Treating (or not treating) the Sick, the At-risk, the Well, and the Hobbyists
My father graduated from medical school in 1955. He completed a rotating generalist internship at City Hospital on Wards Island in New York. He then trained in psychiatry at Bellevue and the Manhattan VA. Later, he did psychoanalytic training and focused his practice on adolescents.
He employed pharmaceuticals in his practice throughout his career -- antipsychotics, tranquilizers, early antidepressants – but psychiatry in general, and his practice in particular, was heavy on therapy and light on drugs.
This changed after the release of fluoxetine in 1988. The expectation of patients and specialty societies was that care would be more about pharmaceuticals. My father did not think that the change was for the worse, but in his last decade of practice, he saw his field becoming unrecognizable.
I sometimes feel like this is happening to me. I chose my field and trained to treat the sick. I learned to (lightly) embrace my role in disease prevention. But now, more and more, people expect interventions that are more about lifestyle. I am not even sure that lifestyle is the right term; performance, wellness, or even cosmetics might be more appropriate. I don’t like offering this type of treatment; I wonder if I should; I wonder if not offering it is acceptable.
There are four types of concerns that people present to me, a general internist. For thee of these concerns, I know where I stand. For the fourth, I am conflicted.
I care for people who are sick. These are people who come to me feeling poorly, or with a diagnosis, or with abnormal test results. This is why I do what I do. I love the intellectual challenge of making a diagnosis and crafting a treatment plan. I love collaborating with colleagues toward improving the health of my patients. I love working with and caring for the patient during the evaluation, the treatment, and beyond. When I eventually stop working, I will read the Case Records of the Massachusetts General Hospital every week just for sport.
I didn’t become a primary care general internist to do screening and health promotion, but I have embraced the role. I retain healthy skepticism about the benefit of treating the healthy. I remain a medical conservative and recognize the risks of screening.1 But I also know that I can help people live longer and better through education and assisting them in changing their behaviors. Simple, evidence-based counseling on diet, exercise, smoking cessation, and harm reduction pays dividends, as does some screening and risk factor modification.
As clear as it is to me that I have a role in treating the sick and counseling the healthy, it is equally clear to me that I want no role in people’s wellness hobbies. Some of these hobbyists feel poorly, and some feel well, but they are all interested in remedies or enhancers being sold to them. The products come with stories but no actual evidence. The elixirs often come with three-word names: Jamaican noni juice, wild Canadian chaga, red yeast rice, apple cider vinegar.2 Some are sold anonymously (or at least algorithmically) online, while others are sold personally through an array of wellness practitioners. When people try to involve me in their hobby, I express my doubts and counsel them about the absence of evidence, the lack of regulation, and the presence of cost. I will get involved when ill effects occur; otherwise, I demur.
The fourth category is the one that challenges me. These are patients who are not sick but recognize that they are not perfect. Some people are experiencing signs of aging: they have less energy, they take longer to recover from an injury, they don’t sleep as well, their libido has waned. Some people are young and feel like they should be better. They are seeking prescription medications, usually for an off-label use. Common requests are GLP-1s, testosterone, stimulants, and 5-alpha reductase inhibitors.
These requests usually lead me to think:
I’m not writing for that. I am not here to prescribe performance enhancers. This is not what I trained for. I am supposed to be helping the sick, helping to keep people well, not prescribing medications to those who have researched what might make them feel a bit better.
But when I reflect more thoughtfully, the complexity presents itself. What separates these requests from some of the treatments we don’t question? I don’t hesitate to treat menopausal symptoms. I would never withhold an SSRI for someone with mild dysthymia. I’ve prescribed odd cocktails of medications to help people with their jet lag.
While my father saw his field change from one based on talk therapy to one based on medications, I am seeing mine change from a focus on the treatment and prevention of disease to one that includes helping people improve. The origin of this evolution is complex. It includes a change in what people expect from medicine and what they think is possible. It includes the strange way we pay for our healthcare. It comes from savvy marketing by drug makers and companies like Hers, Hims, or Ro.
I admit to feeling a bit lost. I can still fall back on evidence-based medicine. Have the enhancers you are requesting actually been proven to be safe and effective? Quite often, they haven’t, as there is little incentive to test an already approved drug for a new indication for which it is already being used. Mostly, though, I need to consider how far I want to stretch my role. Personally, I am fortunate to be at a place in my career where I can refuse to evolve. That is not true for my younger colleagues.
If you’re playing the Ending Medical Reversal/ Medical Conservative citation drinking game, bottoms up!