Writing about lifestyle modification — and blaming the patient

I was pleased when the editors of the TheHeart.org reposted my recent essay, Let’s Stop the Unnecessary Treatment of Heart Disease. As of this morning, there are 167 comments. The majority of them were positive, and supportive of lifestyle promotion. Negative comments represented a small minority, but were notable in their vigor, and occasionally reached the level of vitriol. (“A self-righteous sanctimonious SOB,” said one nurse of the author.)

I’m glad the post touched a nerve. That was the aim.

This beautiful comment, in particular, indicates the power of a physician’s voice and his or her deeds.

My father’s vascular surgeon told him before he would perform a fem-pop procedure (Ed Note: a peripheral artery bypass) on my father that he had to quit smoking, and he did. His wife quit at the same time. That was 15 years ago and I credit that surgeon for saving my father’s life then and to the fact he is still alive today. Patients want us to be honest and straightforward about lifestyle choices.

That specialist did something special. He transcended his role of skilled technician and embraced the notion of being a doctor.

I’ve had a few similar cases with patients who were referred for ICD implants. I didn’t overtly refuse to implant the ICD if they didn’t quit smoking, but I made it clear that continued smoking in the presence of known heart disease would render the device less likely to benefit. (ICDs don’t prevent death from heart attack or stroke or cancer.) Most of these patients quit smoking—an action that conferred far more health benefit than any ICD. I can probably count on one hand the device patients I follow who still smoke.

Blaming the patient?

Another small but distinct group of commenters felt I was blaming the patient for having disease. This line of reasoning got me thinking.

First, I went back to the piece and reread it a couple of times for tone. And yes, maybe, I was bold, or too definitive in my stance. The Swedish study, however, showed up to 80% of heart attacks might be prevented by simple lifestyle choices. And the investigators weren’t looking at the effects of boot camps or triathlon training, but just 5 simple things: a healthy diet (with fruits and vegetables), moderate alcohol intake, not smoking, being physically active and not having a large waist. I found this study and its results worthy of taking a bold stance.

So why is it that writing forcefully about lifestyle gets interpreted as blaming the patient? I suppose it’s complicated, but maybe I should have been more precise. I could have made clear that lifestyle does not prevent all heart attacks—just four of five. This means some patients will develop heart disease even if they make good choices.

I’ve run into this same issue with AF patients, too. When I advocate for lifestyle measures in the prevention (and now treatment) of AF, many patients write back to say they are doing things right and still getting AF. I see that in my practice; these are the ideal patients for catheter ablation, by the way.

Perhaps I make this error because I take for granted that not all disease is avoidable. There are people with genetic predispositions to disease. There is bad luck. And there is…it just happens.

So skilled doctors will always be needed.

The central problem I want to emphasize is the collective misthink that health comes from healthcare. In the majority of cases, four of five in the Swedish study, being healthy comes from making good choices every day. Stacking together the little things.

Doctors who ignore the huge gut, deconditioned muscles of non-use, or smell of smoke in the exam room do their patients and colleagues a great disservice.

JMM