are my colleagues). We do it for you. We do it because it is what we believe will benefit YOUR health the most. Whether you agree or disagree with the advice, whether you understand it or not, I can virtually guarantee you that unless you run across a rare sociopath of a doctor, your physician has YOUR best interests at heart.

    My second point is to address the actual article content. There is much we don’t know about nutrition and much we do. There are many controversial areas. I often tell my patients that every single thing they put in their mouths is either helping them or hurting them–no in between. That is true but that is about all we know for certain. Dietary knowledge among physicians is overall poor because of this lack of certainty in the data. It is difficult to study a single food or point fingers because it is often the entire picture that matters–the outcomes on eating animal-based cholesterol/fat are very different for people who consume modern diets (including sugars/salt) and those who eat only the animal fats and veggies (Atkins-type diets) and those who also incorporate exercise. Nutrition is a complex beast and nutritional needs/abilities vary from patient to patient. It requires LOTS of time to discuss these issues with patients and the yield (number of times I successfully change a persons dietary behaviors) is very low. I have TEN-FIFTEEN minutes to address what my patient wants to address (because I and other physicians are graded based upon patient satisfaction) and THEN get to the dietary stuff if I have a minute or two left. Do you wonder why rates of weight discussions have gone down? You can point fingers but it isn’t productive, it just fuels the fire, burnout, and pain among physicians who already feel overworked, under appreciated, and overly criticized. So, until you have actually had your go at working as a primary care physician seeing patients (most of them are not like you, most of them are obese, many of them severely undereducated about health, many of them NOT interested in dietary/exercise change), being graded on how much they like you, and doing it at a clip of 4 an hour for 8 hours, please don’t flippantly suggest that we can just stop being lazy or avoidant on the issue and add it to the schedule.

    Primary Care Physician wrote on December 5th, 2013
    • As a 3rd year medical student I want to thank you for this response. I have found these comments truly disheartening, and a real let down from Mark readers.
      I think its also important to acknowledge that the issue is so much bigger than just diet and exercise. From my (comparatively limited experience) primary care physicians are the last line of defense in a long line of lifestyle issues. Asking them to fix it, while dealing with everything else is almost impossible.
      I would also like to note, that for THE VAST majority of people I would be willing to speculate that eating less and in general reasonably is more important than what you eat. Its not the whole truth but its a place to start. I have found that patients understand the “plate method” of portioning and a “no seconds” diet. Do they stick to it or not, I don’t know.

      Med student wrote on February 28th, 2014
  4. My friend sent this to me, and I wrote maybe the longest email I’ve ever written with my comments on this. I’m a 3rd year allopathic medical student, I have been seeing patients, generally in a primary care setting for over a year, and I am doing research on lifestyle modification:
    1) Physicians shouldn’t yell at patients… its not effective
    2) Homeopathic medicine may, or may not work, acupuncture has documented benefits, everyone thought St. John’s wart was incredible, until it turned out to have side effects. natural does not equal healthy.
    3) It has been my experience, physicians put the patient before anything else, I am sure many people have had a different experience, but in my experience that has not ben the case.
    4) I don’t think that physician education is the issue. I think there are lots of issues. There are pretty basic lifestyle ideologies that for most people are a big step forward for them. Most patients diets, the standard american diet, is so poor, just basic changes make a difference, forget about carbs vs meat. I’m just talking less food period and certainly less sugar. Or as the physician above stated- ANY exercise. I know all of those things are hard. But we have to get out of the mindset of having people eat perfectly (especially since we don’t know what it is), and into the mind set of getting them to eat/ live better. It would be one thing if patients came in and said “doc I follow the food pyramid exactly and i get 30 min of moderate intensity exercise 5 times a week. its not working”, but thats generally (there are always exceptions) not the case. Additionally when you give people the knowledge, the tools, and the community- retention rates moving forward are generally pretty low. i.e. people smoke, even when most know they shouldn’t.
    5) What we really need are lifestyle medicine experts (there are primary care physicians that do this), these people need training in dietetic, physical training/therapy, and psychology, to help guide people through this who are having problems. We need societal change at every level. From how we supplement agriculture, all the way to how those people who stick to perfect diets view people who don’t…
    6) Thats right even the people here are part of the problem, lets encourage everyone to take 1 step in the right direction instead of judging them for not being at the end of the race.

    Med student wrote on February 28th, 2014
  5. Ok, for thoughts from an MD. I am a specialist, not primary care, but I approach alternative medicine the same way I approach Western medicine- with a critical eye. Mark, I have a lot of respect for MDA, because you also provide a balanced perspective lacking in most alternative med websites. I eat a primal diet because it makes good common sense and I feel great. My non-MD husband agrees! I recommend primal principles to all my family and friends who ask for advice about weight loss and athletic performance.

    Here’s what I get crazy about when I read alternative med literature. 1. Vaccines. I’m not saying everyone benefits, but your doctor is not trying to poison you or your children. Consider the risks and benefits. I get my shots and so does my kid. 2. Leaky gut syndrome. You are wasting your money on live blood analysis. I look at slides for a living as a pathologist. There are not yeast in your blood. This practice is total BS. 3. Sun exposure. I get as much sun as I can for Vitamin D and mood, but I don’t let myself get burned- that’s just silly. A little sunscreen is better than painful red blistering damaged skin. 4. Prescription meds. You might need these sometimes. Be sure to ask about the risks and benefits, and keep an open mind.

    That’s all. Use common sense, think critically about extreme claims, and self experiment! Grok on.

    Sarah E wrote on July 7th, 2014
  6. Ugh, my doctor and nurse that takes the stats before I see the doctor ALWAYS harrass me very rudely about my weight. Granted I do need to lose some of this excess bodyfat, but 1. I’m not THAT overweight, and 2. I own a mirror, I know exactly how overweight I am, THANKS for telling me what I already know. Ugh!

    jay wrote on July 7th, 2014
  7. Nice article, but it brings back terrible memories. I was in the minority of having a doctor who mentioned my weight, although it was definitely more bullying and useless information. When my weight was mentioned during a visit for a case of bronchitis I knew it was enough. I was told to go to a particular website for diet info and start working out. When I came back and said I’d joined a gym and was going 5 times a week, I was criticized for paying to workout. It made me feel like it was all my fault and any efforts were hopeless. People know that they are overweight. They try to lose weight. The problem is they frequently get bad information (the food pyramid) or cliches (eat less, move more). It took me a very long time and the support of some forward thinking people equipped with solid information that has helped me conquer my weight. Whether I’ll ever conquer those past traumas is a different question. Thanks for writing about an important topic.

    JoAnn wrote on July 8th, 2014
  8. Holy cow. That’s a ton of comments already! I just wanted to tell the story of my own experience with medical experts. Once, (gentlemen, please close your eyes), I knew I had a yeast infection and went to a new doctor (I had recently moved) to get some care for it (this was before the days of god bless ‘em OTC fixes). I said to him “Doctor, I believe I have a yeast infection.” His response? “I’m the doctor. I’ll be the judge of that.” (Imagine the most pompous voice you could ever hear). The next week I drove 4 hours to see my old doctor who said “WAS THE MAN BLIND?”

    Another story (of many): I had intense abdominal pain and went to an ER. Xrayed all over the place and eventually they suggested an enema (citing constipation). Whatever. A few days later I got a call that told me one of the xrays revealed a “spot” on one of my lungs. I had to leave for a business trip at that point but upon my return I called back to discuss it. As it turns out, the spot was in reality, . . . (wait for it) . . . a nipple.

    So while I am sure there are doctors and medical professionals who are wonderful people, my own personal experiences reveal there are few of the many who really have a clue.

    I’ll take Primal thank you. Too many issues seem to be addressed by removing offending foods and beverages from my diet. Statins? No thanks. BP meds? No thanks. I’ll live long enough and drop dead.

    Happy birthday, Mark. I turn 57 this month.

    Tinman Julie wrote on July 8th, 2014
  9. As stated above, this is a two-way street. The patient need to unshackle themselves from conventional, spoon-fed, medical “wisdom” and advocate for their optimal human conditions.
    It is blatantly obvious that our societies medical hierarchy is designed to keep the most important part of the system, the patient, in the dark. Simply due to a “lack of education.”
    Congratulations on writing this open letter Mark. It will be shared to the best of my ability.

    Corey wrote on July 9th, 2014

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