Guest post written by: Anonymous
In my third year of medical school, I nearly failed one of the notoriously easier clerkships: family medicine. My preceptor – a morbidly obese, overworked woman – had urged me repeatedly over the course of the six-week rotation to speed up my office visits. She insisted that I cover the patient’s medication list, discuss their current problems, make sure that their chronic conditions have not worsened, do a focused physical exam, then get the heck out of the room. Success in optimizing my life through food and exercise was the reason I was pursuing a career in primary care in the first place, as I hoped I could bring the same satisfaction to my patients, so I certainly had to say something to each of them about diet and physical activity. Indeed, I felt it was my duty as a physician to address a patient’s health in a minimally invasive, cost-effective manner. Lifestyle modification fits that bill.
Despite this daily struggle, I figured that even she would have appreciated a bushy-tailed, bright-eyed medical student taking time to simplify the advantages of a gluten-free diet or the complications of adrenal fatigue. Unfortunately, at the end of the rotation I opened her evaluation, and I was discouraged to find a near-failing grade and comments that read something like this: “He is friendly in patient interactions, but he spends too much time advising patients who clearly won’t benefit from diet and exercise recommendations.”
Patients who clearly won’t benefit? Says who?
I will spare you the details of my thought process, but eventually, after a few more rotations, primary care was beaten out of me. I decided to specialize. I also started my own health coaching company which would give me an outlet to work with patients in a setting outside of my medical practice. I realize that this is an unreasonable solution, and if every budding primary care physician (PCP) chose to the do the same preventative medicine would fly out the window. The state of our health care system may require a solution developed outside of primary care in order achieve real change in the lives of patients, but getting physicians and other health care professionals on board will continue to pose a challenge.
The problem described in my story is multi-factorial:
1) Lifestyle modification is given little focus in medical school education.
This is forgivable to some degree as the breadth of information that we are required to learn in medical school is tremendous. I do not know where best to fit it into the curriculum. However, there have been experiments nationwide with shortening the medical school curriculum to three years by eliminating the basic science courses for those planning to specialize. Likewise, it has been suggested that the more specialized rotations be omitted for those who enter medical school intent upon a career in primary care. We could alternatively re-direct the basic science courses to focus on the application of biochemistry and physiology in weight loss or disease management as a means of priming young physicians’ minds to think critically about these concepts.
2) Physicians are pressed for time in office visits.
Doctors who do have the insight to look beyond the American Heart Association or American Diabetes Association for dietary recommendations may not have time to dedicate sufficient attention to the topic in the office. The state of primary care mandates that PCPs overload their schedules daily in order to make ends meet. This necessitates shortened visits, leaving little time to explore the reasons behind patients’ non-compliance and persistent illness.
3) Preaching lifestyle in an outpatient setting will not make you rich.
There is no billing code for teaching patients about the dangers of wheat. Recent changes in our primary care model are responding to this issue by providing additional compensation to physicians who improve health outcomes, but the system is financially broke. Many years of catch up will be required before such incentive programs will ever actually increase the appeal of drawn-out patient interactions. Perhaps an incentive program based on health markers will lead to an increased demand for specialists in behavioral change and who have a good understanding of more effective nutritional principles (e.g. health coaches, personal trainers, etc.). These specialists can afford to spend the time with patients, neutralizing point #2 above. Kicking some extra dollar signs to physicians that take the necessary steps to get their patients to lose weight or reverse their diabetes through healthy lifestyle modification will take some time, but it will probably help if we can devise a way to afford it.
4) Failure is becoming the norm.
Many patients have not found success in reducing their sugar intake. Likewise, many physicians have not been successful in assisting patients in reducing sugar consumption. Both of these assertions are partially to blame for the assumption that lifestyle modification can not work for the majority of patients. Despite years of failure to help people lose weight or eat healthy, many physicians continue to push the same recommendations: eat less, exercise more, count calories, etc. Dieting is not supposed to be a daily battle between you and a slice of cake. Anybody who has tried to simply eat less knows that it is not sustainable. You will lose weight, but you will also feel like crap. When patients are so used to failing at diets while their physicians are accustomed to seeing patients fail at adopting their recommendations, the topic seems to simply take a backseat at physician office visits. That long heart-to-heart conversation about lifestyle modification is not happening. My preceptor’s attitude suggests that she has tried and failed with many patients, and she no longer sees it as a valuable use of her time. Maybe her approach failed because it was wrong all along? It is time to find something that works better and then to revisit the conversation with patients that have failed in the past.
5) We give up too easily and blame others.
In line with item #4, we tend blame others when we fail. Patients blame their physicians for not helping them. Physicians blame their patients for not complying. If a game plan fails, you have to scrap it and try something new. The person to blame is the person that assumes that lifestyle modification is not useful in optimizing a person’s health. Instead of pointing fingers at the health care industry, food industry, your physician, your patient, “that blogger guy”, or your mom, take a step back and consider what can be done to carry things forward. Maybe one of these resources failed on your first shot at weight loss. You can reliably blame your upbringing for the preconceptions you have about the world or many of the barriers to healthy habit formation that exist in your life, but it is certainly 100% your fault if you choose to do nothing about it. This goes to both dieters and health care professionals.
6) Health professionals can be hypocritical.
I used to live near a dialysis clinic in Pittsburgh. Without fail, there would be at least one white coat standing out back smoking during all operational hours. Likewise, physicians in my hospital regularly take the elevator down two floors to more expeditiously slam a piece of pizza down their throats. I am generalizing, of course, but this behavior is certainly alarming. Physicians claim that their stressful lives and difficult working hours prohibit healthy food choices and exercise habits. If physicians can not develop healthy habits, how can we expect anything better from our patients, many of whom work the long hours without the big paycheck?
Human beings are adaptive organisms, and it is irresponsible for medical professionals to assume that our patients are incapable of adopting basic lifestyle modification. If you casually tell a patient to “lose weight, start exercising” during their six-month office visit, it should be no surprise when they show up at the next visit heavier and sicker than before. Take a step back and reconfigure your strategy. There are volumes of clinical and anecdotal evidence out there to draw from in recommending specific foods and routines that could improve the life of a patient. Unfortunately, the powers that be do not yet support many of them at an institutional level. As a health care professional, patients look to you for guidance. You are the role model for patients and future generations of medical professionals, thus it is your duty to use your extensive training in pathophysiology and biochemistry to weigh the evidence and explore all options rather than accept failure.
Lastly, for the love of Pete, do not give a failing grade to a budding physician for his efforts to initiate conversations with patients about diet and exercise.
The author prefers to remain anonymous. He is a fourth year student at an accredited U.S. allopathic medical school. He is currently in the process of applying to residency training programs in obstetrics and gynecology. He is also a firm believer in the Paleo diet and primal lifestyle in general as a means of managing and preventing his patients’ and health coaching clients’ chronic ailments.