Writing about lifestyle modification — and blaming the patient

I was pleased when the editors of the TheHeart.org reposted my recent essay, Let’s Stop the Unnecessary Treatment of Heart Disease. As of this morning, there are 167 comments. The majority of them were positive, and supportive of lifestyle promotion. Negative comments represented a small minority, but were notable in their vigor, and occasionally reached the level of vitriol. (“A self-righteous sanctimonious SOB,” said one nurse of the author.)

I’m glad the post touched a nerve. That was the aim.

This beautiful comment, in particular, indicates the power of a physician’s voice and his or her deeds.

My father’s vascular surgeon told him before he would perform a fem-pop procedure (Ed Note: a peripheral artery bypass) on my father that he had to quit smoking, and he did. His wife quit at the same time. That was 15 years ago and I credit that surgeon for saving my father’s life then and to the fact he is still alive today. Patients want us to be honest and straightforward about lifestyle choices.

That specialist did something special. He transcended his role of skilled technician and embraced the notion of being a doctor.

I’ve had a few similar cases with patients who were referred for ICD implants. I didn’t overtly refuse to implant the ICD if they didn’t quit smoking, but I made it clear that continued smoking in the presence of known heart disease would render the device less likely to benefit. (ICDs don’t prevent death from heart attack or stroke or cancer.) Most of these patients quit smoking—an action that conferred far more health benefit than any ICD. I can probably count on one hand the device patients I follow who still smoke.

Blaming the patient?

Another small but distinct group of commenters felt I was blaming the patient for having disease. This line of reasoning got me thinking.

First, I went back to the piece and reread it a couple of times for tone. And yes, maybe, I was bold, or too definitive in my stance. The Swedish study, however, showed up to 80% of heart attacks might be prevented by simple lifestyle choices. And the investigators weren’t looking at the effects of boot camps or triathlon training, but just 5 simple things: a healthy diet (with fruits and vegetables), moderate alcohol intake, not smoking, being physically active and not having a large waist. I found this study and its results worthy of taking a bold stance.

So why is it that writing forcefully about lifestyle gets interpreted as blaming the patient? I suppose it’s complicated, but maybe I should have been more precise. I could have made clear that lifestyle does not prevent all heart attacks—just four of five. This means some patients will develop heart disease even if they make good choices.

I’ve run into this same issue with AF patients, too. When I advocate for lifestyle measures in the prevention (and now treatment) of AF, many patients write back to say they are doing things right and still getting AF. I see that in my practice; these are the ideal patients for catheter ablation, by the way.

Perhaps I make this error because I take for granted that not all disease is avoidable. There are people with genetic predispositions to disease. There is bad luck. And there is…it just happens.

So skilled doctors will always be needed.

The central problem I want to emphasize is the collective misthink that health comes from healthcare. In the majority of cases, four of five in the Swedish study, being healthy comes from making good choices every day. Stacking together the little things.

Doctors who ignore the huge gut, deconditioned muscles of non-use, or smell of smoke in the exam room do their patients and colleagues a great disservice.

JMM

14 comments

  1. John,
    What saddens me is that we are wealthiest country on earth, and are taking all this privilege and blessing and using it to become the unhealthiest people on earth. We are leaving a sad legacy to those being born today.

    Let me encourage you to be relentless with your message. First to your patients; then to your peers to be more vocal in their message. We simply dont have to be sick but we want what we want; and eating,
    living well is too high a price for this generation.

    I’ve never met you but hope to one day.

    Don’t be too hard on the negative commenters. There is hope for them as well

  2. Embedded in the negative reactions is the deep and complicated debate over the fundamental nature of health care. Is is a right or a privilege? If health care is a right, then what right does a physician have to deny someone the care they desire? If Americans are entitled to health care as a basic right, do patients have a responsibility as part of some social contract? I think much of the backlash is a strong scream NO!!!!!!!

    It doesn’t take much imagination to see the problems with the logical extension of such a philosophy.

    Also embedded is the question of who pays and how much. As long as patients pay for only a small portion (if any) of their health care, a refusal to make basic behavioral and dietary changes is essentially a demand that others pay for a potentially preventable intervention. Again, it’s easy to see the problem.

    I have no solutions, but I do suspect that the backlash is more than just a desire to keep eating poorly and a refusal to exercise.

    And….people are just bad at self evaluation. A large group is convinced that they’re in the small group for whom lifestyle changes won’t work. It’s Lake Wobeme (apologies to Garrison Keillor) where all the women have bad genetics, all the men are big boned, and all the children are cursed by a slow metabolism.

    1. Thanks Joe. I appreciate your clear outlining of the fundamental social issues.

      I agree with your points.

      One thing I did not want my words to convey is an opposition to treating disease, be it lifestyle-driven or otherwise. I’m a doctor and I enjoy helping people.

      In advocating for lifestyle modification, my main thrust is to help change the default to drugs and procedures for diseases that either didn’t have to be, or could be treated with simple choices. Right now, both the US citizenry and US healthcare profession are moving in the wrong direction. We are failing to master the obvious. You really notice this after returning from Europe. Or…

      Look at the tragedy of childhood obesity. Pediatricians and public health people are sideways about infectious disease yet right before their eyes is a far scarier expanding epidemic. Diabetes, high blood pressure, elevated cholesterol, atherosclerosis are not supposed to occur in young people.

    2. “Also embedded is the question of who pays and how much. As long as patients pay for only a small portion (if any) of their health care, a refusal to make basic behavioral and dietary changes is essentially a demand that others pay for a potentially preventable intervention. Again, it’s EASY to see the problem. ”

      So, what you would have, Joe, is that the fat, martini soaked corporate lawyer or bank executive pay for his own …ablation, say.
      You would also have me, always attentive to my lifestyle and health, but, nonetheless in need of a similar ablation, forego it because my humble yet demanding profession could not possibly provide me with the means.

      Dr John agrees with that?

      1. Hi Jeff-

        I only speak for myself, but there is lot of middle ground between paying almost nothing and paying 100%.

        Right now our system often makes the invasive procedure the cheapest option for a lot of patients. We also make it more rewarding for the hospital and those who work there.

        The technically difficult, riskier, and more expensive procedure should cost patients more than eating less and moving more. That doesn’t mean the price has to be prohibitive.

        In a perfect world, you would be able to afford the care you need AND people who would benefit from lifestyle changes would give those changes a fair shot.

        It goes without saying that our system is far from perfect.

        I often wonder what the upfront cash price for an afib ablation would be at a place like the OK Surgery Center.

        1. Flutter ablation in New England in 2013: $50,500 itemized bill total.

          I get a little nervous when people seem to be invoking Darwin: survival of the fittest when the fittest are those in possession of the most $money$, regardless of their ACTUAL WORTH — to society, to their culture, their family, to themselves.

          It’s a lot easier to conceptualize about “perfection” than to go out and achieve it. It’ll take a lot of small but difficult steps. This could be the beginning of one.

        2. I’ve never had a flutter ablation done so I have no idea. But if I had to pay the full upfront out of pocket price of $681 to see my EP, I would never go. LQTS is not modifiable by lifestyle other than to avoid strenuous exercise and a long list of medications. It would simply go untreated.

  3. As always, just great stuff. Thank you for helping with this “terrible disease”. I believe all of us who suffer this disease must take stock and and identify why/how this has happened and use your Risk Management protocols to help in the treatment of the disease.
    For me weight has always been an issue, alcohol and caffeine are contributing factors for sure. My alcohol consumption has gone from a couple of beers now and then to zero. Caffeine intake is limited – I hate the headache! – and weight is high for me, but not obese.
    I am 58 years young – So….how am I doing? Maintaining, but getting worse. No medication save metroporol, which I use to calm down and wait for the restoration of NSR – usually 6 to 10 hours. The only trigger I have now is……riding my mountain bike! And it is getting to the point that AF initiates about an hour into my ride.
    Since I love to ride and lift weights I am considering RFA as a first line treatment. Sitting around to maintain NSR as my health declines seems like a poor option. Riding my mountain bike for 6 to 8 hours a week has many benefits – mental and physical – that I don’t wish to lose at such a young age.

    Thank you for your down to earth, common sense approach to this vexing problem.

    1. Oh I feel your pain! My trigger was primarily mountain biking, road riding less so. We’d be out in the middle of nowhere and off it would go. One day was particularly bad and I would start to faint, couldn’t see due to the gray mist in the eyes and ran into a cholla. It was just pitiful. It’s really annoying when exercise is the trigger, it’s just wrong. Good luck with it.

  4. To follow my last response, would you consider a post someday about choosing and interviewing an EP Doc? I have one now, but he is trying to throw Anti-arrhythmic my way with no real explanation of the disease and it’s effect on the LA as it relates to the progression of the disease. He did an Echo – told my my LA was enlarged, and that was it! I had to go to the Internet to find out what this meant! Risk factor modification? nope. “Hey, this is only going to get worse. Have they shocked you yet?”!!

    How many RFA procedures – see my last post – should be the minimum number they have completed in their career to consider them for this treatment option?

    Thanks. I really value your opinion. Damn. Too bad I don’t live in Kentucky!

    How is your wife? My new hips came 15 years ago – I have never looked back – a real life saver. I actually started mountain biking about three years after my surgeries. I would be wheelchair bound without those hips!

  5. I first read the initial post on Medscape, and thought I would explore your blog further. I am a family doctor and an avid cyclist. Your comments echo some of my thoughts with regard to many illnesses that I treat daily. I will note we all have our own areas where we choose to be “non adherent” because of our own prioritization. You wrote about one of yours after your cycling spill and splinting sometime back. I have had similar prioritization issues in the past, and I find it difficult to be too demanding of my patients as a result. Proper encouragement and help in a search for motivation is *always* a good idea, however. It’s a fine line to walk between the two.
    Keep up the good work.

  6. Hello John
    I was so happy to read this article.
    Thank you for seeing the whole picture and the whole patient not just the next procedure.
    Thank you for making my job easier by encouraging wellness.

    I am an internist with special interest in wellness exercise diabetes treatment but most importantly plant based diet. I cannot tell you how great it is to have my colleagues in the cardiac neurology and other specialties back us up when they stress diet and exercise. Too often the knee jerk is to prescribe more stents or more drugs or [email protected] shocks/ [email protected]@ .

    More emphasis needs to be on you and me telling patients the truth about the extra weight, the extra drink, the lack of exercise. Too often, we insult our patients by assuming they will not or cannot change!

    The New Ulm Minnesota Cardiac Survey looked at 7 items in a rural population. I think you would agree these are well known to help prevent and reverse heart disease, and that most individuals can achieve all of these.

    http://www.jaha.ahajournals.org/content/2/3/e000058.full.pdf+html

    7 items they investigated
    1) No smoking/ smoking status
    2) BMI under 25
    3) Exercise 30 minutes 5 times a week (150 per week)
    4) 5 fruits and veggies every day
    5) BP 120-80 or under
    6) Cholesterol <200
    7) Sugar under 120

    The results were staggering: in this rural population 99.9% of the men failed to get all 7! What a whopping disaster. This from the "best health care system in the world".

    Now I am an optimist so I know we can do better. We need to invest in healthy communities, wellness programs, and shift incentives of patients doctors and hospitals.

    "Instead of sending ambulances to pickup bodies at the bottom of the cliff we need to build a fence at the top of the cliff".

    Keep writing !

    PS

    I am a fellow biker with a new AC grade 1 separation thanks to inattention and a pothole! Glad to hear you are on the mend I am itching to get back to it myself.

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