I’ve recently read with great interest a couple of blog posts that have generated a lot of discussion. The articles were written after Tony Gentilcore, one of my favourite bloggers to read in the field of training, strength and conditioning posted a comment on Facebook that read, “I’m sorry but just because “your doctor said so,” doesn’t mean you’re right.” The first response to that was by Joe Lightfoot a strength coach and medical student http://www.tonygentilcore.com/blog/just-because-a-doctor-said-it-a-response/ . His article was then responded to by Dr Bojan Kostevski, a practicing physician in Sweden http://www.lift-heavy.com/a-doctors-response-to-a-response-from-a-doctor/. The issues brought up in the blogs challenged the notion that your doctor should have an answer for all of your health related questions. Is that a reasonable assumption in this day and age? Should your doctor know more about nutrition, weight loss and fitness? Or are these issues that should be relegated to professionals outside of medicine? How much should we hold our doctors responsible for?
Before I get started, for those of you reading this who don’t know me, let’s get a few things out of the way. First, I am a chiropractor. Now before you jump to conclusions about what that means to you, let me toss a few facts your way. Before I became a chiropractor, I was a medical radiation technologist for over 10 years, working in tertiary care teaching hospitals in London, Toronto, and Seattle. I am very familiar with the medical system and how it operates. My chiropractic practice is very heavily rehabilitation based, meaning that if you come to my clinic to receive treatment, be sure that I’m going to ask you to do some work to help yourself. I am a big fan of Charlie Weingroff’s Training = Rehab, Rehab =Training, which is why I tend to read a lot of blogs like Charlie Weingroff http://charlieweingroff.com/, Tony Gentilcore http://www.tonygentilcore.com/ , Jon Goodman’s PTDC http://theptdc.com/ and http://www.jonathangoodman.ca/ and Gray Cook’s book Movement http://graycookmovement.com/ – they provide me with a lot of information that helps me rehab my patients. I am not a subluxation based chiropractor, meaning I don’t believe that alignment of the spine is the keystone to your every health problem. Is it an element of good health? Sure. Will you die if you’re not adjusted every week? No. My patient intakes consist of an extensive history where we address not just the musculoskeletal complaint, but also talk about lifestyle, nutrition and stress. Why? Because it usually all relates to the initial complaint. One of the areas where western medicine has dropped the ball is that it has gotten very good at divorcing the physical from the mental/emotional/spiritual aspects of the patient. We spend more and more money on expensive tests and technology that are able to look at the body in smaller and smaller pieces, instead of treating the person as a whole. But we are more than just bones and tissue, we have other vital aspects of us that make us who we are and can affect our health. To ignore those is to attempt to fix a body part, not restore health in an individual.
Don’t Blame the Patient, It’s Part of My Job…..
Dr Kostevski’s article to me encapsulates what is wrong with our medical system. And I mean no disrespect to Dr K or any other medical practitioner; it’s the system that’s at fault, not the doctor. I’m sure that Dr K is a very caring, empathetic physician, skilled at what he has been trained to do, and passionate about going beyond what his medical training provided. A quick look at his blog is a testament to that. But it’s not about him or any other doctor. It’s about the system.Sure our doctors overworked. Many of them find it near to impossible to keep up with the daily demands of their practices as it is. Based on the number of journal articles published, estimates are that the amount of scientific knowledge has been doubling approximately every 15 years since 1900. How could anyone stay on top of all of that? It’s just not possible. But should doctors know more about how nutrition, exercise, and lifestyle affect the health of the people they are trying to help? Absolutely. What the medical doctor has to say for many people, especially those in the older generations, is the gold standard and is rarely questioned. We live in a culture where the public has the expectation that their doctor has all of the answers to every question. Really though, it’s completely unreasonable to expect this from any medical provider. But here’s the kicker – it is the medical system that has created this culture. The medical community wants to be known as the primary source for health information. People have been socialized to expect that their doctor has the answers they are looking for, and to question your doctor is generally frowned upon. Additionally, many doctors dismiss the notion that other healthcare providers, like chiropractors and naturopathic doctors could possibly have anything to offer their patients. At best they don’t suggest it, and at worst they openly disparage chiropractors and naturopaths and direct patients not to see them. So it’s not unreasonable for the population to look to the medical community for answers to their questions. People are more educated about their health and have a strong desire to know more, which is great. People taking responsibility for their health is never a bad thing. But the problem is that there is so much information out there, it’s hard for them to be able to critically look at the information and decide what information is good and what is not. That is where the doctors have an opportunity to help. If the doctor doesn’t have the information the patient needs, then they should at least be able to point them in the direction of someone who does. Chiropractors and naturopaths are perfectly positioned to be able to assist with many conditions that are lifestyle related. As a chiropractor, my training has given me the skills to identify other conditions that may not lie within my scope of practice so that I can make the appropriate referral. The medical doctor may have to invest some time into finding practitioners whose clinical judgment they can trust, but then the payoff is that they would able to triage their patients to practitioners who have the skills, time and knowledge to help take care of these chronic conditions and provide patients with the answers they are looking for.
In his article, Joe Lightfoot states, “Doctors need more education on everything to do with lifestyle advice, particularly exercise and nutrition. That is indisputable.” The response given by Dr K really illuminates why modern healthcare is struggling. He states that the idea that doctors should know more about exercise and nutrition is a fantasy. “Sure, doctors need to understand human physiology and the effects of lifestyle on the pathological processes, to a minimal degree. This is a very important point, which is why I will repeat it: they need to understand it, to a minimal degree (his emphasis).” Minimal degree? That makes me cringe. Again, no disrespect to Dr K, because he is working within the construct of a dysfunctional paradigm. It shouldn’t be a fantasy that your doctor has good sound current advice on nutrition, exercise, and lifestyle. Doctors should have an extensive body of knowledge on how physiology and lifestyle affect pathological processes. Why? Because understanding that and utilizing that information in educating patients moves into the realm of preventative medicine, keeping people healthy and giving them the tools and information they need to stay healthy. Keeping people well is more cost-effective than fixing them after they’re broken. Reactive medicine is in my opinion why our healthcare system is under such duress. Because we fail as a system to adequately educate people about health, sending mixed messages about what is and is not healthy, and we put most of our health care dollars into treatment instead of prevention, we allow people to develop these chronic conditions like diabetes, hypertension, obesity, and chronic pain which take up a lot of a doctor’s time and suck tens of millions of dollars out of the healthcare system. Doctors can’t possibly have all of the answers, but that shouldn’t let them off the hook for not having an adequate body of basic, current knowledge on issues relating to exercise and nutrition. Doctors are required to take part in continuing education every year. Typically these days, much of this education is provided by drug companies educating doctors on their newest medications. The number of journal articles documenting this unfortunate association with its inherent conflict of interest is legion http://policymed.typepad.com/files/esc-white-paper-cme—executive-summary2.pdf . As a chiropractor, the mandate by our licensing body is that about a quarter of my continuing education requirements deal with proficiency in reading x-rays, MRI and CT scans. Why not mandate that medical doctors have to include a mandatory number of hours of education on nutrition, exercise, and lifestyle and their effects on health? You can’t learn it all at school, but the learning doesn’t stop when school ends. Why wait for disease? Preventative medicine saves lives and improves health at an acceptable cost.
Figure It Out??
So why do doctors give advice? Perhaps it is just because they want to help, even if they don’t have the most current information. But the article states that it’s up to the patient/consumer to be smart enough to know who to listen to. “That does not mean they (medical doctors) know what they are talking about, and YOU are the misinformed one who thinks that’s what they are supposed to know. If you’re not smart enough to know who to listen to, then you’re just as “dumb” as they are. Don’t blame others because they tried to help your ass out.” I disagree. I think in many cases, doctors give advice because they feel they have to. They have a patient sitting there in front of them waiting to hear a response from the one person they’ve been told has all of the answers. The doctor feels the pressure of that expectation, knows that if they don’t have an answer the patient will think they’re not a good doctor, or aren’t very smart or will be back in their waiting room in a week asking the same question. So they say something, anything, to satisfy the patient and get them out of the office. I see it a lot. Patients leaving offices with diagnoses of “arthritis” in their spine, or “old age” or as Louis CK says “shitty ankle.” http://youtu.be/WzEhoyXpqzQ
And yet we know more and more that structural changes in the spine like arthritis often have no bearing on why a patient is having pain. It’s less about structure and more about function. And while age can be a factor in musculoskeletal conditions, that’s all it is. It’s not the cause. Telling a patient their problem exists because they are old instantly sucks every bit of hope out of them, leaving them feeling defeated. Age is causing my problem, I can’t change my age, I guess I’ll just have to suffer. Should that be the result of a “health care” interaction? In reality, even if age is a factor, there is almost always something a patient of any age can do it improve their condition. How can people be “smart enough” when there is so much information out there that it’s difficult even for us as physicians and health professionals to sort through all of it? It’s nearly impossible for the health care consumer to be able to consistently access good quality, reliable information and be confident that the information will provide the answers they are looking for. On top of that, the majority of people out there are educated by media that tells them which drug to ask their doctor about, or that Nutella is part of a healthy breakfast, or that “X” product is “heart healthy”, even though the company simply had to pay the Heart and Stroke Foundation for the privilege of putting their Health Check logo on its box, regardless of the truth in the statement.
Our Ability to Communicate is Part of the Health Care Interaction. Actually, It’s Kinda a Big Deal….
It is true that these days the general population does have access to a lot of the same information that medical doctors have, but they do not necessarily have the critical thinking skills or education to know how to use those resources safely or appropriately. That’s why they ask us. When we as physicians answer a patient’s questions we must not forget that this patient-doctor communication is also part of the health care interaction. We are addressing the patient’s psychosocial need for answers, helping the patient feel more in control of their health situation and giving them reassurance that there is more information that can help them as they try to regain health or improve their condition. And that is no small thing. An article in the Journal of Biobehavioural Medicine titled “Rethinking medicine: improving health outcomes with cost-effective psychosocial interventions” states,
“This critical mismatch between the psychosocial health needs of people and the usual medical response leads to frustration, ineffectiveness, and wasted health care resources. There is emerging evidence that empowering patients and addressing their psychosocial needs can be health and cost effective. By helping patients manage not just their disease but also common underlying needs for psychosocial support, coping skills, and sense of control, health outcomes can be significantly improved in a cost-effective manner”
It’s not about smart or dumb. It’s about education. And as front line health care providers, a lot of that responsibility lies with us.
Dr K continues, “ lifestyle and related conditions are not what doctors work with on a day to day basis”. Seriously? If we even just take obesity out of the picture, think about the effect on the healthcare system when we see less of the illnesses related to obesity: Type 2 diabetes, heart disease, stroke, hypertension, nonalcoholic fatty liver disease, gallbladder disease, osteoarthritis, respiratory illness like sleep apnea, breast, colorectal, endometrial and kidney cancers, pregnancy and menstrual issues. I do think that more training about nutrition, exercise, and lifestyle for our doctors is a big part of the answer. As well, medical schools would do well to foster an environment of collaboration by providing education for medical students about the training and skill-set that chiropractors and naturopaths possess and the ways we can help.
I can’t stress enough that I am not trying to personalize this against Dr K. To some degree he is simply communicating the realities of medicine in this day and age. I don’t agree with disparaging doctors and blaming them for not having all of the answers. They are in a tough spot. Not enough doctors, too many patients, limited time and resources, having to see more patients in a day in order to pay for escalating costs in insurance and overhead- it’s a hard to win situation for many of them. But the answer is not to blame the population for not fitting the system; the answer should be changing the system to meet the needs of an ever changing and growing population. We owe it to our patients to admit when we don’t have the answer, and to assist them in finding someone who does.
In a perfect world the system would provide the training the doctors need, not leave it up to the pharmaceutical industry, or put the onus on the doctor to somehow squeeze more work into an already impossibly crowded schedule. As Joe stated in his article, “Someone once told me that to change a health care philosophy would take 50 years. So I figured we best get started. A major step is getting doctors and coaches to work together, and it starts with mutual respect of each other skills”. I agree. This also applies to the medical practitioners and chiropractors or naturopathic doctors. Discussions like the ones started by Joe Lightfoot and Dr K’s blog posts can only help this process along. One of the things about the blogosphere which has excited and motivated me so much is seeing the interaction and sharing of ideas between all professions – medical, chiropractic, physio, strength and conditioning – and continuing to develop these relationships and discussions will only help medicine, rehabilitation, and fitness evolve a better healthcare paradigm for everyone.The Canadian Physiotherapy Association in a position letter to the Canada Health Council regarding their “Value for Money” initiative states,
“Value in healthcare happens when patients receive the right care in the right place at the right time. By removing traditional barriers to early intervention and encouraging inter-professional collaboration, innovative (multidisciplinary) health centers can reach for better outcomes at lower cost. The results are healthier living, disease prevention, and prompt return to function and a reduction of the impacts of chronic disease on quality of life.”
I couldn’t agree more.