July 19, 2023
"Why Most Doctors Don't Recommend Diet & Exercise"
by James P. Johnston, D.O.
There are five reasons why most doctors don't recommend diet and exercise:
- It makes no difference
- We’re just in too much of a hurry
- We’re ignorant
- We’re cowards
- We’re hypocrites
It Makes No Difference
It’s this same reason we rarely prescribe life saving medicines like Metanx not covered by insurance.
Because patient’s simply won’t comply with our instructions. It’s discouraging. We feel like we’re wasting our breath.
For three months of my fourth year of medical school, I had an interesting experience. I did a rotation in a town in central Florida providing care at an indigent clinic, caring for almost exclusively Spanish-speaking fruit-picking Mexicans. One of the ways I found them strikingly different from Americans is their quickness to actually follow physician’s instructions. If I diagnosed chronic obstructive pulmonary disease in a smoker, for example, and urged them to quit smoking, at a follow up I was surprisingly pleased that they actually did it! When I diagnosed a patient with an esophageal stricture and chronic GERD and urged them to not eat any calories within three hours of bedtime or else they’re going to need medicine the rest of their lives and scopes every 5 years, they actually followed instructions! They actually took the doctor’s instructions seriously.
Americans, on the other hand, rarely follow instructions to change their lifestyle. Most patients want their symptoms controlled with medications or surgery, but they didn’t want to make the lifestyle changes that would have cured them.
Almost every sleep apnea patient would reverse their disease if they lost weight. But they don’t follow instructions to lose weight. They’d rather wear a CPAP mask during sleep for the rest of their lives. And doctors don’t waste their time with recommendations that patients don’t follow. We're simply too busy.
Well, why do Americans not follow physicians instructions for exercise and diet? Evidence shows that vigorous exercise and maintaining ideal body weight is disease-preventing and life-prolonging. However, it involves lifestyle changes more drastic than a single sentence from a physician can motivate.
An understanding of human psychology will help us understand the deficiency. To motivate change in a reluctant person, we have to do more than tell them what to do. Imagine me telling my child to “clean your room”. Alternatively, imagine me telling my child to “clean your room and I’ll give you $20. Don’t clean it and I’ll take $10 from you.”
Which do you think will motivate the teen to get off his cell phone or X-box and clean his room? The latter, of course. Commandment without power to motivate compliance is worthless. Worse than worthless, as it ads guilt. One of the ways people assuage their guilt is more of the act that brought the guilt in the first place. Like people who feel guilt about their bad habits will engage in the habit more or take on another bad habit to cope with the guilt and feelings of worthlessness.
It’s obvious that a detailed plan to diet and exercise, including emphasizing negative consequences for non-compliance as well as positive rewards for compliance, is going to better motivate that teenager. It’s the biological law of homeostasis. We generally don’t like change, even if it’s change for the better. Momentum carries us the way we are headed and it takes a genuine “push” sometimes to change directions.
Compare these two admonishments and imagine them directed to you from your doctor.
1. “In addition to taking your medication, regular exercise is something you can do to lower your blood pressure."
Versus
2. “In addition to taking your medication, I want you on the elliptical breaking a sweat 55 minutes 5 days a week. It’s got to be vigorous. Be breaking a sweat within 5 minutes or you’re not going fast enough or steep enough. Do it either before breakfast, before lunch, or before dinner, because a stomach full of food will slow you down. I want a 24 ounce bottle of water during that exercise to keep you well-hydrated. A study of over 116,000 Americans published in the medical journal Circulation recently demonstrated that 5 to 10 hours of vigorous exercise weekly lowered death from all causes 31%, while lowering cardiovascular mortality 38%. If a medicine could do that, it’d be the most famous medicine in the history of the world! But it's not medicine, it's vigorous exercise. Once your blood pressure, measured daily with an upper arm cuff, is averaging 125/75, I want you to cut your BP med in half.”
A physician’s chances of getting his or her patients to comply with instructions goes WAY UP with the latter admonishment as opposed to the former.
It’s more likely to make a difference.
This leads to my second point. One of the reasons we don’t recommend diet and exercise more is…
We’re Just In Too Big of a Hurry
When I was chief resident of the Ohio University Family Practice Residency in Portsmouth, Ohio in 2001, the program director told me, “When the rooms are filled, run down the hall, but turn the doorknob slowly.” His point was, when you’re busy and the waiting room is full, move fast, but don’t let the patients know you’re moving fast. Act like you're taking your time with them, even if you're not.
A physician’s salary, more or less, is directly related to how many patients he or she can see in a day. That means, move fast. Be efficient. No time for small talk. No time for wasteful movements and wasteful words. A few five minute conversations about the Ohio State Buckeyes results in patients being mad at the end of the day for having to wait too long for their appointment, and staff upset for being kept late at the office.
It’s just the field doctors are playing on in our insurance-dictated medical practices. We get paid for what we bill, and overhead remains the same regardless of how many patients we see an hour. Talkative doctors get paid less. I rotated with some physicians who simply cut patients off and said, “Make another appointment to discuss that problem. We’ve deal with three problems already today and I need to move to the next patient.” It inconveniences the patient, but increases the physician’s profits from the patient’s complaints.
This really highlights the special, unique care you receive from my concierge direct primary care practice. I had a patient today who literally small-talked for an hour as I tried to gather his medical history. But he had a two hour appointment! No rush. No cutting him off. He started off the conversation by announcing that he didn't want medications, but by the end of the discussion, he was prepared to take my life-saving prescription. He trusts me. We became friends! That just doesn’t happen at a normal doctor’s office unless he’s really slow and has a low salary as a result.
I have a cash-only practice. No insurances accepted. (Insurances pay lousy for primary care anyway, which is why most doctors have to see 40-50 patients a day!) Moreover, I see patients in their home. I don’t have a brick-and-mortar location that consumes 4/5 of receipts, like most doctors. Most doctors literally work 4 days a week to pay for the mortgage on the building and the staff and the overhead, and one day for their salary. I practiced that way for 19 years. The lack of the massive overhead gives me the opportunity to spend more time with patients.
Most concierge doctors cater to rich folks, who want to get their sleeping pills without getting out of their pajamas. My prices are 1/3 the cost of my nearest local competitor! I love the freedom my direct primary care family practice office provides me, and my patients appreciate the low cost and high quality care. It's what family practice was before the bureaucrats and insurances companies took over.
Another reason doctors don’t recommend diet, supplements, and exercise to patients is…