I saw a patient recently who came in for knee pain. Fairly typically, he was a fifty-ish, smiling, slightly chubby guy who thought he was pretty healthy, felt ok, and never went to the doctor. As I like to do with people like this, I evaluated his knee pain and then suggested we look at his overall health and risk factors, since he was here. “Yeah, OK, my dad died of a heart attack, so it’s probably a good idea,” was the response.
That’s how, a week later, I had this genial guy sitting across from me looking crestfallen when I told him he had high blood pressure, high cholesterol, and the beginning of type II diabetes. “But I feel fine, doctora!” is the refrain of these patients. And that’s the hard part– they do feel fine. How do you tell someone who feels fine that he could make himself healthier, extend his life, and feel great, but he’d have to change, a lot? Yes, we could start drugs to control the blood pressure, the blood sugar, the cholesterol, but these might make him tired, give him diarrhea, give him muscle pain. They might take a guy who feels fine and make him feel less fine. So, with this patient, as I often do, we decided to start with so-called “lifestyle measures,” which is really code for diet and exercise. (There could, and should, be so much more to it than this, but that’s a rant for another day). We talked about what this means, about what kind of diet to follow, how to evaluate food choices, what level of exercise is needed. We talked about how to make it work– getting family members on board, finding which healthy foods he likes, how to phase out the soda and the bacon. We talked about how tiny, incremental changes likely wouldn’t be enough to reverse disease without medication. We made a plan to follow up for support and retesting. And he left, resolving to change.
He wanted to make himself healthier. I truly believe that he did. He had the information about what to do. He had access to a place to walk outdoors and a place to buy fresh produce. He had recipes and lists of good foods to seek out. So why, when he came back to see me, had we not moved the needle?
I think I wasn’t able to offer him anywhere near enough support to make the kind of change necessary to transform his health. Have you ever tried to change something in your life that you knew would be good for you? It can seem truly impossible, insurmountable, even undesirable. Discussions in the office and pamphlets can’t remove these obstacles. I think about how we treat substance addiction in facilities where you stay for weeks or even months, spending all day removed from the ability to use, learning about yourself and your history and the skills you need to function in the world. Yes, you have to want to change to succeed here, but you also have the support and tools and time to learn. Insurance often pays for this. But we don’t have this for people who need to learn nutrition and activity and relaxation and stress management. Yes, there are spas and fat farms and medical weight-loss programs, but there’s nowhere for regular people to go to learn “lifestyle management.” I would love to teach and facilitate this. I want to. But I can’t do it from my clinic, 20 minutes at a time. Let’s find a better way, shall we?