Ever since that glorious and emotional Fellowship Match day back in December, the title of this blog post has been one of my most frequently asked questions. It's funny because to me, it doesn't even seem like a question (doesn't everyone want to do GI?) but when I take a step back and really think about what this specialty entails I start to laugh because I get it.Read More
I'm not writing this to villainize donuts or to get in some debate about processed foods or GMOs or eating organic. Donuts aren't the problem. Fast food isn't even the problem. But you know what is? Believing that discussing the health implications of donuts at all, or any other facet of nutrition, is a taboo topic in the healthcare field.
You know what I think? I'm so glad you asked :-) I think the only doctors who don't need to feel comfortable talking to patients about nutrition, are the doctors who don't see patients. Psychiatrists should be comfortable with the idea of gut-brain axis, exploring dietary habits as a cause/effect of certain mental illnesses. Rheumatologists should be proficient in explaining how diet can contribute to chronic low grade inflammation that exacerbates autoimmune conditions. Same with dermatologists, opthalmologists, general surgeons, pediatric oncologists. Each specialist should be an expert in how diet affects the specific disease for which they are so well-trained in treating. The burden of discussing nutrition should not solely fall back on the primary care provider.
It's similar to what we know about smoking cessation-- the more involved and consistent that all physicians are in encouraging patients to quit, the higher the success rate in quitting (source.) I'd have to say that we (as in, we as doctors across most specialties) have gotten pretty good at this; we aren't afraid to speak gently to patients about smoking cessation, and we're quick to offer all support in how to quit. We are taught in medical school all the steps in counseling patients on tobacco use (ask, assess, advise, assist, arrange follow up!) I think this is absolutely wonderful; as a result, tobacco use has significant declined over the past several decades. So why aren't we doing the same about an issue that is quite possibly creating a bigger epidemic than cigarettes? We can easily apply the same principles: ask the patient for readiness to make dietary changes, assess their actual readiness, advise on an individaul approach, assist their journey to better nutrition habits by providing appropriate resources, and arrange for follow up to talk about it. So I'll ask it again: Why aren't we all talking about food??
For starters, we're beginning to recognize the pathetic amount of training we get in a topic that is so intrinsic to health maintenance and healing. There's a wonderful paper written in Academic Medicine by Eisenberg et. al (read it here) highlighting the fact that U.S. medical schools offer 19.6 hours of nutrition-related education across four years school (that's less than 1% of estimated total lecture hours!!) But I was more bothered by the other statistics shared: Cardiologists during their fellowship training must complete 10 cardioversions and 100 cardiac catheterizations, but have zero requirements in nutrition. ZERO. A heart doctor who treats disease that is so closely tied to diet, does not need to know about diet. WHY NOT?! WHY. NOT?!
On top of basically non-existent structured training, nutrition is far more complicated than simply advising patients to quit a habit like smoking (which is completely malignant and has no actual benefit to someone's life.) See, nutrition is tricky. It requires trial and error, and individualization. You can't just tell someone to "quit eating" as you can with cigarettes or illicit drugs. And as with almost every heartbreaking burden of the modern doctor, it all comes back to the lack of time. We have been backed up into a corner of increasing demands for productivity and "patient outcomes" that we're too busy clicking boxes and documenting appropriately that we miss out on valuable time to speak to our patients about this time-intensive topic (but one that is fundamental to overhauling the current state of health in most westernized countries.)
Don't get me wrong, I am so excited to see medical students and younger doctors who seem to "get it," and feel a passion for incorporating lifestyle medicine into their everyday practice. I don't know if I've just attracted like-minded people who agree that nutrition will change the healthcare world, but needless to say I am pleased to know that slowly but surely, the topic is shifting from "non-issue" to "ummm we're really missing the point if this isn't at the forefront of our treatment plans." I'm thrilled to see healthcare providers truly living by example and bringing their passion for preventive medicine to their work environment. But that doesn't excuse the stories I hear so frequently of physicians scoffing at the idea that lifestyle interventions can be just as affective as a renowned advanced therapy. Recently a friend told me about their oncologist, when asked for recommendations on how they should be eating while undergoing treatment, stated something along the lines of, "Just eat all the junk you can get your hands on." Um, WHAT?! And this is just one of several stories I hear about the polarization between "medical therapy" and "complementary and alternative medicine." Can I be the first to say that nutrition as medicine is neither complementary, nor alternative? Rather, it is FUNDAMENTAL to both prevention and augmenting the advantages of advanced medical technology.
For the most part, nutrition by itself is not magic. It doesn't prevent polio, or fix a broken leg, or perform appendectomies. Western medicine is absolutely brilliant at treating and managing acute illnesses. But without the utilization of nutrition as a foundation of health maintenance, we will continue to be horrible at treating/preventing chronic disease. I don't need to provide statistics on obesity, diabetes, heart attacks, strokes; we all know that we're in trouble. What I can write about, however, is small bits of advice for the patient and doctor to better communicate in how nutrition can aid someone in living their best life.
If you're a patient and you bring up how your diet may be affecting your health, and your doctor disagrees, please RUN. Even without the formal education in medical school, we as doctors should be continuously reading literature and with the explosion of data on nutrition in the past coupe decades, it's hard to not feel the heaviness of its importance. If you're a patient and your doctor gives you ultimatum, generic diet advice, slowly jog out of the room. I've said it before and I'll say it again: Nutrition is NOT one size fits all. If you're in a doctors appointment and he/she listens to your dietary concerns, has an open mind of possibilities to improve, and even provides a referral to a trusted dietitian [edit: can I just highlight that dietitians are greatly underutilized for their expertise?! Request a referral if it’s not offered to you!] (because let's be real, the clock is ticking during that office visit and we can't save the world) then stay. Listen and be heard. Work on dietary changes that are safe and healthy based on your current medical conditions. Come back for a follow up. Make it a foundation of your wellness.
On the doctor side, we have to work on finding the balance between "nutrition is bullsh*t" and "my way of eating is the best way and everyone else should do it because it worked for me." You have some doctors stuck in an old-school mentality, as if caring about nutrition is a waste of time and too hippie in the age of advanced medical technology. But I also see the latter far too often, especially on social media. Doctors and other healthcare providers promote a very specific way of eating as if its the *only* way to live healthy, and that's just not fair. But what about the cost and cultural implications of certain eating styles that may truly affect a patient's emotional or financial wellbeing? Plant based veganism, keto, paleo, blah blah blah- there is so much more to consider than just the food. It becomes dogmatic and that can be incredibly counterproductive for those just starting out on a journey to better nutrition. The best we can do is live by example, but keeping an open mind to how our method is not THE method. We have a long way to go, but just the willingness to care is the first step.
And maybe, just maybe, opting to bring a fruit tray for the office instead of donuts? Just a suggestion :-)
I was wondering when I would get around to writing this blog and wrapping my thoughts around this topic. It's touchy, sensitive, and requires a lot of self-reflection (something that takes a lot of effort when you're knee deep in work and would rather just share a picture of your smoothie bowl next to a stethoscope.) I hope this blog post captures my intent to make fun of, but also defend myself and others in medicine who choose to have a presence on social media. We do a lot of funny things but when I take a step back and look at the intentions, I think we're doing good here.Read More
I've been wanting to share my thoughts on this topic because apart from questions related to medical training, it's the most popular inquiry I receive. My message center is filled with questions like "How much collagen do you think I should be consuming a day?," and "Which probiotic should I be taking?Read More