An Ounce of Prevention
I saw a middle-aged man in my office the other day for evaluation of shortness of breath (dyspnea, we call it in the medical world). He came with his wife, who was obviously quite concerned about him and who did most of the talking during the appointment. His primary doctor had already ordered a thorough panel of studies and they’d all come back normal. The EKG showed normal rhythm; the echocardiogram confirmed that the heart strength was good and that all the valves functioned appropriately; and the nuclear stress scan ruled out the possibility of significant high-grade coronary obstruction.
Still, his symptoms persisted. He found himself panting with even low levels of exertion such as walking up a flight of stairs or carrying groceries in from the car. To make matters worse, his wife reported that her husband seemed fatigued more often and wanted to spend more and more time on the couch. “He’s always so wiped out,” she repeated.
My exam revealed nothing of great interest. In typical American fashion, he was moderately obese with the bulk of his bulk hanging over his beltline. His heart sounded normal, but I knew that already from the normal echocardiogram.
His wife wanted to know what was wrong with him and what testing needed to be done next. She was sure that his heart must be sick in some way that we’d failed to detect. As he sat there in silence I realized I really wanted to know what he thought the trouble was.
“What do you think is wrong?” I asked him.
He paused a moment, then answered: “I’m fat and out of shape.”
Cardiology Consultation: $250
Nuclear Stress Test: $1400
Insight into real problem: Priceless
I had to hand it to the guy—he knew exactly what was going on. He was just waiting for us to get through all our testing to come to the same conclusion (I’m no marriage counselor, but I got the sense that most of the testing was for the spouse’s benefit). At that point we were free to begin the really useful discussion about exercise, diet, and personal responsibility for one’s own health status.
Let’s take a look at a hypothetical patient. Mr. X is a 50-year-old male who has not engaged in any meaningful exercise since he was on the football roster in high school and continues to eat like a linebacker. He now weighs 270 pounds and spends his days sitting at work or sitting at home. He picked up smoking as a teenager and has continued to the present time. Over the years he’s developed hypertension and diabetes and is not terribly compliant with his medications.
Mr. X comes to his doctor with several complaints. His main problem is fatigue—he’s tired all the time and can’t find the energy to get stuff done around the house. When he walks up a flight of stairs he ends up gasping for air. His knees ache, his back hurts, and he has cramping in his calves anytime he has to walk up a hill. His legs are constantly swollen and he occasionally has small ulcerations around his ankles that don’t heal well.
One visit to his doctor and Mr. X comes away with the following diagnoses:
- Obstructive sleep apnea
- Cor pulmonale
- Degenerative joint disease
- Claudication (peripheral arterial disease)
- Chronic venous insufficiency
He’ll go through extensive testing and get placed on a long list of medications. His fatigue will improve if he becomes compliant with CPAP therapy (for sleep apnea) and his leg pain could resolve with interventional treatment for blockage in the arteries of the legs, but in the end he’ll probably not feel a whole lot better. Needless to say his medical bill could fund the economy of a small third-world country.
On the surface you’d look at Mr. X and say “What bad luck this guy’s had!” but look a little deeper and you’ll come to a different conclusion.
The most interesting thing about Mr. X is what type of medical illness he doesn’t have. He’s suffered no trauma, been afflicted with no cancer, has no disease that his genes have destined him to, and has incurred no problem that strikes randomly. Every single diagnosis in the list above has arisen as a result of Mr. X’s lifestyle, and hence each was preventable at some point. If Mr. X had never started smoking, had watched his diet a little more closely, and had engaged in regular aerobic exercise he would have never had any of the problems that beset him now.
I have dozens of patients in my clinic who are virtually identical to Mr. X. I see people all the time for shortness of breath, fatigue, leg swelling, and aches and pains that are all both preventable and treatable with nothing more than lifestyle modification. When I try to explain that the best treatment is also the simplest, many of these people seem incredulous and appear disappointed that I don’t have a more high-tech option.
This reminds me of a story from the Old Testament where Naaman, a highly regarded and decorated Syrian army general, is sent to the prophet Elisha to be cured of leprosy. Elisha’s mentor and predecessor Elijah had already set a precedent for visually stunning, over-the-top miracles, and I’m sure Naaman expected nothing less from Elisha. To his dismay, however, Naaman was told that his cure lay not in fire from heaven or mystical incantations but in the simple act of taking a dip in the muddy Jordan river.
But Naaman went away angry and said, “I thought that he would surely come out to me and stand and call on the name of the LORD his God, wave his hand over the spot and cure me of my leprosy. Are not Abana and Pharpar, the rivers of Damascus, better than any of the waters of Israel? Couldn’t I wash in them and be cleansed?” So he turned and went off in a rage.
Thankfully for Naaman, his trusted advisors talked him into giving Elisha’s therapy a try and he found himself cured of leprosy. Naaman sang Elisha’s praises from that point on.
Sometimes I wish Naaman’s advisors could be in the room with me when I try to talk my many Mr. X’s into foregoing further testing and simply initiating a healthier lifestyle—perhaps I’d have more success.
My best plan to combat this problem is to invent a time machine and travel back through time to when Mr. X and all his friends are young and healthy. I’ll bring a videotape recording of what they’ll look like 30 years in the future when they finally show up in my office. I’ll convince them that small changes in their youth will provide them big gains in the future. Cut back on the calories a bit, take up daily running, walking or biking, and just say no to cigarettes. It’s not that hard. Of course, if I have a functioning time machine I’ll probably head back to Naaman’s time and hire his advisors as my assistants—they seem to be pretty good at talking sense into people.
There are plenty of bad diseases out there for which we have no prevention, early detection, or even successful therapy. At some point even those of you who lead the healthiest lifestyles will succumb to something out of your control, but until then do your best to avoid the things that are actually easy to avoid. You (and your advisors) will be much happier for it.
In the ER, Marc saw a patient who needed an MRI performed but unfortunately, he was too overweight to fit inside the hospital's MRI machine. So he was told to go to Hogle Zoo to use the MRI machine used for elephants. You would think that after being told something as humiliating as that, he would have changed his lifestyle. Not so; he died a year later from complications from obesity. I'm not sure there is a doctor that can motivate someone to lose weight. If it doesn't come from within, it's not going to happen.
Wow, you'd use a time machine to help improve the health of your patients? Talk about a dedicated physician! I'd rather give my younger self a sports almanac to get rich.
Dr. Van De Graaff, Do you think their is a difference in outcomes when the patient states he is "fat and out of shape" versus a medical professional telling the patient that he is "fat and out of shape"? In the first example that you presented, the patient knew years ago that he was "fat and out of shape." The problem is that being "fat and out of shape" only recently was hindering his lifestyle (or lack their of). Our bodies are pretty forgiving, we can put years of abuse into our bodies before we see negative consequences (in some cases). Do you think that people would be more apt to change their poor lifestyle habits if the negative effects would present sooner?
Dr. Van De Graaff
Brett, Good point about "fat and out of shape." The effects of sedentary living are slow, insidious, and sneek up on people only over the course of years. I think we can blame the industrial age for this. After their years in high school, most people never have the need for aggressive physical activity imposed on them. Most of our jobs (even labor jobs) don't require prolonged aerobic or intense anaerobic exertion on a regular basis. My job is a good example. I do a lot of walking and standing, but unless I forego the elevator I could go years without breaking a sweat or getting my heart rate over 120. By the time a person gets to the point of realizing he is out of breath walking up a single flight of stairs he has already experienced years of gradual decay. He doesn't realize this because he never tests the physical capacity of his body. On the one hand this is probably a good thing. The human body can tolerate a lot of neglect and misuse without as much as a hiccup of malfunction. On the other hand, your body will forgive you only so long before it cries "uncle." Thanks for the comments. Dr. VDG