A New Role for the Physician
by Paul E. Lemanski, MD, MS, FACP
Editor’s Note: This is the 52nd in a series on optimal diet and lifestyle to help prevent and treat disease. Any planned change in diet, exercise or treatment should be discussed with and approved by your personal physician before implementation. The help of a registered dietitian in the implementation of dietary changes is strongly recommended.
Medicines are a mainstay of American life and the healthcare system, not only because they are perceived to work by the individual taking them, but also because their benefit may be shown by the objective assessment of scientific study. Clinical research trials have shown that some of the medicines of Western science may reduce the risk of heart attacks, strokes and cardiovascular death, while others may reduce certain types of cancer.
In the first 51 installments of the Non-Medicated Life, informed diet and lifestyle have been shown to accomplish naturally for the majority of individuals, many, if not most of the benefits of medications in the treatment of chronic medical conditions. But in the age of the Internet, when we are flush with information and there seem to be as many diets and suggestions for healthy lifestyles as the people who promote them, how is one to separate the wheat from the chaff?
I would suggest that optimal implementation of the Non-Medicated Life requires the individual partner with a health care provider who: 1) Has formal training in human nutrition or an appropriate background in science and an established interest; 2) Bases recommendations on scientific study evidence; 3) Always discusses risk and benefit when suggesting alternatives to medications; 4) Provides metrics to track the response to treatment; and 5) Works as part of a healthcare team, recognizing that the multiple skills needed for success will rarely be found in one individual. While I believe physicians are providers best suited to lead the implementation of the Non-Medicated Life, the promotion of the rational avoidance of medication and the discontinuation of medication not truly needed suggests if not a new role for physicians, at least a new emphasis.
While few medical schools in the country have formal coursework and training in human nutrition, all medical schools cover essential knowledge in courses on anatomy, biochemistry, and physiology in the first two years. In the second two years devoted to clinical training, physicians gain experience in nutritional and lifestyle related diseases during the study of internal medicine. Such knowledge is essential to asking the right questions so as to be able to effectively evaluate claims made regarding diets, supplements, vitamins and nutritional products, which the lay person is bombarded daily in media and advertisements.
Moreover, physicians who have an interest in human nutrition and medical nutrition therapy will be best suited to know the limits of such therapy. For example, sodium restriction, weight control, and exercise can help prevent high blood pressure in those with early signs of the disease, but generally cannot take a severely elevated blood pressure and return it to the normal range. Likewise, while a heart healthy diet may reduce the low-density lipoprotein or bad cholesterol on average 30 milligrams per deciliter, it generally cannot reduce the LDL 100 points. Physicians with an interest in nutrition will better be able to set reasonable goals and expectation for individuals seeking the Non-Medicated Life.
More importantly, medical schools provide training in the discipline of evaluating clinical studies so that physicians base their recommendations on not “any” evidence, but scientifically meaningful evidence. The personal testimonial of an individual while interesting and potentially important does not constitute meaningful medical evidence. The clinical “trial” of a supplement with 30 participants which has no control group does not constitute meaningful medical evidence. To be meaningful and evidence-based clinical trials, they must have a control group and an experimental group, which differ only in the aspect being studied, must have participants chosen randomly to avoid selection bias, and must be statistically evaluated to ensure a low probability that the experimental result is a consequence of chance rather than causality.
Physicians are trained in such assessments. Moreover, such training allows physicians to point out the weakness and potential biases in observational studies and other less evidence based studies and show that many times the advertisement claims made of a product being “clinically proven” are at best a misrepresentation and more likely simply fraud.
Physicians prescribe medications after an assessment of risk and benefit in which in the judgment of the physician the benefit of the medication outweighs the potential risk of use. In the pursuit of the Non-Medicated Life, a similar careful weighing of the risk and benefits of the avoidance or discontinuation of medication is essential. Physicians are, therefore, very well suited to make this assessment and to discuss the assessment in detail with individuals under their care so a true informed consent during a change in treatment results.
Just as important as assessing potential risk and benefit, before deciding on avoidance of medication or discontinuation of medication, is measuring the response to the new treatment to ensure it is working as anticipated. Physicians routinely collect such metrics, whether it is measuring a weight for calculation of body mass index, measuring a blood pressure, measuring blood sugar, or measuring blood cholesterol. Such an ongoing numerical analysis allows an objective assessment of response that is essential to assuring all concerned that the avoidance or discontinuation of medication and the use of diet and lifestyle alone is safe. Moreover, in those who cannot completely avoid or discontinue a specific medication with diet and lifestyle change, such monitoring many times allows for a reduction in dose with a concomitant reduction or elimination of untoward side effects.
Finally, physicians today look upon themselves as part of a healthcare team, acknowledging the important skill sets of nurses, nurse practitioners, physician’s assistants, psychologists, dietitians, acupuncturists, and exercise physiologists to help individuals make changes in diet, lifestyle and exercise. For example, while the physician may suggest that a two-gram per day sodium diet is desirable, helping an individual to understand how to accomplish this in the real world takes the special expertise of the dietitian. While a physician may suggest an individual burn 300 calories per day in exercise to help control body weight and triglyceride levels, an exercise physiologist can help an individual find the safest, most practical, and injury free way to proceed.
In summary, the pursuit of the Non-Medicated Life requires partnering with a healthcare provider with the right training and expertise, who can discuss the risk and benefits in the rational avoidance or discontinuation of medication and then monitor the results. Physicians with an interest in nutrition are well-suited for this role. Partnering with such a physician will potentially allow an individual to thus avoid the proverbial bottle of pills commonly used to address our most pressing health problems.
Paul E. Lemanski, MD, MS, FACP is a board certified internist with a master’s degree in human nutrition. He is director of the Center for Preventive Medicine of Paul E Lemanski MD PLLC. Paul is an assistant clinical professor of medicine at Albany Medical College and a fellow of the American College of Physicians.
**Originally published in Adirondack life magazine