Thank you for your insight and for having the courage to share some of your deepest concerns. I speak as someone who feels, in many ways, like a time-traveler from another era. My medical career began 60 years ago—45 years in emergency medicine followed by 15 years in family practice.
In emergency medicine, our specialty treats more patients with acute and life-threatening illnesses than any other. That work fills the soul. We know, without question, that we are making a difference—literally saving thousands of lives over the course of a career.
Family practice is different. Many patients now come in essentially well, or with chronic conditions that require long-term management. And I’ve asked myself: What do we truly do for these well patients? It has become painfully clear that our healthcare system is built around treating sickness. The sicker the patient, the more the system rewards us. The more tests we order and the more medications we prescribe, the more “productive” we appear. We try, within that framework, to help patients stay well—but the model itself is backward.
We should be paid for keeping people healthy. But we aren’t. And that single fact would change everything.
In your article, you mentioned food and exercise almost as a footnote. Yet that is exactly where our focus should be—because that is how we help our “well patients” live longer, healthier lives.
The statistics are staggering: more than one million Americans die prematurely every year from preventable diseases—obesity, diabetes, infections, hypertension, heart disease, cancer, stroke, liver failure, Alzheimer’s, autoimmune illnesses, joint disease, depression. These conditions are overwhelmingly driven by lifestyle: lack of exercise, insufficient sunlight, chronic stress, sugary drinks, and the flood of highly processed “food” laced with thousands of untested chemicals manufactured by Big Food.
As primary care physicians, we have been derelict in our fundamental duty. Instead of addressing root causes, we have been treating the aftermath.
With my “well patients,” I no longer rely on lectures or generic advice. That approach has limited effect. Instead, I enroll them in an interactive, web-based program where we set specific, measurable goals together: nutrition, hydration, daily steps, sleep hours, weight changes, and more. They return weekly or monthly to record their progress, creating accountability. That allows me to encourage, redirect, and support them toward real, sustainable success.
The results have been profound. More than 100 of my patients have lost over 50 pounds each using this regimen. A1Cs normalize. Many are able to discontinue their blood pressure medications, statins, and diabetes drugs altogether.
If we don’t change our approach as a profession, we will become obsolete. The public is waking up.
As a layperson (I would say "patient" but I no longer access the medical system unless there's an acute issue) I saw years ago that medicine was concerned only with treating sickness. I was trying to find a practice that would help me with my goal of ultimate health, and it was so hard! I then realized that doctors do not understand real health, they aren't taught it in medical school and new ideas take tens of years to make it into clinical practice. So, I fired my PCP and have managed my own health ever since.
I just had my annual checkup, where my doctor told me I needed a pneumonia vaccination and I said OK. When I saw the itemized bill later, I was shocked to see that the vaccine alone was $522! Of course my insurance paid it all, but we really need more price transparency so people understand why insurance is so expensive. It's not just greedy CEOs.
Am commenting as a lowly peon, simply thinking about the state of affairs from the perspective of a person working very hard to avoid being sucked under by the medical system. If you want to really crank an individual during a well-patient (at least one with a brain) visit, just automatically give them a form to fill out on lifestyle and depression. Poorly prepared, with contradicting terms in the columns, and to top it off, with the fine print at the bottom: the acknowledgement by the preparing puffed-up Doctors of the funding provided by Pfizer. Yes, just another way to corral the patient into more medication. I mark “refused to participate”, and strike through all the sections. I will not comply, and find the present state of manipulative medicine to be at an all-time high (but it could get worse). My ‘real’ doctor was an old-school General Practitioner/Osteopath; he died in 2016. There is no one coming into medicine - at this time - with his diagnostic skill, earned over years of hand’s-on doctoring, which will never be obtained through looking at a computer screen and following mandated protocols. Please excuse butting in to a discussion by your peers.
Not all doctors want to be doing these forced depression screens. I recognize that, at some level, it is just another way to get patients on the hamster wheel of illness, AND these surveys distract us from what we are there to do. Deep inside, I applaud the patients that mark "not participating" or even provide saltier comments. Keep eating good food, exercising and practicing your faith. Why do we do it? We are forced to by corporate medicine.
As a physician in his late 60’s who works hard with diet, exercise and helpful medications to stay healthy, I loved this thoughtful and caring piece.
Bad health is going to happen to all of us. Where there are signs that something may be on the horizon that treatment may help, I’m all for investigations, and that includes judicious thoughtful screening (think, colonoscopy).
In contrast, PSA is a screening test that, as Adam and Co so ably discussed recently, is likely to markedly worsen the quality of life for 11 men who act on the results for every man whose life is saved. Personally, I am currently caught in the cycle of persistently somewhat elevated, yet non-diagnostic PSA tests that only serve to make me anxious and promote more surveillance. Yet I feel unable to get off this hamster wheel. The idea of shared decision making is, in theory a good one. But I just want to be told by someone I trust, that I can stop being tested. (But, can I?)
It is worth noting that, in newborns, universal screening for a raft of rare genetic diseases does save lives and improve long term outcomes — at the right end of life.
From the patient side, I am the patient you describe in your example. At a "check-up" I expect some kind of examination of me and my health concerns, but instead I have to run a gauntlet of questions / pressure tactics / sales pitches - the same ones every time. It degrades or prevents any kind of connection with the doctor (not "my" doctor - in our health systems I've had to give up on that). Such guideline-directed care is counter-productive and a barrier to real medical care. It makes me more likely to avoid appointments and less likely to receive care I might actually need - and I am sure I am not alone.
Has anyone attempted to study the "patient alienation" downside of all these guidelines?
I don't like and try not to use the term "healthcare". Health does not require care---illness does. The doctor's job is to diagnose illness and recommend treatment to cure or, most often, moderate the course of an illness. No one really knows how to prevent much of anything. I have never seen or heard of any "lifestyle" advice that differs in any significant way from that which our parents and grandparents passed on to us. The data on screening tests and early detection are not very encouraging. In forty years of medical practice, my advice was to see a doctor if you have unexplained symptoms or questions about your health. Otherwise avoid the medical system entirely as the chance that you will experience harm may well exceed the potential benefits. Most people ignored this and wanted "well" exams and screening anyway. But I felt it was important to give them information so that they could make their own choices. Most of this took place during a time when, believe it or not, many people only carried low cost and high-deductible medical insurance and paid routine bills out of pocket.
As a patient: agree on the term “healthcare” and the medical insurance issue. “Back in the day”, I carried what was called major medical insurance. If something big happened, I would be relatively covered. Otherwise, I paid my own bills. There were few, as I grew up in a family which advocated taking care of oneself. You have forty years of medical practice, so there is a possibility I may be ahead of you in age by 10 years. Am fortunate to take NO medications and continue to remain very active. It also helps the mind to research many subjects extensively. My revered father often said if you don’t stay active, you will grow roots. Take care.
Good article and I really enjoyed the podcast on this. When you have a mildly effective treatment for an infrequent condition the NNT explodes. It is always refreshing to see a study which confirms my underlying biases. I have long ignored the popups reminding me that to be a good doctor I should recommend Prevnar for otherwise healthy individuals.
Over time I have seen the conversion with patients shift slightly from "Which immunizations am I due for" to "Which immunizations do you recommend?" I try to save my credibility and capital with healthy patients for the immunizations that will benefit them and the answer is usually shingles.
I do feel however that I can do a good service to healthy people in the context of an annual physical or wellness visit. I often tell patients that 60-70% of all chronic illness is rooted in lifestyle and I think that lifestyle counseling is high yield.
My scheduling template allows for an extra 15 minutes for preventive exams and AWVs. I try to reframe these visits from "What icons do I need to click" to "How can I use this extra time to best serve the patient?" If that means looking at their creaky shoulder I do that and do not bill extra with a 25 modifier. Sometimes its just talking to them to get to know them better which may help us both down the road when they are sick.
One more thought, from years on the clinical lab beat: Ask yourself, and discuss with your patients, "What will I do with the results of this test?" If the answer, no matter what you find, is "supportive care" or the like, maybe skip it for now. I decline DEXA bone screening every year because I have no desire to take bisphosphonates, and I already know I should get weight-bearing exercise and get more calcium. And so forth.
As a 40-year medical writer and also a Healthy Boomer with a brilliant primary care doc, I have several suggestions for this dilemma of the ever-expanding brief for "well care":
1. Common sense. As I once heard a senior physician counsel a junior one (his son, as it happened): "Look at the patient." The elderly church-going widow can skip the HIV screening; the heavyset smoker needs the whole battery of monitoring for metabolic mayhem every year. Etc.
2. Avail yourself of the lovely educational handouts ginned up by every professional society, disease group, etc. Have someone print them out online or ask for a stack of them. The AHA does great ones. Hand them out judiciously but take a moment to make the patient understand you're not just giving them the brush-off, they gotta read this thing. And first, make sure the patient can read and that the pamphlet is in their primary language.
3. Have a nurse educator on your staff to do lifestyle counseling, new med onboarding, etc., and have the number of a diabetes educator at your fingertips!
4. Trim your budget and make your visit times longer. Because in a 10-minute visit with an oldie who takes 10 minutes to simmer down and stop yakking about tangential matters, you will not be able to do #1, above: Look at the patient. The extra time in the OV will be breathing space in which you can make better decisions about "how much to do" and what you can skip.
Wonderful (but also sobering and somewhat depressing) Friday thoughts.
I deal less often in primary prevention so my NNTs generally aren’t quite as high.
But even for no-brainer slam dunk interventions with an NNT of 10 (as a hypothetical example)….9 of those people are still going through the motions for nothing.
As I get to late career, I find myself paying much more attention to pt autonomy and the difference btw (as Dr. JMM puts it) maximizers and minimizers. Some people want to do “everything”; others, not so much. Of course this gets at the heart of the Sackett EBM Venn diagram sphere of “pt values and preferences”, which all clinicians at all career phases would do well to remember.
While yes there is a lot of money in producing and selling vaccines and statins, remember that a low-efficacy therapy with a high NNT may have a benefit to a population of people and thereby reduce healthcare costs even if it offers only a trivial chance of benefit to an individual in that population. That is a conflict of interest. Benefit to the insurer and the payer and the manufacturer, trivial or no benefit to the individual. Is it a surprise there is so much support for the treatment and so little explanation of how small is the benefit to an individual?
It’s an ethical question our society hasn’t become aware of. If we honor the sovereignty of the individual, which would be the Judeo-Christian, American value proposition, we would give him the NNT information for every test and therapy and ask him whether or not he wants it, rather than presuming it’s his duty to take it for the sake of lower insurance premiums or corporate profits.
I've stopped listening to my doctor during routine check ups. It's more a perfunctory checklist of "do you want to take XYZ?" Hell, an automated kiosk that takes my blood can replace the routine check up. My proposal would be to de-link the blood draw and the physical I can read the "in range" "not in range" But what makes my cardiologists GREAT is that we have a conversation. About risk and reward. And an explanation of why the risk is higher for this or that. He asks how I lost the weight, how I'm going to maintain the weight loss etc. The litmus test for a GREAT vs GTM (Going Through the Motions) doctor is that they LISTEN after asking "how're you doing?" The GTM doctors ask, then immediately login/type/lookup stuff etc. so they aren't listening to your answer. Not that I blame them, the PE bosses want efficiency so they don't have time for idle chit chat. But that idle chit chat about *you* the patient is what makes us, the patient, feel like we matter. Like it or not, Covid lockdown COMPLETELY opened my eyes. My default reaction is to NOT trust doctors who sound like they are reading from a pharma-reps play book. Before Covid, I thought doctors actually cared about me as a patient. And no one, but no one looks out for your wellbeing more than your family.
"Can we—or the FDA or guideline committees—say no to preventive therapy that works for a few but costs us all?"
How about a more modest proposal: can we make sure that patient preferences in chosing what care to pursue (after clear and easily understood solid discussions around benefit and harms have taken place ) are given the highest priority instead of lip service? Right now doctors are actually penalized for doing that...and patients do not know it.the whole thing is highly unethical.
Amen to "I would like to spend 20 minutes with my patients coaching them on their lifestyle habits, which brings the real value." Having a healthy diet and getting a reasonable amount of exercise and sleep have such powerful health benefits. One problem is that many doctors themselves do not follow healthy lifestyles or know little about how to implement them.
Thank you for your insight and for having the courage to share some of your deepest concerns. I speak as someone who feels, in many ways, like a time-traveler from another era. My medical career began 60 years ago—45 years in emergency medicine followed by 15 years in family practice.
In emergency medicine, our specialty treats more patients with acute and life-threatening illnesses than any other. That work fills the soul. We know, without question, that we are making a difference—literally saving thousands of lives over the course of a career.
Family practice is different. Many patients now come in essentially well, or with chronic conditions that require long-term management. And I’ve asked myself: What do we truly do for these well patients? It has become painfully clear that our healthcare system is built around treating sickness. The sicker the patient, the more the system rewards us. The more tests we order and the more medications we prescribe, the more “productive” we appear. We try, within that framework, to help patients stay well—but the model itself is backward.
We should be paid for keeping people healthy. But we aren’t. And that single fact would change everything.
In your article, you mentioned food and exercise almost as a footnote. Yet that is exactly where our focus should be—because that is how we help our “well patients” live longer, healthier lives.
The statistics are staggering: more than one million Americans die prematurely every year from preventable diseases—obesity, diabetes, infections, hypertension, heart disease, cancer, stroke, liver failure, Alzheimer’s, autoimmune illnesses, joint disease, depression. These conditions are overwhelmingly driven by lifestyle: lack of exercise, insufficient sunlight, chronic stress, sugary drinks, and the flood of highly processed “food” laced with thousands of untested chemicals manufactured by Big Food.
As primary care physicians, we have been derelict in our fundamental duty. Instead of addressing root causes, we have been treating the aftermath.
With my “well patients,” I no longer rely on lectures or generic advice. That approach has limited effect. Instead, I enroll them in an interactive, web-based program where we set specific, measurable goals together: nutrition, hydration, daily steps, sleep hours, weight changes, and more. They return weekly or monthly to record their progress, creating accountability. That allows me to encourage, redirect, and support them toward real, sustainable success.
The results have been profound. More than 100 of my patients have lost over 50 pounds each using this regimen. A1Cs normalize. Many are able to discontinue their blood pressure medications, statins, and diabetes drugs altogether.
If we don’t change our approach as a profession, we will become obsolete. The public is waking up.
As a layperson (I would say "patient" but I no longer access the medical system unless there's an acute issue) I saw years ago that medicine was concerned only with treating sickness. I was trying to find a practice that would help me with my goal of ultimate health, and it was so hard! I then realized that doctors do not understand real health, they aren't taught it in medical school and new ideas take tens of years to make it into clinical practice. So, I fired my PCP and have managed my own health ever since.
I just had my annual checkup, where my doctor told me I needed a pneumonia vaccination and I said OK. When I saw the itemized bill later, I was shocked to see that the vaccine alone was $522! Of course my insurance paid it all, but we really need more price transparency so people understand why insurance is so expensive. It's not just greedy CEOs.
Am commenting as a lowly peon, simply thinking about the state of affairs from the perspective of a person working very hard to avoid being sucked under by the medical system. If you want to really crank an individual during a well-patient (at least one with a brain) visit, just automatically give them a form to fill out on lifestyle and depression. Poorly prepared, with contradicting terms in the columns, and to top it off, with the fine print at the bottom: the acknowledgement by the preparing puffed-up Doctors of the funding provided by Pfizer. Yes, just another way to corral the patient into more medication. I mark “refused to participate”, and strike through all the sections. I will not comply, and find the present state of manipulative medicine to be at an all-time high (but it could get worse). My ‘real’ doctor was an old-school General Practitioner/Osteopath; he died in 2016. There is no one coming into medicine - at this time - with his diagnostic skill, earned over years of hand’s-on doctoring, which will never be obtained through looking at a computer screen and following mandated protocols. Please excuse butting in to a discussion by your peers.
Not all doctors want to be doing these forced depression screens. I recognize that, at some level, it is just another way to get patients on the hamster wheel of illness, AND these surveys distract us from what we are there to do. Deep inside, I applaud the patients that mark "not participating" or even provide saltier comments. Keep eating good food, exercising and practicing your faith. Why do we do it? We are forced to by corporate medicine.
Im going to add this to the "things we do for no reason" series I give to medicine students. Thanks!
No mention of PCV 21?
As a physician in his late 60’s who works hard with diet, exercise and helpful medications to stay healthy, I loved this thoughtful and caring piece.
Bad health is going to happen to all of us. Where there are signs that something may be on the horizon that treatment may help, I’m all for investigations, and that includes judicious thoughtful screening (think, colonoscopy).
In contrast, PSA is a screening test that, as Adam and Co so ably discussed recently, is likely to markedly worsen the quality of life for 11 men who act on the results for every man whose life is saved. Personally, I am currently caught in the cycle of persistently somewhat elevated, yet non-diagnostic PSA tests that only serve to make me anxious and promote more surveillance. Yet I feel unable to get off this hamster wheel. The idea of shared decision making is, in theory a good one. But I just want to be told by someone I trust, that I can stop being tested. (But, can I?)
It is worth noting that, in newborns, universal screening for a raft of rare genetic diseases does save lives and improve long term outcomes — at the right end of life.
I like "Bad health is going to happen to all of us."
Thanks
Adam
From the patient side, I am the patient you describe in your example. At a "check-up" I expect some kind of examination of me and my health concerns, but instead I have to run a gauntlet of questions / pressure tactics / sales pitches - the same ones every time. It degrades or prevents any kind of connection with the doctor (not "my" doctor - in our health systems I've had to give up on that). Such guideline-directed care is counter-productive and a barrier to real medical care. It makes me more likely to avoid appointments and less likely to receive care I might actually need - and I am sure I am not alone.
Has anyone attempted to study the "patient alienation" downside of all these guidelines?
I don't like and try not to use the term "healthcare". Health does not require care---illness does. The doctor's job is to diagnose illness and recommend treatment to cure or, most often, moderate the course of an illness. No one really knows how to prevent much of anything. I have never seen or heard of any "lifestyle" advice that differs in any significant way from that which our parents and grandparents passed on to us. The data on screening tests and early detection are not very encouraging. In forty years of medical practice, my advice was to see a doctor if you have unexplained symptoms or questions about your health. Otherwise avoid the medical system entirely as the chance that you will experience harm may well exceed the potential benefits. Most people ignored this and wanted "well" exams and screening anyway. But I felt it was important to give them information so that they could make their own choices. Most of this took place during a time when, believe it or not, many people only carried low cost and high-deductible medical insurance and paid routine bills out of pocket.
Great comment. Thanks. I especially like "Health does not require care---illness does." So true.
Adam
As a patient: agree on the term “healthcare” and the medical insurance issue. “Back in the day”, I carried what was called major medical insurance. If something big happened, I would be relatively covered. Otherwise, I paid my own bills. There were few, as I grew up in a family which advocated taking care of oneself. You have forty years of medical practice, so there is a possibility I may be ahead of you in age by 10 years. Am fortunate to take NO medications and continue to remain very active. It also helps the mind to research many subjects extensively. My revered father often said if you don’t stay active, you will grow roots. Take care.
Adam
Good article and I really enjoyed the podcast on this. When you have a mildly effective treatment for an infrequent condition the NNT explodes. It is always refreshing to see a study which confirms my underlying biases. I have long ignored the popups reminding me that to be a good doctor I should recommend Prevnar for otherwise healthy individuals.
Over time I have seen the conversion with patients shift slightly from "Which immunizations am I due for" to "Which immunizations do you recommend?" I try to save my credibility and capital with healthy patients for the immunizations that will benefit them and the answer is usually shingles.
I do feel however that I can do a good service to healthy people in the context of an annual physical or wellness visit. I often tell patients that 60-70% of all chronic illness is rooted in lifestyle and I think that lifestyle counseling is high yield.
My scheduling template allows for an extra 15 minutes for preventive exams and AWVs. I try to reframe these visits from "What icons do I need to click" to "How can I use this extra time to best serve the patient?" If that means looking at their creaky shoulder I do that and do not bill extra with a 25 modifier. Sometimes its just talking to them to get to know them better which may help us both down the road when they are sick.
As someone tortured by the AWV, I like this approach. Thanks.
Adam
One more thought, from years on the clinical lab beat: Ask yourself, and discuss with your patients, "What will I do with the results of this test?" If the answer, no matter what you find, is "supportive care" or the like, maybe skip it for now. I decline DEXA bone screening every year because I have no desire to take bisphosphonates, and I already know I should get weight-bearing exercise and get more calcium. And so forth.
As a 40-year medical writer and also a Healthy Boomer with a brilliant primary care doc, I have several suggestions for this dilemma of the ever-expanding brief for "well care":
1. Common sense. As I once heard a senior physician counsel a junior one (his son, as it happened): "Look at the patient." The elderly church-going widow can skip the HIV screening; the heavyset smoker needs the whole battery of monitoring for metabolic mayhem every year. Etc.
2. Avail yourself of the lovely educational handouts ginned up by every professional society, disease group, etc. Have someone print them out online or ask for a stack of them. The AHA does great ones. Hand them out judiciously but take a moment to make the patient understand you're not just giving them the brush-off, they gotta read this thing. And first, make sure the patient can read and that the pamphlet is in their primary language.
3. Have a nurse educator on your staff to do lifestyle counseling, new med onboarding, etc., and have the number of a diabetes educator at your fingertips!
4. Trim your budget and make your visit times longer. Because in a 10-minute visit with an oldie who takes 10 minutes to simmer down and stop yakking about tangential matters, you will not be able to do #1, above: Look at the patient. The extra time in the OV will be breathing space in which you can make better decisions about "how much to do" and what you can skip.
Cheers,
Your Friendly Neighborhood CME Writer
Great points, thanks.
Adam (Son of Anne from Lefferts Gardens)
Wonderful (but also sobering and somewhat depressing) Friday thoughts.
I deal less often in primary prevention so my NNTs generally aren’t quite as high.
But even for no-brainer slam dunk interventions with an NNT of 10 (as a hypothetical example)….9 of those people are still going through the motions for nothing.
As I get to late career, I find myself paying much more attention to pt autonomy and the difference btw (as Dr. JMM puts it) maximizers and minimizers. Some people want to do “everything”; others, not so much. Of course this gets at the heart of the Sackett EBM Venn diagram sphere of “pt values and preferences”, which all clinicians at all career phases would do well to remember.
While yes there is a lot of money in producing and selling vaccines and statins, remember that a low-efficacy therapy with a high NNT may have a benefit to a population of people and thereby reduce healthcare costs even if it offers only a trivial chance of benefit to an individual in that population. That is a conflict of interest. Benefit to the insurer and the payer and the manufacturer, trivial or no benefit to the individual. Is it a surprise there is so much support for the treatment and so little explanation of how small is the benefit to an individual?
It’s an ethical question our society hasn’t become aware of. If we honor the sovereignty of the individual, which would be the Judeo-Christian, American value proposition, we would give him the NNT information for every test and therapy and ask him whether or not he wants it, rather than presuming it’s his duty to take it for the sake of lower insurance premiums or corporate profits.
What do you think about that?
Excellent. I've got one on ethics of screening in a few weeks, I look forward to your take on it.
Thanks.
Adam
I've stopped listening to my doctor during routine check ups. It's more a perfunctory checklist of "do you want to take XYZ?" Hell, an automated kiosk that takes my blood can replace the routine check up. My proposal would be to de-link the blood draw and the physical I can read the "in range" "not in range" But what makes my cardiologists GREAT is that we have a conversation. About risk and reward. And an explanation of why the risk is higher for this or that. He asks how I lost the weight, how I'm going to maintain the weight loss etc. The litmus test for a GREAT vs GTM (Going Through the Motions) doctor is that they LISTEN after asking "how're you doing?" The GTM doctors ask, then immediately login/type/lookup stuff etc. so they aren't listening to your answer. Not that I blame them, the PE bosses want efficiency so they don't have time for idle chit chat. But that idle chit chat about *you* the patient is what makes us, the patient, feel like we matter. Like it or not, Covid lockdown COMPLETELY opened my eyes. My default reaction is to NOT trust doctors who sound like they are reading from a pharma-reps play book. Before Covid, I thought doctors actually cared about me as a patient. And no one, but no one looks out for your wellbeing more than your family.
"Can we—or the FDA or guideline committees—say no to preventive therapy that works for a few but costs us all?"
How about a more modest proposal: can we make sure that patient preferences in chosing what care to pursue (after clear and easily understood solid discussions around benefit and harms have taken place ) are given the highest priority instead of lip service? Right now doctors are actually penalized for doing that...and patients do not know it.the whole thing is highly unethical.
Amen to "I would like to spend 20 minutes with my patients coaching them on their lifestyle habits, which brings the real value." Having a healthy diet and getting a reasonable amount of exercise and sleep have such powerful health benefits. One problem is that many doctors themselves do not follow healthy lifestyles or know little about how to implement them.