In Defense of Doctors

How the medical system, society and human biology is working against our primary care physicians (and the patients themselves!) in the quest of health.

The majority of medical conditions primary care physicians treat today could be considered “lifestyle diseases”. Although in most of these conditions, genetics and other factors  likely play a role, the disease usually presents after years (or decades) of poor lifestyle. Examples of poor lifestyle include unhealthy diet, lack of movement and exercise, excessive amounts of stress, excessive alcohol intake, tobacco and drug use, inadequate or unrestful sleep, and social isolation. Suffering in just one of these areas increases your risk for so many conditions, including anxiety and depression, heart disease, stroke, metabolic diseases such as obesity and diabetes, cancer and even premature death. What’s worse, is that a significant amount of the population is walking around with not just two areas, but three or more aspects of their lifestyle severely lacking. 

Most, if not all, of these diseases are indolent, meaning that they cause no symptoms initially. Therefore, they are usually either first caught on screening tests like the physical exam, labs and imaging, or they present for the first time as a massive event, such as a heart attack, hospital admission for uncontrolled diabetes, or a cancer diagnosis.

The goal of primary care physicians is not only to try to prevent these diseases from occurring, but also to identify them as early as possible and get them treated. What’s more, these are usually the exact same goals as the patients themselves have! So what’s the problem?

The issue lies in the ability to break old habits and make new ones. 

How many times have you tried to lose weight, or start an exercise program, or stop smoking, or cut back on drinking, or get more sleep, or  … (fill in the blank with whatever habit you tried to fix)? How many times have you had the desire to change one of your daily habits, but you weren’t even sure where to start? Change is HARD.

Now, imagine that you’re a doctor seeing 20 patients per day. You have a patient who comes in and has high cholesterol. He or she meets criteria for a statin (cholesterol lowering medication). The alternate option would be to try lifestyle changes for 3 to 6 months and then recheck to see if the cholesterol numbers are improving. Now you have a few options: 

1. You can spend 2 minutes starting a medication that will get the job done. 

2. You can spend 2 minutes explaining that with improved diet and regular exercise, the cholesterol numbers should improve. But you’ve done this before, and it never works. The patient really tried to make the changes, but man it was tough. Their family didn’t support them, or they got confused about information they read online, or preparing the meals was taking way too long. They wanted to come back in to discuss further during a visit with you, but you were booked out for two months so it never happened. 

3. Or you can spend an extra 20 minutes with them to describe a handful of changes they could make, overbook them for a follow up appointment in four weeks to check in and make additional changes from there, continue doing this monthly until their lifestyle has improved and then recheck the cholesterol then. Of course, this means that now you get behind every time you see them. And that’s just for one patient. That’s not including the 19 other patients you need to see that day, 15 of which would likely benefit from this intensive lifestyle counseling. 

Clearly, the third option is what’s best for the patient. But it’s just not sustainable for physicians. If the choice is between making it home to have dinner with my family or burning myself out, I have to choose the first option. Our medical system is not set up to make the right choice the easy choice (or even a viable choice) for physicians. Of note, it’s much cheaper for insurance companies to pay for a statin each month than a monthly doctor’s office visit to improve lifestyle… just saying. 

Next, let’s review how human biology is set up to make change very hard, and how our society exploits this.

The primary drivers for human action are 1) seek pleasure, 2) avoid pain, and 3) expend as little energy as possible in the process. This was great as we were evolving and food was scarce and danger was plenty. But the society we live in currently is the exact opposite. True danger is now scarce and food (and other sources of pleasure) are plenty. 

Overindulging in these pleasure sources is not only extremely easy, but essentially the norm these days. And marketing companies are well aware of this and use it to get you to buy and consume an excessive amount of their products.

What’s more is that your own primitive brain is actively working against you making any changes to this system because this system meets all three of its primary criteria. We have to expend almost no energy to get highly pleasurable substances without any chance of danger. Again, what’s the problem? 

The problem is we feel like crap and have chronic diseases that can be completely treated by changing our lifestyle habits. 

As you can see, counseling on lifestyle change is extremely hard to do in a busy clinic setting, everyone’s brain is designed to resist change at all cost, and our society has convinced everyone that many of these lifestyle changes are actually abnormal. Of course it’s so much easier to prescribe a pill!

So what can YOU do?

First, awareness of the fact that your own brain and society is working against you in the process of change can go such a long way. Know that you’ll get weird looks from others (and even yourself) when you decide to start changing your diet, or add in a walking program, or get to bed 1 hour earlier each night. Know that it will be uncomfortable to start out. Know that your brain will try to convince you at every turn that you should go back to what you were doing previously. And know that this is NORMAL. It doesn’t mean that anything is going wrong. 

Next, understand that it is your daily actions that ultimately account for your health. The journey of 1000 miles starts with 1 step. You don’t have to tackle everything at once. Pick one thing you want to work on and start there. Do it for 3 weeks straight, as that’s how long it takes on average to solidify a habit. 

Additionally, take responsibility for the change. It is your health and you are responsible for it. No one else can work out for you. No one else can prevent you or force you to eat anything. No one else can manage your stress. You have the privilege and the responsibility of taking care of your one body in this life. 

Finally, improve your doctor’s office visits with the following tips:

• Tell them EVERYTHING you want to discuss up front, don’t save any concerns for when they’re wrapping the visit up (the medical profession calls these “door handle questions” and they are very frustrating). 

• Be prepared for them to want to schedule a follow up appointment if they can’t get to everything on your list that day - they’re trying to respect both their time and yours. 

• Advocate for yourself! If you want to try to improve something through lifestyle and not take medication right away, say so. Ask to make a follow up appointment with them to ONLY talk about ways you can improve whatever condition you are trying to treat (or make a visit with me!). 

• If possible, make a follow-up appointment BEFORE you leave for the day. Contrary to popular belief, doctors have little control over their schedules and are usually booked way in advance for these non-urgent follow up visits. Take the initiative and make the follow-up yourself. 

If you're ready to make a change and want an expert guide to work with you, come for a visit with me and I will systematically help you improve every aspect of your lifestyle!