What I Didn’t Learn in Medical School: Health and Wellness vs Disease Diagnosis and Treatment

To reverse or even slow down the unsustainable rise in health care costs in the U.S., there will have to be to substantial reform in medical education. No one is happy with the current system, except perhaps insurance companies, health systems, and the pharmaceutical industry. Least happy of all are patients--the consumers of health care--and their employers, both of whom are paying the bills.  Payment reform, while essential and necessary, is insufficient by itself to achieve the significant changes required to prevent chronic diseases from occurring, reversing them and restoring health when they develop, and managing them better when they can’t be prevented or reversed. Patients no longer want to be considered the sum of their parts, having different providers for their head, heart, kidneys, knees, hips, and spines. They want someone who will look at them and treat them holistically and they want more immediate access to these providers. For there to be sufficient providers to meet patients’ expectations, major reforms are required in the way we train physicians, nurse practitioners and physician assistants.

At the end of 2021, at the age of 66, I passed the Board exam for the American College of Lifestyle Medicine (ACLM), an organization that did not exist when I went to medical school in the 1980’s. In preparing for the exam, I realized how much I did not learn in medical school, internship, residency, or fellowships. Even worse, I came to recognize all the important things I failed to teach my own medical students, residents, and fellows over my 40-year career in academic medicine. Overwhelmingly, what we were taught was how to diagnose and treat diseases. At least that is what we did after the first couple of years learning anatomy, physiology, pathology, biochemistry, and pharmacology. We learned little about health, wellness, and restoration of health. For example, we learned all the tests used to diagnose diabetes and we even memorized the abnormal serum glucose values of a fasting, 2-hour, or 3-hour glucose challenge tests. We learned about every type of insulin and oral hypoglycemic agent, their side effects, half-lives, mechanisms of action, etc. But we did not learn that with appropriate intervention and lifestyle changes, health can be restored, and normal blood sugars can be regained—without pharmacologic intervention. I should make clear at this point that I am not against pharmaceutical interventions and treatments when appropriate. But they should not always be the FIRST thing we try. Type 2 diabetes was not as common as it is today; today there are more than 34 million people in the US with diabetes (7 million of them don’t even know it yet as they have not been diagnosed) and more than 90% have type 2. What we don’t learn is that nearly 100% of type 2 diabetes is preventable. We also did not learn that patients with newly diagnosed type 2 diabetes can be restored to normal, non-diabetic status with lifestyle changes. We also did not learn that for every person with type 2 diabetes there are more than 2 waiting in the wings—so-called pre-diabetics (estimated to be about 88 million Americans). It would be even easier to effect change in these pre-diabetic patients who have not yet crossed the diagnostic red line. In general, we ignore this group of future patients. Without intervention, most of these pre-diabetics will develop type 2 diabetes over the next 5 years or so.

Not surprisingly, we learned little about the specific interventions and lifestyle changes required to restore health in patients with these newly diagnosed so-called “chronic conditions”. For example, we learned little about nutrition. Sure, we learned that carbohydrates and proteins have 4 calories per gram and fat has 9 calories per gram, but we did not learn how to take a brief dietary history or what practical suggestions to make to patients regarding their own diets. We didn’t learn that humans are the only mammals that continue to drink breast milk after we are done weaning. And we don’t even keep drinking milk from our mothers, but we drink the breast milk of another species altogether, a cow. Don’t get me wrong; I have always been a staunch advocate for breast feeding. Breast milk is remarkable; it contains fat, protein, carbohydrates, vitamins, minerals, and other factors that protect newborns from infection and inflammation. Breast milk is important for an infant’s immune system and helps to establish a healthy microbiome; the important bacteria that we carry in our intestinal tract (we didn’t learn about this in school either, but to be fair, the microbiome has only recently become appreciated in its importance to human health). But we shouldn’t lose site of the role of breast milk, whether in a whale, a lion or a human; it is designed to make babies grow really fast so that they can survive without their mother. Why are we still drinking and eating 655 pounds of dairy products (e.g., milk, cheese, ice cream, yogurt, cream cheese, etc.) per year after we are done weaning? We also didn’t learn that the leading source of saturated fats in the American diet is cheese. We did not learn about the well-established health benefits of a whole-food plant-based diet. We did not learn that processed meats increased your chances of cancer. Indeed, the World Health Organization has classified processed meats including ham, bacon, salami, and frankfurters as Group 1 carcinogens; that’s the same category that tobacco and asbestos are in! Okay, I do eat a hot dog when I go to a baseball game. But I only go to two or three games a year and I eat one each time, at the most. Many Americans start their day with bacon, egg and cheese sandwiches and then follow it up with a fast-food burger, fries and large soda—a meal laden with salt, fat and high-fructose corn syrup--for lunch. Which brings me to obesity. When I was an intern in 1981, fewer than 10% of pregnant women presenting for their first prenatal visit weighed more than 200 lbs. Today, about 25% are over 200 lbs at their first visit; indeed, about 10% are over 300lbs! Not only does this put their pregnancy at increased for virtually EVERY obstetrical complication, but it also puts their unborn fetus at risks for developing diseases and obesity later in their own lives. Once again, to be fair, this last fact, was not appreciated in the early 1980’s; indeed, this concept and field of epigenetics was pretty new then. Epigenetics is the impact of our environment and behavior on our genes. Regarding obesity, it might soon surpass cigarette smoking as the largest preventable cause of death in the United States.

Change can be difficult; there is no denying that. But it is critical to inform patients of the risks of continuing their current lifestyle choices, and to ask them if they are ready and willing to try to make a change. But to do that, we had to learn about change behavior and learn to recognize the stage of change-readiness a patient is at. Instead, we are often told that patients won’t change their risky behaviors, despite our warnings. Sure, we remind them that they shouldn’t smoke, or we suggest they lose a few pounds, like they didn’t already know that. When they get very heavy, we refer them for bariatric surgery.  The transtheoretical model, or TTM, also referred to as the “stages of change,” was described in the late 1970’s.  In TTM, the stages of change readiness go from:  Precontemplation (e.g. “I’m fine; I have no intention to stop smoking”) to; Contemplation (e.g. “I’m thinking about quitting”); Preparation (e.g. “a friend of mine died of lung cancer recently, and I am looking into some smoking cessation programs”); Action (e.g. With the help of my doctor, some meds, a smoking cessation program and strong support from my family, I was able to quit two months ago, and I plan to make it permanent”); Maintenance (e.g. “It’s been six months since I’ve quit, but I am still around a lot of people that smoke and I’m trying to resist the temptation to start up again”) and finally: Termination (e.g. “I can’t believe it’s been a year since I quit; I feel so much better and my clothes don’t smell like cigarettes. I’ll never smoke again.”. Health care providers should be taught to query patients about their risky behaviors, assess their willingness and readiness for change, and coach them from one stage to the other until the desired change is implemented. If they are not ready to make a change, we must reinforce the potential consequences of continuing the unhealthy behavior, whether it be smoking, obesity, inadequate sleep, poor nutrition, or lack of exercise.

Interestingly, researchers and authors such as Dr. Dean Ornish, clinical professor of medicine at the University of California, San Francisco and Dr. Caldwell Esselstyn, Director of the Heart Disease Reversal Program (read the title of the program he runs again) at the Cleveland Clinic, demonstrated more than 2 decades ago, that coronary artery disease can be prevented and/or reversed. Ornish also showed that a program of mindfulness or stress management, exercise, and a whole food plant-based diet (low in processed foods, refined sugars and polyunsaturated fats) can also turn on good genes and turn off bad genes related to cancer.  This work was recently reinforced by Dr. Kara Fitzgerald, highlighted in her recent book, “Younger You: Reduce your bio age and live longer, better”.

I think the most important thing we did not learn in school was the natural progression of disease (maybe it should be called, the unnatural progression, since health is the normal state). Yes, we learn about the effects of obesity, cigarette smoke, diabetes, hypertension, stroke, vascular disease, coronary artery disease and heart failure. But we do not really learn that these evolve over time as a continuum. Of course, primary care physicians watch this evolution in real time if they follow their patients over 20-30 years. First, their patients get a little heavy. Then they develop high blood pressure and type 2 diabetes. Then, over time, they develop complications of either or both: strokes, heart disease, kidney disease, etc. Today, much of the emphasis of those seeking to reduce health care costs (it really should be called sick care), soon to consume $4 trillion of our GDP, is to reduce the cost of managing those at the top of the cost pyramid, who consume a disproportionate amount of the total spend. For example, we frequently hear that the top 10% of patients on the cost pyramid consume about 80% of the total costs. These are predominantly patients with complications of diabetes and/or hypertension and/or obesity with heart failure, vascular disease, chronic kidney disease, etc. But the truth is, the horse is out of the barn on these patients. Sure, we can make some marginal and incremental improvements in their lives, but in the long term, it would be far more cost effective to keep patients in the bottom of the pyramid, in their healthy states. And we should take those in the next layer, with newly diagnosed so-called chronic conditions like diabetes and hypertension, and first try to restore their health to get them back down into the bottom layer. If we cannot do that, we certainly need to do a better job in managing their chronic condition. Sadly, only about half of patients in the US being treated for chronic hypertension have blood pressures in the normal range. Likewise, fewer than half with type 2 diabetes have HbA1c (the test of long-term blood sugar control) levels in the normal range. We know that with appropriate lifestyle changes, the health of these patients can be restored. Specifically, these conditions are largely related to poor nutrition, lack of physical activity, stress, and inadequate sleep. We also know that if changes are not made, one can predict with a high degree of confidence, that over the ensuing ten to twenty years, these same people will become the patients with chronic kidney disease, coronary artery disease, peripheral vascular disease, strokes and heart failure at the top of the pyramid!

Nearly 80% of Americans over 55 have at least one chronic condition and nearly half have two or more. More than 40% of Americans are obese; almost 20% of young people from 2-19 years of age are obese (this figure was 5.5% in the 1970s). Nurse practitioners, physician assistants and physicians might not be the cause of the epidemic of obesity, diabesity and other chronic diseases, but they can, should and must be part of the cure. However, in order for this to occur, educational reform away from the traditional “diagnosis and treatment” model must occur at all levels of medical education. Ben Franklin said, “An ounce of prevention is worth a pound of cure”. Although he was referring to fire prevention (remember he was the one who started the first fire house), the analogy applies to chronic health conditions.