A Dose of Our Own Medicine
Ben Ferguson -- I often see fellow graduate and medical students while walking around campus, and while it’s not nearly as common as in the general population, I am appalled by the percentage of smokers among them. Keep in mind, I’m a medical student, and I’m a graduate student in cancer biology. It’s not as though my classmates are non-medical people who don’t have the dangers of smoking pounded into their brains for 4 straight years and don’t see the effects of smoking on one’s health first-hand. I guess what I’m trying to say is: You’d think they’d know better.
This is merely an extension of a question that’s often raised in the context of health care professionals: To what extent should they themselves remain healthy, for whatever reason? (Reasons here could include the promotion of good habits among their patients through exemplary living, health for its own sake, and, perhaps above all, the avoidance of hypocritical actions, e.g. a physician recommending to his or her patients that they adhere to a healthy lifestyle that the physician does not personally follow as a “lay person of society.”) Honestly, could you take a 300-lb. physician seriously if he or she told you to lose a few pounds? Would you follow the advice to stop smoking from a doctor who reeked of cigarette smoke?
Let’s face it. Medical students aren’t always exactly specimens of good health. We have irregular sleeping habits. We often eat too much while studying or too little while on a surgery rotation. We drive while exhausted. Screw driving -- we operate on patients and do procedures on patients and tell patients to get some rest … while exhausted. We are too competitive with each other for our own good. We drink, sometimes heavily so, after exams. We inhale pot after pot of coffee and pull all-nighters from time to time. We eat the communal donuts at nurses’ stations on slow nights. We will wind up divorcing our spouses more often than not, and we will pay too little attention to our kids. It’s all right there in the journals.
So where does it end? If it doesn’t end, where do we get off telling our patients to avoid all of these things? We -- our patients and us -- are human. We are the same, and we all care to some extent about our own individual health. We simply have different professions. Should we be expected to follow all of the advice we give others? In my mind, the answer is “not entirely.” The same could be said for police officers who break laws, or IT people who don’t have every single virus protection software suite installed on their home computers, or financial advisors who happen to have slightly less-than-perfect credit scores as remnants from some poor decisions in college.
But I would love it if we smoked a little less.
Our job as physicians is not to tell our patients what to do. We give health advice, not because we are mandating how our patients 'should' live, but because it is our role to educate them and give them the knowledge and tools to help them maximize their own health. Our patients, just like us, can choose to modify their lifestyles based on that information--or not.
Posted by: | Oct 27, 2007 3:43:13 PM
hi ben. interesting post. To begin with, i dont think patients read too much into what their doctor does and what he/she preaches.and frankly if there is a person who can have an honest discussion about weight problems with someone who has such problems is his/her likeness. only a "fat" doctor can truly appreciate what it means to be "fat" and only a smoker can truly appreciate how hard it may be for someone to give up smoking. i am not saying that doctors need to be fat or to be smokers to understand their patients problems. what i suppose im getting at is that every doctor/patient relationship has its own dynamics, its own advantages and disadvantages.
Posted by: Andy | Oct 27, 2007 5:20:25 PM
It's good to see you as a member of the Differential.
I was once referred to a nutritionl specialist to try and determine if there was something I could change & whether what I was eating was affecting my poor health. I was overweight-not obese, but overweight. On short people 10# has no place to go but out. This doc was morbidly obese. WHen I returned to the referring physician who asked me whether it was beneficial, I told him, "You can't expect me to place any credibility in a nutritionist who is morbidly obsese do you?"
The behaviors and appearances of healthcare providers DO impact and influence their patients (or lack there of in my example). Andy, your examples only work if "ex-" is placed in front of your examples--ex-smoker, ex-fat doctor.
I would NOT see a cardiologist, pulmonologist, oncologist who smoked. They have no credibility in my book.
Posted by: gayCMEguy | Oct 30, 2007 11:44:31 AM
Great points, Randy, and glad to hear a first-hand account of this in real practice. I agree: I wouldn't take any of those people seriously if they smoked. How could you? It's the height of hypocrisy.
The obesity thing is a whole other story altogether, too. Don't even get me started on how poor an indicator the BMI really is. I think we should really try to redefine obesity because these days, everyone is overweight. I have a fairly good build, but I'm also fairly short, and so that makes me obese. It's kind of like how no one's ever come across a medical school with below-average board scores; everyone is "above average." How exactly does that work?
Posted by: Ben | Oct 31, 2007 9:12:37 AM
Geez, give people a break!
I think the prevalence of smoking and obesity among members of the medical profession says something about the stress and pressures placed on professionals in today's society. Perhaps it is time to stop scrutinizing every molecule of our physicians' bodies and instead give them more credit for the hell they sometimes put themselves through in order to help others? Quitting smoking is very difficult under stress -- one of the rotten things about nicotine withdrawal is that it tends to create a feeling of heightened stress/anxiety that's relieved by having that next cigarette. As for obesity and other lifestyle issues, you've no doubt seen the studies connecting the "obesity epidemic" or "diabesity epidemic" to our ridiculously stress-and-work-driven lifestyles. It's placing too many demands on doctors to expect them to be perfect in their personal lives on top of such a demanding career. Perhaps the fat nutritionist is fat because he spends hours and hours sitting at a desk doing medical research so that he can help you improve YOUR health. Perhaps he is aware of how obesity stigma has hurt him, and perhaps that's what motivates him to help others to avoid the discrimination he's faced (such as being rejected by patients who don't take him seriously). Stigma plays a huge role in the public's perception of people who smoke, people who are obese, etc., when your doctor's cigarette smoking or his obesity are aspects of his personal life that have nothing to do with you (unless of course he's offering you candy bars or smoking in his office).
Posted by: anonymous | Oct 31, 2007 1:04:36 PM
"What a doctor does to himself should be the best out of HIS medical experience" that's what the patients say and are ready to bet on that versus the doctor's advice to them.
Posted by: | Oct 31, 2007 1:22:31 PM
I disagree with many of the comments posted here. I think that doctors have a huge influence on their patients, and Ben is right, how is a patient going to take a doc seriously if he reeks of smoke and advising quitting or if he is 300 pounds and encouraging a healthy lifestyle?? I personally find it disgusting to see an obese physician. It is so easy to maintain a healthy lifestyle, even if you don't have an hour a day to go to the gym. Things such as eating right and walking up and down stairs instead of taking the elevator everyday can contribute just as much.
Posted by: ks | Oct 31, 2007 1:30:59 PM
I think we must remember that we are all on our own path. All we can do is give people the most up to date information as we know it (and that changes regularly and is often conflicting!). If we or our patients don't always "do the right thing" - then we/they must accept the consequences. It is not our job to be judgemental about anyone. The 21st century seems to be the "guilt" century full of rules which suggest that everything that has gone before was WRONG!
Posted by: Linda Steggall | Oct 31, 2007 2:40:02 PM
Doctors, nurses, and PA's are under a lot of stress. We tend to be high-energy people in the first place! But, so is the rest of the world. Everyone is stressed to some degree and everyone, including the medical profession, deals differently with that. I think we should strive at least to teach not with our mouths but with our lives. I know from experience that exercise keeps my attitude up, my weight down and my body awake. I know that over/under-eating is a coping mechanism for something bothering us inside. I know that it is bad to drink excessive amount of caffeine to stay awake or finish some work. I know what it all feels like because I am trying to find the balance too, just like my patients. I want my patients to have a better quality of life and more balance in their life. Sometimes, though, "balance" is just an averaging out of a lot of imbalance.
It's important to put our medical knowledge into practice because like it or not people do look to you for guidance, example and encouragement. You are in a position of influence, not only to your patients but with your co-workers, family and friends (who actually probably see more of your everyday choices!). People are watching, and you don't just represent you; you represent your hospital/clinic and profession. You tell someone that smoking is not a big deal when you smoke. You tell someone that family is not important when you neglect your own. You tell someone that it is okay to binge drink when you do yourself.
You don't have to have everything mastered yourself, but you have the responsibility to put into practice all the privilaged learning you have. You are there to give patients the knowledge and tools they need to succeed. You don't have to be an angel, but maybe just start thinking about the messages you send to people. Maybe you can relate to someone better because you struggle with weight, or being a stressed-out person, or despise running - just use it as a springboard for conversation in order to develop an authentic relationship with the pateint. It's not just about your physical appearance either, but also in your attitude & how you treat others.
Posted by: Kristie | Oct 31, 2007 5:32:00 PM
And what about the case FOR smoking? It is so grouse! Get amongst it!
Posted by: Kristen Johansen | Oct 31, 2007 5:41:21 PM
I am a non-medical person but am an attorney by profession. I am of the view that excuses are a mere rationalization for failure less the rare exceptions. It goes back to the credibility to the doctor's suggestions, how much weight will patients give to doctor's advice if they themselves are schizophrenic in their delivery of the message. What is the role of the medical profession as a whole in terms of drawing the boudnaries of behaviour. Communication is not merely orally delivered and often not articulated, but can be expressed through motions, sounds and behaviour.
Posted by: sala | Oct 31, 2007 5:41:27 PM
the knowledge of medicine has its own price. if a physician wants to be a good one, he must spend hours and hours sat studying.Is there time under these circumstances to achieve a good life style?
Posted by: fabian moreno | Nov 1, 2007 7:04:47 AM
I disagree with Andy's comment diane, and Fabian moreno; agree with gayCMEguy, and sala. As a medical student, they teach us that we need to give a good impression, devote hours of study, dress appropriately and blabla (you know the rest).
As patients we are always judging. I recall from my childhood that I had a skin illness and my dermatologist gave me instructions in skin care. I remember that I used to follow all of his instructions because his face looked really healthy and smooth.
I met a psychiatrist once and while in what I thought was an interesting conversation, he expressed so improperly and disrespectful towards some of his patients that made me think very badly about that specialty.
Same thing happened with my nutrition class, she was this overweight doctor that constantly told us what to eat or avoid. Why follow her advice when she wasn't following it?
And, okay, it's not the fact of pretending that physicians and health professionals have to be perfect in every aspect. But honestly, would you go to a financial advisor that you know it's in terrible debt? Would you lend your car to a friend that you know has trashed at least 5 cars in the last 2 years?
I'm exaggerating, but think about it. You won't accept that that person is going "through a lot of stress", or that "he/she devoted strong hours of education". However, we know that this profession requires a "full package". We need not only to pass successfully our academic challenges, but know about the world, news, sports (even if we hate it), and ethics in order to make a good connection with our patients. As healthcare providers we need to know that our brain is important, but cannot go on without the body. Taking good care of ourselves is the first silent advice we give our patients.
Posted by: Soniely Lugo | Nov 1, 2007 4:37:33 PM
Sala is perceptive, I believe. Communication involves so much more than words. Patients are often able to tell, for example, how enthusiastic we are about our subject and how well we belive what we are saying, by our manner and appearance, and all those other pragmatic elements that go with the words. This can have a big effect on compliance, as is well-documented.
Posted by: speechie | Nov 1, 2007 11:24:03 PM
I should have gotten into the fray last week before everyone had said everything! But, I've debated this both internally and aloud for at least my three years of medical school now, and I'm sure will continue to struggle with it as time goes on, so as I mulled over Ben's post all weekend, I may as well throw in my two (or eight thousand?) cents.
The "ideal" position is easy to articulate (though perhaps more difficult than one might think to defend) - of course physicians "shouldn't" smoke, overeat, or otherwise endanger health and safety in any way. Surgeons "shouldn't" tear around town recklessly in their sports cars (though one famous one was famous for his propensity to do so), you would think emergency physicians would "know better" than to engage in extreme skiing, skydiving, and motorcycles, and everyone should always practice what they preach. However, as a resident friend's motto goes: "Expect hypocrisy", and as Neibuhr says in a slightly less cynical manner (paraphrased): "the world of ethics can be divided into two camps - those who strive for purity, and those who strive for responsibility".
Folk psychology tells us that persons engaging in unhealthy behaviors or especially behaviors that run counter to the ideal that they advocate are hypocrites, and that this settles the issue rather simply, as they therefore have failed ethically and lose (at least some) credibility. However, as we peer deeper into the link between brain and behavior, scientific psychology begins to paint a very different picture, one where despite the incredible prefrontal reasoning capabilities which truly correlate with the special attributes of our species (and by extension, in my humble opinion, "make us human"), the majority of our neural processing (i.e. sensory input and behavioral control) operates far below the level of consciousness. Control of behavior and rational understanding of reality are not necessarily directly correlated, as the history of western ethics has assumed as a premise, and while the more complicated reality holds promise for more realistic understandings of why we act, how we can change behavioral patterns, and the most accurate worldview, it also brings in to question the concepts of free will, choice, and even therefore responsibility (see e.g. Hallet & McHugh at http://www.dana.org/news/cerebrum/detail.aspx?id=9088).
For example (and to return to the point), in the case of addictive and other "reward-commandeering" behaviors, it seems now apparently obvious that a complex interplay of genetics and experience is identifiable as altered representations of the world within the brain (see e.g. Dani & Montague Nat Neurosci 2007). Does this mean that we as individuals are not responsible for this behavior? Probably not. But, does it also mean that we as individuals are incapable of having important knowledge to share with others regarding these and other issues? Also, almost definitely not.
This point goes back to the first two (and much more succinct) replies from Andy and ___, which I view as a question of what a patient expects from the doctor-patient relationship. I've come to believe in two competing models of what we expect: the "pillar of health" model and the "expert repository" model. If you accepted completely (and solely) the first, then there is no need at all for discussing anything with your doctor: just find the healthiest doctor (or, maybe, just person?) you can, get a copy of his schedule, diet, exercise, and medication regimens, and try to follow them exactly. If you accept the second, however, then the more appropriate course is to try to divorce the logical conclusions of an "expert's" experience from their personal preferences (and/or shortcomings).
Of course, reality probably falls somewhere in the middle, which is why this discussion exists at all. One of the behaviors we can identify as part of our unconscious processing is a natural tendency towards judgement and bias, which is understandably a highly adaptive way to navigate the world. Which means that, whether we want to or not, we do evaluate the credibility of information based on the behaviors of those giving them to us, and therefore see effects of physician behavior on compliance. So, while striving to be a pure pillar of health is respectable, slipping into irrational judgements of patients and fellow professionals who are not meeting such standards begins to reflect irresponsible thinking. Yes, we should strive to follow the advice we give to patients. But we should also strive to frame our information as experts as cause-effect relationships, not as moral statements of what a patient "should do" (the irony in that sentence is duly noted).
Great post Ben, very articulate thoughts on this and an interesting issue for discussion and thought. I do love your last line on the issue, and look forward to reading future posts.
Conflict of interest disclosure: this medical student smokes. Way too much. But is trying to quit. And does lots of other "healthy" things.
Posted by: AC | Nov 5, 2007 9:10:17 AM
I've been away at the AAMC Conference--was anyone there? Anyway just trying to catch up on the post(s). For point of clarification in my example: this nutrition doc was not overweight, he was definitionally morbidly obese. His practice was more consultative and not strictly clinician, and big on pushing supplements. In addition, his office and waiting room were messy--stack of magazines and papers everywhere. This visual did NOT add to his credibility.
Annonymous, -a physician (or other healthcare provider) who is overweight is someone with whom I could actually relate to and would probably feel an added level of comfort in knowing that s/he 'walks in my shoes', and knows my battles and frustrations. The disparity between 15 and 100 pounds is too great in my book.
First impressions and appearances matter. Perhaps you think I'm too harsh in judgement. But, there have been other health professionals (at risk of getting stoned by the masses--a chiropractor) that I saw once on referral. Again, morbidly obese. I never went back a second time. I DO hold my health care providers to a high standard. I make no apologies for it.
Posted by: gayCMEguy | Nov 7, 2007 11:00:08 AM
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