I’m a Doctor, Not a Magician
I get accused of being a cynic and a realist, especially by people who are themselves self-proclaimed idealists. Why it is wrong to be a realist or cynical is the topic for another day. But I do actually have an idealistic heart and one that would shame the pretensions of even those whose bumpers are festooned with a kaleidoscope of stickers announcing their support for the typical things that pass for idealism nowadays. I just have a different sort of idealism, especially when it comes to the practice of medicine. It’s an old-fashioned idealism to be sure, and one that many may view as being slightly stodgy at best or a throwback to the stone age at worst.
I’m talking, of course, about the difference between reactive and proactive medicine.
In reactive medicine, the traditional model of medical practice, the physician is trained to diagnose and treat the diseases of people who seek him out when needed. This is my idealism and probably why I chose Emergency Medicine as a specialty. Our entire job is to react to medical problems. In this manner I live my ideals in a way that, unless it involves parachuting into the Himalayas, those whose ideals involve freeing Tibet can never hope to do.
Some believe in “proactive” medicine and to a certain extent I can understand and applaud their ideals. Family Medicine, for example, is full of motivated physicians keeping a careful watch on their patients in the expectation of catching and preventing health problems early enough so the treament is a pill instead of a heart transplant. Some work in preventative medicine and struggle to eradicate the common diseases that afflict the human herd.
Idealism is a good thing except when it becomes zealotry at which point (as absolutism brooks no dissent) reason, moderation, and respect for the heretic are abandoned. The hard-core purveyors of proactive medicine long ago passed into zealotry and have never looked back. Many of you have read of my experiences with community medicine at Duke University where the Department of Community and Family Medicine was the beating heart of proactive zealotry and about which I relate the following cautionary tale:
During our orientation as interns, we sat through many conferences extolling the virtues of Community Medicine, the Shining Path of proactivity that involved physicians, mid-level providers, nurses, social workers, dieticians, and various other minor functionaries of the dependocracy in a coordinated effort to bring good health to the to jibbering inhabitants of North Carolina’s urban and rural hinterlands. One such effort involved a pilot project to combat obesity. A local Baptist church was selected as a test site and the obese parishioners were subjected to all manner of testing, nutritional counseling, cooking classes, motivational speakers and everything and everyone that the initial grant money could bring to bear. To say that this group was targeted would be an understatement. They received the full broadside from the great ship of state which, for good measure, came about and raked them from the other side.
You’d think the pounds would have dropped like French soldiers at the sound of gunfire but, when one of the interns tentatively asked if the target group had lost weight, it turned out that the test subjects had no statistically significant weight loss.
There were no outliers. The most lost was a little more than the weight of a couple of pork chops and some actually gained.
Anybody could have predicted this. Most education, like most preaching, is ineffectual. The parson can talk himself blue in the face but the bars will still be open and the fancy women will have no shortage of customers because unless people have some strong personal motivation for change, a motivation which cannot be accessed by the usual uninspired preacher or government scold, they will continue to indulge their immediate gratification at the expense of of some unknowable future punishment.
Late at night, when the motivational speakers have gone home and the skinny lady from the university has stopped trying to extract impossible promises, the siren call of the pecan pie in the refrigerator is irresitable. Pie will out. This simple yet seductive desert will trump our best efforts. When you’re three hundred pounds hoping to lose the fleshy equivalent of a couple of sixth graders, the smooth seduction of caramelized Karo syrup and the smokey crunch of jumbo pecans offers immediate gratification with which no nebulous promise of low blood pressure can hope to compete.
I am a stocky fellow myself and even though I know better, after approximately twenty years of education and a medical degree I still succumb to the demonic allure of baked goods including that of the very arch-devil of pastry, the apple fritter.
You can lead a horse to water and, if you hold his head underwater, he will eventually drink. But you have to stand there and hold him down. Likewise, we can probably modify people’s bad habits but the level of involvement required is immense. If a small platoon of earnest social workers cajoling and lecturing for a month could only show a couple of pork chops for all their effort and a a couple hundred thousand bucks worth of their time, those are mighty expensive pork chops. So unless you’re willing to swallow the cost of providing everybody in the country who needs one with their own personal trainer to hold their head underwater, well, you need to let it go. People are going to do what they want. They’ll suck down crack, inject heroin, free-base Big Macs, and make love to the pastry cart and nothing short of locking them in a jail cell with Richard Simmons and a crate of lettuce is going to make much of a difference. What little difference it makes is probably not going to be worth the gigantic expense of providing nannies to a third of the population.
It’s probably more cost effective to just say to hell with it and confine ourselves to reactive medicine where at least we can make a difference. Remember, no matter how much you spend, it can all be undone by an 89 cent piece of pie.
As someone who is actually certified in Preventive Medicine I can truly appreciate what you say.That certification came years after I became what at the time seemed to be a real doctor,namely IM and Pulmonary, which again at the time was largely reactive medicine.IM now seemes to have become-unless you are a hospitalist where you still react to and try to fix or mitigate serious medical problems- has become almost indistinguisable from the community medicine preventative pretenses of family practice. Still you have to wonder how much prevention can come out of a 12 minute patient encounter.
Now, I’m not saying that preventative medicine is useless. But it should focus on things like vaccination, sanitation, and relatively inexpensive broad-based efforts like anti-smoking campaigns and general health education, not expensive individualized nannying that is impractical and expensive.
And of course, when a patient expresses a real interest in changing some behavior it is time for the full-court press. But physicians need to treat patients, not demographic groups.
Right on, Panda. To paraphrase what Penn (of Penn and Teller fame) said on his show ‘Bullshit,’ people will stop overeating just as soon as they stop f**king. The power of the brain’s positive feedback mechanisms should never be underestimated.
I agree. I think a societal change has to occur before the USA will win its battle against obesity. Being overweight may become less and less acceptable, or people will learn the value of self control and moderation. Like James Gaulte said above, what can be accomplished in 12 minutes, and why is the obesity “epidemic” thrust onto the shoulders of health care?
If our country really cared about preventive medicine, it would ban tobacco, trans fats, and high-fructose corn syrup. However, no politician would ever suggest such a thing, so we’re left with people like Obama telling us that we need to spend billions of dollars on preventive health task forces to clean the country’s arteries.
“…the smooth seduction of caramelized Karo syrup and the smokey crunch of jumbo pecans offers immediate gratification with which no nebulous promise of low blood pressure can hope to compete.”
Amen.
By the way, I have received some irate private emails accusing me of blaming pie for the nation’s bad health.
Folks, the pie is a metaphor. I know it’s not obvious but it is.
Panda,
Are your readers really that zealous/stupid? The only emails I receive are from bloggers asking me to link to their websites.
Re: corn syrup and other cheap and delicious yet evil foods. Michael Pollan fired a shot across the bow this weekend with his latest piece in the New York Times. Now, I know the NYT tends to have un-Pandaish political leanings, but this article is a must-read for anyone interested in why junk food is so cheap and good food so expensive. It ties in to the obesity epidemic too.
http://www.nytimes.com/2007/04/22/magazine/22wwlnlede.t.html?em&ex=1177646400&en=12a655b3ae2b92a9&ei=5087
you’ll be back, ohhhh you’ll be back
What do we do for those who are really interested in changing and yet still have an incredible propensity to get the pecan pie in the middle of the night. (Or Mountain Dew and Cheesecake).
What do we do?
Fuck ’em. It’s a free country. If they’re interested in changing they will change.
Look, we’re either going to regard people as free agents or we’re not. If we’re not, then “liberty,” “choice,” “preference,” “opinions” and even “rights” have no meaning and it’s then acceptable to treat people as nothing more than robots.
The ironic thing is that cynical misanthrope as I am, I apparently have a lot more faith in people’s ability to rise to challenges then those who profess to love everybody.
As much as I hate to agree with this one, I agree – people will only change given significant personal motivation (speaking for myself on this one, as regards weight), and advice still boils down to exactly that at the end of the day: simple, sound, intangible advice. God bless the folks that actually do find a reason to stop some stupid thing they’re doing, but for the rest of ’em… it’s awfully fucking hard to help those that haven’t an interest in helping themselves.
All the ER docs I’ve known have always preferred my lemon meringue, made from scratch using fresh creamery butter and lemon juice. One doc was forbidden by his wife to eat my pie because she had put him on a “diet”. She even took all the cutlery out of the call room one night when I’d brought my pies. I found him in there later shoveling my pie in with a tongue depressor. The pie will out.
Now mind you, I’m not saying that counseling and support are useless, they certainly are not. But the cost to provide this for the what, 50? 60? 70 million Americans who are obese, drug addicted, or partake of any other activity harmful to their health would be immense. We cannot afford to have half the population employed as full time counselors for the other half. It’s just unworkable and unfeasible.
Could we please put to rest the tired cliche of the cowardly French? In WWI 1,385,000 French soldiers died and an additional four million were wounded. In WWII while it’s true that 212,000 soldiers died, there were civilian casualties that brought the total of French deaths to more than 562,000 people.
I always hear, “If my knee didn’t hurt I could exercise.” “How can I exercise with the arthritis I have.” When the studies show people are more like to gain weight than lose it after a total knee arthroplasty. People don’t want to hear that and they sure as heck aren’t going to use their new knee for exercise in most cases.
One of my favorite all-time lines from one of my attendings.
“Doctor, why do my knees hurt?” asks a patient.
The Doctor calmly replies, “Because you are crushing them.”
Can I have some ice cream with that metaphoric pecan pie?
“…the smooth seduction of caramelized Karo syrup and the smokey crunch of jumbo pecans offers immediate gratification with which no nebulous promise of low blood pressure can hope to compete.”
I’m afraid that I’m just going to be mystified by many of my patients, because the above description has no sway on me. Very rarely does anything inspire a strong craving in me (other than Mountain Dew), and my appetite is never particularly strong. Nevertheless, your little scrumptious soundbite described a whole lot of what’s wrong in this country. Immediate gratification and delayed punishment? Where do I sign up?? Credit cards, interest-only mortgages, a Royale with cheese, etc.
And I laughed in the library at the “Why do my knees hurt?” “Because you are crushing them.” Oh, so true. The only knee replacement I’ve seen performed was on a woman who was about 5′ and 400 pounds. Yikes.
Is there an ‘obesity epidemic’? I’ll take the word of doctors before I’ll believe the bureaucrats and politicians. But if there is one, it may be one building since the fifties when food became more plentiful and cheap, and most people had jobs and were able to buy it.
Recently a man who was born in 1935, who grew up on family-owned farms in Nebraska and Oregon, told me he’d never known what it was to have a full belly til he joined the Army during the Korean War. He said the chow was amazingly plentiful and he was allowed to eat his fill. Every day! Today, he has something of a weight problem.
Think of the parents who grew up during the horrible Great Depression when maybe millions died of starvation (primarily because of government bureaucratic control of food production) then had children born just before, during and after WWII when there was food rationing. When jobs and food became more plentiful and accessible there was joy in eating, eating til one was filled. Those babies grew up and continued those attitudes toward food.
Has anyone complaining about the average American’s diet today checked out the American diet during the 1950s? Lots and lots of breads, potatoes with lots of butter and gravy. Lots of fried stuff, and creamed (real cream) vegetables. And ‘prepared foods’ hit the stores in volume and variety. Nutritionists basically approved of it all. Good food, plentiful (at last). Milk drinking (milk fortified with vitamin D) was encouraged.
And let us not forget sugar! The government actually regulated (and still does) sugar production in this country (and keeps imports out) to keep it one of the cheapest ‘foods’ you can buy! Doctors who discouraged all the fat and sugar were ostracized (really!) as quacks. I remember.
So, is it any wonder people became fatter? Though no one mentions they are generally taller and regardless of the extra weight still are living longer and longer.
I am an absolute believer in personal responsibility for one’s own health and enjoy excellent health because I work at it (including a bit of daily exercise). But I also respect, as Panda and others have said, the absolute right of other individuals to make their own choices. I’m also too old to have any illusions about the health nazis fully practicing what they preach.
I think a huge problem today is that during the 1960s the New Left and its cross-eyed sheep began propounding the idea that everyone should do and have whatever they want..now, without restraint, without cost. That is embedded in the culture, now. Good luck convincing people to use restraint and common sense with food.
I hesitate to call it an epidemic. It’s not contagious, after all. My wife has been hanging out with me for almost fifteen years and she’s, not meaning to brag, as svelte and good-looking as a trophy-wife should be.
I think it’s a huge problem with the poor. While it is not as expensive as the nail-biters and social scolds think it is to prepare nutritious, healthy meals, it does take some effort and some cooking knowledge. In a system of public education that fritters away classroom time learning to put condoms on bananas, you’d think they could teach the unwashed some cookery…you know, how to prepare rice and vegetables, how to cook a chicken, how to make soup, etc. I mean, since they’re bound and determined not to teach them how to read, write, or do simple sums they might as well teach ’em something useful.
Some of my poor patients in Louisiana didn’t even know how to prepare collard greens for God’s sake, about the healthiest and cheapest thing that can be ‘et. It is just too easy to hop on down to Popeye’s.
There’s one more issue. The chips, the muffins, the hostess cakes, the snickers bars all taste better than rice and veggies! I am always amazed at the argument that the poor end up eating junk food just because it’s cheaper. People eat it because they like how it tastes! Throw in the zero preparation time factor and you’ve got the most seductive combination to squash even the smallest pang of hunger you might have three hours after lunch. Show an average overweight 15 yo a snickers bar or a plate of garden salad and ask him to pick one or the other solely based on the taste he would prefer. Nobody cares that the plate of salad is 4 times more expensive – they don’t want it in the first place. If they did, we would have good humor trucks driving through neighborhood selling broccoli wraps.
Actually, sugar prices are being kept about 2x higher here in the US than world market prices thanks to import restrictions and price controls, mostly due to lobbying by Archer Daniels Midland. A company which incidentally controls most of the corn produced in this country. This is the main reason that corn syrup is artificially cheaper than sugar and gets used in so many junk foods, despite being much more unhealthy.
It’s also the reason that modern Coke tastes like crap compared to the real cokes I can only find now at Mexican restaurants, made using real sugar down in sunny Mexico. Stupid ADM.
An economist would say “if you want more of a behavior, subsidise it.” So I wonder if it would have worked to just offer people $100 for every pound they took off and kept off for 3 months. They probably would have spent less and acheived more.
Funny but true story: At Duke, I had a wierd conversation with a Community and Family Medicine bureaucrat who insisted that Cuba had better health care than the United States and as proof, she offered that all the people there were thin.
Now, they certainly are thin but they’re even skinnier in North Korea where…um…they don’t have food.
The point is that the level of government control to make us thin would be intolerable to most people (skinny compassionocrats excepted) and is probably the one injustice that would make the people rise from their sofas in full, bloody rebellion.
“They can take our lives but they’ll never take our twinkies!”