Although the fix is usually focused on the system…we may be overlooking a better, surer solution sitting on the other side of the clinical encounter.

If you ask doctors how they envision their ideal outpatient practice, most will say something about a bustling, thriving environment.  Doctors, nurses, and other support staff work together in a spirit of harmony while beloved community members happily come and go, receiving appropriate care.  It’s a beautiful picture, one that inspires a sense of compassion, selflessness, and gratitude.  

There’s only one problem: most of those beloved patients are sick.  If you ask me, that image is more troubling than tranquil.

Health in the United States is in a sad condition and getting worse.  Daily, we are confronted by reports of ballooning rates of obesity and diabetes.  Physical activity levels are at an all-time low, and there is constant hand-wringing about illegal drug and narcotic abuse nationwide.  

At the same time, recent Mercer analyses affirm concerns over physician shortages, overloaded hospitals, and higher costs of care.  Increasing percentages of our population have limited access to healthcare, and there seems to be little hope on the horizon.  Constant rancor over proposed government solutions stymies progress, and no one knows if privatization, centralization, or something in-between will best address our nation’s ills.  Which direction should we turn?

Although the fix is usually focused on the system – larger hospitals, greater access, and better physician training – we may be overlooking a better, surer solution sitting on the other side of the clinical encounter: building healthier patients.

Enter preventive medicine, which strives to address chronic disease before it starts.  Preventive medicine thinks forward, recognizing that poor sleep habits, unhealthy eating, and inactivity manifest as future dementia, diabetes, and obesity.  For example, a 2023 Cureus systematic review by Klein et al revealed that school-based interventions to optimize nutrition, physical activity, and dietary education significantly improved multiple obesity measures.  Numerous other studies reveal similar benefits when patients are educated about tobacco use, drug abuse, and adequate exercise.  Investing in patient education and empowerment pays dividends in the future.  

“An Ounce of Prevention…”

We are familiar with Benjamin Franklin’s anecdote “An ounce of prevention is worth a pound of cure,” but how does that translate monetarily?  Honestly, research examining cost effectiveness in disease prevention is a little murky.  For instance, it is not clear how much money should be spent on exercise promotion to prevent diabetes.  

However, we do have some data to guide us, as well as statistics showing the cost of not doing so.  A 2017 Johns Hopkins study found that moving a 20-year-old person from the obese to normal weight category saves $17,665 in direct medical and lost productivity costs over the lifespan. Since 42.4% of the U.S. population is obese, helping them all obtain a normal weight would save almost $2.5 trillion, more than half the total national healthcare expenditure.  Although we don’t know how much we would have to spend in advertising and preventive services to reach this goal, it probably is less than $2.5 trillion.   

To be fair, healthcare already funds disease awareness campaigns, and the amount spent increased from $177 million in 1997 to $430 million in 2016.  However, this represents only 3% of healthcare and pharmaceutical digital advertising costs.  This makes sense when we realize corporate healthcare is a service business; to be solvent, there must be customers.  I do not believe there is a nefarious conspiracy afoot, but asking healthcare corporations and drug companies to invest substantially in preventive medicine represents a conflict of interest.  

More troubling is that many physicians are implicit and sometimes complicit in this paradox.  According to the AMA, the past decade has seen an increase in the number of employed physicians from 41.8% to 49.7%, and that percentage is greater among those under age 45.  This means more physicians are entering care systems driven by patient quantity rather than care quality.  Current clinic templates make it easier to prescribe medications, order labs and imaging, and plan procedures than empower a person to make good health decisions.  Lifestyle counseling certainly takes a backseat during a fifteen-minute appointment.  

So what is to be done?  Sadly, we probably can’t count on corporate healthcare or Big Pharma to push preventive medicine.  Doing so cuts into the client pool.  Therefore, the push must come from doctors.  

Promoting Preventive Medicine

Putting preventive medicine at the forefront requires a LOT of buy-in.  For starters, it necessitates a change in the way medical schools train physicians.  Since the days of Morgagni, students have learned from pathology: we see abnormal things and think backwards to figure out how they happened.  As stated previously, preventive medicine thinks forward, identifying unhealthy behaviors and encouraging change to prevent future abnormalities.  

Preventive medicine in medical training is an elephant in the room; although recognition of its necessity has grown as “value-based care” has become the watchword, implementation of curricula has been, at best, uneven.  Residency programs in preventive medicine have decreased over the last decade by 17%, and students still learn what a bubo is before being taught infection mitigation strategies.  To impact future generations of disease preventers, we must start at the ground level in medical school or earlier.

Next, physicians must be allowed time to provide preventive counseling to patients and be compensated for it.  The current corporate medical environment is not built for that degree of facetime with the patient.  Physicians need to be loud in demanding just payment for the most important labor.  If that doesn’t work, we need to be prepared to buck the employed physician trend and control our own practices.  The time may be ripe for this pendulum swing as both physician and patient dissatisfaction are increasing.

The beautiful thing about providing lifestyle education is that doctors don’t have to carry the whole load.  Many programs use a mix of health advocates, including registered dietitians, psychologists, counselors, or trained lay persons.  These invested, interested individuals teach their peers to make good health choices in clinics, schools, and around the dinner table at home.  

Championing preventive medicine also requires policy changes to make healthy living easier, including increasing green space and decreasing the cost of nutritious food.  These are traits of a healthy country, and we can advocate at all levels for change.

Lastly, we can start today to help our patients recognize their own responsibility for good health.  Hospital advertising is rife with messages such as “Trust Our Experts,” “Put Your Health in Our Hands,” and “Come to Us for All Your Healthcare Needs.”  This has none-too-subtly created the belief among patients that they are dependent on doctors to make them well, forgetting that good health is largely a product of their own behavior.  “Physician” means “teacher,” and we must step up to the responsibility to educate our patients about what they can do to individually lessen disease burden.  

We mentioned earlier that most physicians visualize the ideal practice as a bustling place full of sick patients.  Do you know what my ideal practice looks like?  It is empty.  It looks this way because patients take ownership of their health, eat right, exercise regularly, and avoid harmful substances.  They come to see me when they sprain their ankles while trail running or when unfortunate genetic predispositions rear their heads, but mostly they take care of themselves.  And I am bored at work.  Maybe I don’t make as much money.  Maybe I lose some prestige.  But I feel fulfilled knowing I have taught patients what they can do to keep themselves healthy for life.  And what is ideal for my patients is ideal for me.