I can help you with this in two categories. Dr. Lordon a nephrologist and Chief of Medicine who terrorized us at morning report, told us to “never trust your mother.” he basically said that the history is the most important part of being a doc and as physicians we have to really understand when we’re being lied to. Which is always.I can tell you as a cardiologist so many patients have told me they are “asymptomatic.”- but they need an asterisk that defines asymptomatic as no problem while sitting with your feet up watching television for 12 hours. You put them on the treadmill they walk 20 seconds and get chest pain and out of breath. There was also a study that you’re probably more familiar with where they took random people off the street gave them Prozac and they actually felt dramatically better. The reality is most of us are dysthymic ; just watch TV every night. My partner literally went into atrial fibrillation with RVR four times a week usually at 5:30. He’s a well-known cardiologist -he didn’t put it together. He was watching cable news. Did he need flecainide or Netflix?
The absence of disease is not the same as the presence of health. Tirzepatide for me has been life-changing - I became depressed after forced medical retirement and gained 60 pounds. I got my life back ; (the blood work and everything got better and now Humana doesn’t want to pay for it. )The difference was if the doctor had told me to walk more and eat less three years would’ve gone by and I would be a lot worse off plus have lost that life -literally lost it. Our jobs as physicians, especially in cardiovascular disease is not just to prolong life, but in every aspect to help people improve the quality of their life. Talk therapy has helped so many people in that regard. Anyway - picking up the rare disease ( I dx a melanoma while examining the posterior lungs of a patient who clearly had non-cardiac chest pain for example) may feel heroic. My PCP taking time to tell me that being a grandfather is can be just as important as being a doc and I should embrace my new role in retrospect was very heroic. We just don’t often appreciate the daily impact we have. I am confident that you are doing this on a daily basis and have done so for years. I can tell you that cause I’m probably older and a senior. I also spend a lot more time in the waiting room these days and I hear what the people are saying. They don’t want miracles with someone who cares.. that is the most valuable treatment.
But you did once prescribe a literal performance enhancer for me, and I was SO grateful! It was propranolol for my Boswell-Jazz singing gigs. As far as I was concerned, you were dispensing magic. :)
One comment about Red Yeast Rice. For those of us with both intense medication sensitivities and familial problems with statins, it's an excellent alternative, since it has Monacolin K, the same active ingredient as statins, but structured differently. My LDL is going down with Red Yeast Rice, and I have not had side effects. BTW, it was "prescribed" by my PCP (from UCSD).
Adam , as an internist with decades of experience that align with yours, my lifestyle advice has been well received, but very poorly executed. So it is with a mixture of excitement and fear that I see some friends, family, and patients injecting themselves with compounded GLP-one agonists—no physician supervision required!—finally achieving substantial weight loss that they’ve been struggling with for decades.
It’s unfortunate that at least in this country these drugs are so damned expensive that many people that could benefit from them the most can’t afford them.
I await the results of this grand experiment with bated breath.
I have heard that it is a problem that nutrition isn’t taught in medical school. The truth is more complicated. Nutrition is taught — but mostly in the form of biochemistry and disease‑state management. We learned metabolic pathways, micronutrient deficiencies, and how to manage things like total parenteral nutrition. What we didn’t learn was how real people actually eat.
No one taught us about carnivore, keto, Mediterranean, or whole‑food plant‑based diets. And part of the reason is simple: there’s very little consensus on what an “optimal” diet even is. The evidence shifts, the cultural noise is loud, and every specialty has its own angle.
My own bias — and it is a bias — is that a plant‑forward pattern is the most sustainable approach for long‑term health. When you look at the diets that consistently show benefit, they all share one feature: an emphasis on whole plants. That’s the part that seems to endure, even as trends come and go.
Linda University, where they teach nutrition pretty well, and emphasize the benefits of a vegetarian diet. They were way ahead of their time on that one.
The doctor's role is to differentiate health from disease. Health is our natural condition and is simply the absence of disease. No one knows how to provide health or prevent disease. Some that claim the ability to do so are sincere in their beliefs but there is often no scientific evidence or even biologically plausible mechanism to justify it. In fact, much of the advice given regarding "lifestyle" factors is scientifically unfalsifiable. I often told patients that there was no reason to pay me or anyone else for advice that they got free from their grandmother. I never met a patient that didn't already know that it might not be a good idea to inhale smoke into their lungs on a regular basis.
I think you're too hard on the hobbyists. Provided something is safe and not too expensive, I am excited for my patients to try elixirs of hope. True, I won't prescribe them, and true, I won't endorse their effectiveness, and true, I might throw some shade on the profit-motive of the supplement pushers. But I am very happy to follow along and see if the red cider vinegar does the trick! Let me know how it works! When I see you back for my next visit, you have to update me on whether it solved your problem! This could help out other patients too!
Why, I'll even try an unpleasant tea made from expired Mexican bark brought to me by a dialysis patient that is the secret to his well-preserved kidney health.
Timely article for sure, I have dipped into the 4th category and am somewhat embarrassed to admit it. My doctor listens to me and will support what I want to "try" and she will stress what is protocol and the data behind it. Recently asked about switching oral progesterone to vaginal after hearing about the first pass liver metabolites leaving less for the bones, brain, and uterus. Doing so would be off label but in the end it is up to me
It's exactly the 4th category that I'm most fascinated with. I didn't see much positive result in my family medicine practice when I would constantly escale medications, treatments, and referrals. Perhaps that was the nature of the disease or the patient pool. Now I quite enjoy working with those who are seeing the first signs of aging like stubborn weight, fatigue, or brain fog and figure out how to get them back to normal without magic supplements or cleanses. Just some good old, back to the basics lifestyle changes.
Unmet market needs will be filled. Ride sharing, nurse practitioners, urgent cares, VRBOs, restaurant delivery companies, medical marijuana all met (or created) market needs that had been unsatisfied. I think the wellness universe has emerged and prospered in a similar context. Wellness consumers are not demanding persuasive medical evidence. They seek the promise of relief particularly for maladies and health maintenance and longevity that conventional medicine hasn’t reliably delivered. The billions of dollars at stake along with superb and ubiquitous marketing and seemingly limitless public demand have created a growing wellness behemoth.
Great insightful piece as usual. This a huge chunk of my clinic that is spent on not sickness but improvement of already reasonably good health. Also much harder than treating the sick. And far from as rewarding.
I see category 4 as an extension of cat 3. If group 3 are the wellness folk, I’d characterize group 4 as the maximizers. Maybe not quite as crass as the “looksmaxxers” du jour, but on the same spectrum.
I’d lean on that conservatism principle. It also keeps the convo short. “Is there evidence of benefit for what you want to use, to achieve what you want to do? If not, then I’m not your guy.”
For those would be 'enhancers' I have to ask myself (and them), what do you think you are improving from and to, and why. I look at my job as easing the slow of decline to a death they are prepared for. Not to stop it or reverse it (as if that were possible). The choice is gradually, gracefully going into that good night or racing blindly headlong towards a cliff they are not prepared for. It may be too spiritual for some, but I see my job as helping patients to integrate inevitable decline and death into a healthy, enjoyable life. Where Medicine is in the background and living is forefront. Sad how much we promote and cash in on the mantra "You can be and do more". And this in the face of a costly, poorly performing medical system compared to other much healthier medical cultures.
The Facebook world has taken our carefree children to a be better do more place and it is not hard to see the results of that if you have watched any previous generations grow up.
From the Greatest Showman, it will be, "never enough"
As a young general internist—an increasingly rare species, apparently—I agree with much of what you said.
On the fourth point, I have found myself reframing how I see my patients. In the inpatient setting, patients often arrive at a stage of illness where, even with excellent medical care, we are largely managing chronic disease rather than truly reversing it. There is a point at which the body seems to cross a threshold of accumulated physiologic “entropy,” where the burden of disease becomes much harder to meaningfully undo.
That naturally makes me wonder: what if we had intervened earlier? What if stronger primary care, earlier risk modification, better lifestyle counseling, and more longitudinal relationships could have prevented some of these conditions—or at least delayed their progression?
With GLP-1s and related therapies, I feel we now have another tool that can help patients change the trajectory of their metabolic health. These medications are not a substitute for lifestyle, but they can create a window of opportunity: a chance to reduce appetite, improve weight, modify behavior, and reinforce exercise, nutrition, sleep, and other foundational habits.
At the same time, I see the other end of the spectrum: truly healthy patients in their 80s who remain active, exercise consistently, have favorable genetics, and often require only a few medications. Seeing both extremes—the severely ill inpatient and the highly functional older adult—has shaped the way I think about prevention. It shows me what is possible, and it reminds me that many patients still have tremendous potential to alter their trajectory.
I also believe we are undertrained in exercise physiology, resistance training, and the long-term compounding benefits of physical fitness. Strength, muscle mass, cardiorespiratory fitness, and metabolic health are not minor lifestyle details; they are central determinants of how people age.
I try to practice this myself. Given my own family history of type 2 diabetes, I see exercise and metabolic health not just as abstract counseling points, but as a personal form of prevention. Our role as physicians is evolving. I think we are standing at the edge of a new kind of medical revolution—one that brings prevention, behavior change, pharmacology, and human agency together in a much more serious way.
Your piece encapsulates my own feelings about my role (as a nephrologist) during the past thirty years. The other side of this is that many people feel that disease is the consequence of not adhering to whatever recommendations are currently fashionable to promote good health. I always believe that illness is not God's punishment for bad behavior but rather something that can happen to anyone. Like you, I try to reinforce 'good' behavior but would much rather spend my time treating the sick than counselling the well.
Just a nice, thoughtful article. Thanks.
I can help you with this in two categories. Dr. Lordon a nephrologist and Chief of Medicine who terrorized us at morning report, told us to “never trust your mother.” he basically said that the history is the most important part of being a doc and as physicians we have to really understand when we’re being lied to. Which is always.I can tell you as a cardiologist so many patients have told me they are “asymptomatic.”- but they need an asterisk that defines asymptomatic as no problem while sitting with your feet up watching television for 12 hours. You put them on the treadmill they walk 20 seconds and get chest pain and out of breath. There was also a study that you’re probably more familiar with where they took random people off the street gave them Prozac and they actually felt dramatically better. The reality is most of us are dysthymic ; just watch TV every night. My partner literally went into atrial fibrillation with RVR four times a week usually at 5:30. He’s a well-known cardiologist -he didn’t put it together. He was watching cable news. Did he need flecainide or Netflix?
The absence of disease is not the same as the presence of health. Tirzepatide for me has been life-changing - I became depressed after forced medical retirement and gained 60 pounds. I got my life back ; (the blood work and everything got better and now Humana doesn’t want to pay for it. )The difference was if the doctor had told me to walk more and eat less three years would’ve gone by and I would be a lot worse off plus have lost that life -literally lost it. Our jobs as physicians, especially in cardiovascular disease is not just to prolong life, but in every aspect to help people improve the quality of their life. Talk therapy has helped so many people in that regard. Anyway - picking up the rare disease ( I dx a melanoma while examining the posterior lungs of a patient who clearly had non-cardiac chest pain for example) may feel heroic. My PCP taking time to tell me that being a grandfather is can be just as important as being a doc and I should embrace my new role in retrospect was very heroic. We just don’t often appreciate the daily impact we have. I am confident that you are doing this on a daily basis and have done so for years. I can tell you that cause I’m probably older and a senior. I also spend a lot more time in the waiting room these days and I hear what the people are saying. They don’t want miracles with someone who cares.. that is the most valuable treatment.
But you did once prescribe a literal performance enhancer for me, and I was SO grateful! It was propranolol for my Boswell-Jazz singing gigs. As far as I was concerned, you were dispensing magic. :)
One comment about Red Yeast Rice. For those of us with both intense medication sensitivities and familial problems with statins, it's an excellent alternative, since it has Monacolin K, the same active ingredient as statins, but structured differently. My LDL is going down with Red Yeast Rice, and I have not had side effects. BTW, it was "prescribed" by my PCP (from UCSD).
Adam , as an internist with decades of experience that align with yours, my lifestyle advice has been well received, but very poorly executed. So it is with a mixture of excitement and fear that I see some friends, family, and patients injecting themselves with compounded GLP-one agonists—no physician supervision required!—finally achieving substantial weight loss that they’ve been struggling with for decades.
It’s unfortunate that at least in this country these drugs are so damned expensive that many people that could benefit from them the most can’t afford them.
I await the results of this grand experiment with bated breath.
I have heard that it is a problem that nutrition isn’t taught in medical school. The truth is more complicated. Nutrition is taught — but mostly in the form of biochemistry and disease‑state management. We learned metabolic pathways, micronutrient deficiencies, and how to manage things like total parenteral nutrition. What we didn’t learn was how real people actually eat.
No one taught us about carnivore, keto, Mediterranean, or whole‑food plant‑based diets. And part of the reason is simple: there’s very little consensus on what an “optimal” diet even is. The evidence shifts, the cultural noise is loud, and every specialty has its own angle.
My own bias — and it is a bias — is that a plant‑forward pattern is the most sustainable approach for long‑term health. When you look at the diets that consistently show benefit, they all share one feature: an emphasis on whole plants. That’s the part that seems to endure, even as trends come and go.
I attended medical school at Loma
Linda University, where they teach nutrition pretty well, and emphasize the benefits of a vegetarian diet. They were way ahead of their time on that one.
The doctor's role is to differentiate health from disease. Health is our natural condition and is simply the absence of disease. No one knows how to provide health or prevent disease. Some that claim the ability to do so are sincere in their beliefs but there is often no scientific evidence or even biologically plausible mechanism to justify it. In fact, much of the advice given regarding "lifestyle" factors is scientifically unfalsifiable. I often told patients that there was no reason to pay me or anyone else for advice that they got free from their grandmother. I never met a patient that didn't already know that it might not be a good idea to inhale smoke into their lungs on a regular basis.
I respectfully suggest that our natural condition is disease (aging).
on a long enough timeline the survival rate for everyone drops to zero”
I think you're too hard on the hobbyists. Provided something is safe and not too expensive, I am excited for my patients to try elixirs of hope. True, I won't prescribe them, and true, I won't endorse their effectiveness, and true, I might throw some shade on the profit-motive of the supplement pushers. But I am very happy to follow along and see if the red cider vinegar does the trick! Let me know how it works! When I see you back for my next visit, you have to update me on whether it solved your problem! This could help out other patients too!
Why, I'll even try an unpleasant tea made from expired Mexican bark brought to me by a dialysis patient that is the secret to his well-preserved kidney health.
I love this comment.
Thanks
Adam
Timely article for sure, I have dipped into the 4th category and am somewhat embarrassed to admit it. My doctor listens to me and will support what I want to "try" and she will stress what is protocol and the data behind it. Recently asked about switching oral progesterone to vaginal after hearing about the first pass liver metabolites leaving less for the bones, brain, and uterus. Doing so would be off label but in the end it is up to me
It's exactly the 4th category that I'm most fascinated with. I didn't see much positive result in my family medicine practice when I would constantly escale medications, treatments, and referrals. Perhaps that was the nature of the disease or the patient pool. Now I quite enjoy working with those who are seeing the first signs of aging like stubborn weight, fatigue, or brain fog and figure out how to get them back to normal without magic supplements or cleanses. Just some good old, back to the basics lifestyle changes.
Unmet market needs will be filled. Ride sharing, nurse practitioners, urgent cares, VRBOs, restaurant delivery companies, medical marijuana all met (or created) market needs that had been unsatisfied. I think the wellness universe has emerged and prospered in a similar context. Wellness consumers are not demanding persuasive medical evidence. They seek the promise of relief particularly for maladies and health maintenance and longevity that conventional medicine hasn’t reliably delivered. The billions of dollars at stake along with superb and ubiquitous marketing and seemingly limitless public demand have created a growing wellness behemoth.
Great insightful piece as usual. This a huge chunk of my clinic that is spent on not sickness but improvement of already reasonably good health. Also much harder than treating the sick. And far from as rewarding.
I have to think this is some of the motive for specialization, the greater leeway to focus on treating or curing disease. Primary care is hard.
I see category 4 as an extension of cat 3. If group 3 are the wellness folk, I’d characterize group 4 as the maximizers. Maybe not quite as crass as the “looksmaxxers” du jour, but on the same spectrum.
I’d lean on that conservatism principle. It also keeps the convo short. “Is there evidence of benefit for what you want to use, to achieve what you want to do? If not, then I’m not your guy.”
For those would be 'enhancers' I have to ask myself (and them), what do you think you are improving from and to, and why. I look at my job as easing the slow of decline to a death they are prepared for. Not to stop it or reverse it (as if that were possible). The choice is gradually, gracefully going into that good night or racing blindly headlong towards a cliff they are not prepared for. It may be too spiritual for some, but I see my job as helping patients to integrate inevitable decline and death into a healthy, enjoyable life. Where Medicine is in the background and living is forefront. Sad how much we promote and cash in on the mantra "You can be and do more". And this in the face of a costly, poorly performing medical system compared to other much healthier medical cultures.
The Facebook world has taken our carefree children to a be better do more place and it is not hard to see the results of that if you have watched any previous generations grow up.
From the Greatest Showman, it will be, "never enough"
As a young general internist—an increasingly rare species, apparently—I agree with much of what you said.
On the fourth point, I have found myself reframing how I see my patients. In the inpatient setting, patients often arrive at a stage of illness where, even with excellent medical care, we are largely managing chronic disease rather than truly reversing it. There is a point at which the body seems to cross a threshold of accumulated physiologic “entropy,” where the burden of disease becomes much harder to meaningfully undo.
That naturally makes me wonder: what if we had intervened earlier? What if stronger primary care, earlier risk modification, better lifestyle counseling, and more longitudinal relationships could have prevented some of these conditions—or at least delayed their progression?
With GLP-1s and related therapies, I feel we now have another tool that can help patients change the trajectory of their metabolic health. These medications are not a substitute for lifestyle, but they can create a window of opportunity: a chance to reduce appetite, improve weight, modify behavior, and reinforce exercise, nutrition, sleep, and other foundational habits.
At the same time, I see the other end of the spectrum: truly healthy patients in their 80s who remain active, exercise consistently, have favorable genetics, and often require only a few medications. Seeing both extremes—the severely ill inpatient and the highly functional older adult—has shaped the way I think about prevention. It shows me what is possible, and it reminds me that many patients still have tremendous potential to alter their trajectory.
I also believe we are undertrained in exercise physiology, resistance training, and the long-term compounding benefits of physical fitness. Strength, muscle mass, cardiorespiratory fitness, and metabolic health are not minor lifestyle details; they are central determinants of how people age.
I try to practice this myself. Given my own family history of type 2 diabetes, I see exercise and metabolic health not just as abstract counseling points, but as a personal form of prevention. Our role as physicians is evolving. I think we are standing at the edge of a new kind of medical revolution—one that brings prevention, behavior change, pharmacology, and human agency together in a much more serious way.
Your piece encapsulates my own feelings about my role (as a nephrologist) during the past thirty years. The other side of this is that many people feel that disease is the consequence of not adhering to whatever recommendations are currently fashionable to promote good health. I always believe that illness is not God's punishment for bad behavior but rather something that can happen to anyone. Like you, I try to reinforce 'good' behavior but would much rather spend my time treating the sick than counselling the well.