A Doctor’s Response, To A Response From A Doctor

Bojan Kostevski

Joe Lightfoot, a last year medical student, wrote a guest article named Just Because A Doctor Said It – A Response on Tony Gentlicore’s blog, and its popularity has been spreading like this year’s strain of the influenza virus. You should definitely read that blog post; it’s a good piece with some thought-provoking points, and you’ll probably need it to understand my arguments fully.

I’m constantly bombarded by stories of people’s “stupid doctors” who said X,Y and Z about fat loss diets on my Twitter and Facebook news feed. This bashing is getting tiresome, and if you ask me, it’s based on completely the wrong premises of what I do as a medical doctor versus what I did when I worked as a personal trainer, or what I do currently with my online consultations.

As a physician working with real patients on daily basis, I do have a few opinions which I’d like to share. Joe Lightfoot and I agree on many points, but there are a few aspects that I believe needs to be added to the discussion. So far, the discussion seems solely focused on two parties: the health practitioner and the trainer. We have completely forgotten to include the third, and biggest party: the general population.

Point one: the misconception about what doctors do

Question: As a doctor, do you know I do on a daily basis?

Answer: I see ill people (also called patients). I sit by their bed, I comfort them, listen to their stories, examine them, use the x-ray to get under their skin so I can give them a diagnosis, plan their treatment, prescribe the right medicine and do a follow up.

Doctors need more education on everything to do with lifestyle advice, particularly exercise and nutrition. That is indisputable.

That is an interesting point by Joe Lightfoot, and in a fantasy world where you could ride the rainbow, shower in moonbeams, and do wand-wielding magic, that could probably be feasible. Reality however, is a cruel mistress.  In most countries med school is six years long, and that is before any kind of specialization comes into play. In the real world, there is just not enough time to learn everything. Specially if it is not going to be a part of what you will be doing on day-to day basis because to become a good clinician, we need to get students out of med school as fast as possible and get them to start building real world experiences.

Sure, doctors need to understand human physiology and the effects of lifestyle on the pathological processes, to a minimal degree. This is a very important point, which is why I will repeat it: they need to understand it, to a minimal degree.

What often comes to light in these discussions is that the advice given by your idiot doc was not the “optimal” advice. Nor was it in accordance to the latest paper published in the British Journal of Nutrition (which you have probably only read the abstract of). That’s considered talking about expert opinions, not general guidelines. I repeat once again: doctors need to understand human physiology and the effect of lifestyle on the pathological processes to a minimal degree, as a way to understand ILLNES and the treatment thereof. Because THAT is what doctors do. There is just no time to learn all that other stuff, unless that’s something you are genuine interested in (and even then, people will still call you an idiot because you don’t follow the same nutritional cult as they do).

This brings us to the next point

Point two: The reason doctors give advice on fitness and nutrition even if they shouldn’t

So if doctors really don’t have a clue about optimal nutrition or exercise physiology (the two weeks spent touching on that during med school just aren’t enough) – why the hell do they give you advice about it?

Just like Joe Lightfoot said:

Whilst some are motivated by money and titles, the vast majority of people became doctors because they want to help their patients.

They will give you advice because of the very same reasons anyone gives advice about nutrition or fitness. With a few exceptions, your doctor wants to help you, and will say what he or she truly believes will do so. So does your mom, your neighbour and your personal trainer. That does not mean they know what they are talking about, and YOU are the misinformed one who thinks that’s what they are supposed to know. If you’re not smart enough to know who to listen to, then you’re just as “dumb” as they are. Don’t blame others because they tried to help your ass out.

Point three: Your doctor is not the idiot. You are.

Nutrition and the education on lifestyle and preventive medicine during med school was minimal. And like I stated above: I don’t necessarily think that including more lectures and adding years to med school is the solution, since that is not what we work with on day to day basis once school’s out. When you ask anyone on the street what you should eat to lose weight, you’ll get the answer this person happens to have, which is usually influenced heavily by external factors. This could be yesterday’s magazine, some random documentary or from last week’s episode of The Biggest Loser. Understand this: Your doctor has the SAME source of information as the general public. It’s you who thinks that just because your doctor said it, there should be some validity to it. In a way, calling doctors stupid because of the nutrition advice they give, tells more about the knowledge of the audience than the doctor.

The focus needs to shift from the doctors being stupid and not knowing shit, to the general population who are the misinformed ones about what they can expect from their physician. Give your doctor a pair of strange sounding lungs and you should expect him/her to diagnose pneumonia and prescribe you with the right antibiotics. However, don’t expect him to know which the optimal diet is for fat loss, even if he does think he knows, and there is a stethoscope hanging around his neck.

The conclusion

In the perfect world, doctors would stop giving advice about areas outside of their expertise (so would the general population). In the meantime, the general masses need to get their facts right about what a physician’s job is and most importantly, what it’s NOT… before they start hating for the sake of hating.  On the same note, trainers need to shut up with advice about how much water people should drink to reduce risk of kidney stones, how sleep deprivation causes cardiovascular disease and why gluten is the most evil thing since dairy.

Finally, I want to get back to the original question:

 Is it true because your doctor said so?

I’d say it depends on the initial question you asked your doctor. If your physician is trying to explain what bacteria caused your pneumonia and how you should go about treating it – the yes, you should expect your doctor to know, because THAT is what we do. When it comes to nutrition, preventive medicine, or exercise physiology? No, not any more that you trust your mother, neighbour or favourite columnist – they all get their information from the same sources anyway.

The takeaway is this: Stay critical and ask for people’s sources, never ever trust people blindly just because of their title – be it your doctor, mother or columnist.

Trust me – I’m a doctor

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17 comments on “A Doctor’s Response, To A Response From A Doctor
  1. shawnmccarthy says:

    Doctors should be able to offer effective treatment plans for a variety of common ailments, and most importantly for conditions affecting a large % of population or causing immediate risk. While obesity isn’t likely to kill anyone over the span of a few days (compared to one of your examples, an acute lung infection) it contributes to overall poor health and compounds the effects of other illnesses, leads to return visits, and additional cost burden to the patient and the health care system.
    That’s not to say doctors need to be experts on weight loss any more than they need to be experts on emphysema, but the responsibility of providing either correct and current information or a referral to a better suited practitioner is part of good care.
    -via shawnmccarthy. 

    • BojanKostevski1 says:

       @shawnmccarthy In a way that’s the poing I’m trying to get through, and obviously spark some discussion where I think wee need it. What you are describing as the knowledge to know about obesity, the risk to the population and treatment thereof, I most certainly agree. And I do believe this goes under “basic knowledge”. The critique however often is about the minor details and “expert opinions” – THAT’s what I’m against. When it comes to treatment of obesity, we simply don’t have very good methods, and most studies shows that conservative long term weight management (ie not surgery) is very hard, but that’s not something that the doctor should be held responsible for. I believe a large part of the problem with obesity lies in the obestigenic society we live in, and to be honest – our methods with dealing with the problem are just not good enough…Thanks for your input to the discussion. DIscussing it is the first step to getting better at understanding the problem.

  2. Nurdin says:

    Maybe we could use doctors with a specialization in nutrition and exercize?

    • BojanKostevski1 says:

      I agree. First step to finding a long term solution is having enough understandment about it. I sure would be interested in such a specialization.

  3. JSyatt says:

    Bojan, THIS WAS AWESOME!!!!
    Great points all around.

    • BojanKostevski1 says:

      Thanks @JSyatt . I’m glad so many are interested in discussing it, because I truly believe this is a discussion we need to have.

  4. Mark Young says:

    Great post!  I think we can hardly blame the public for their confusion. When they go to a trainer or doctor they typically assume that they are acting within their scope of practice. When a trainer starts talking about gluten intolerance or a doctor starts talking about lifestyle I think that the masses simply believe that there is some sort of control over these types of acts. After all, why would a professional offer advice beyond their level of expertise? And how could this be permitted? I know that in a hospital setting I, as a  kinesiologist, have a clearly defined scope of practice. I cannot deviate from this without a medical directive. Perhaps greater regulation is needed? Or maybe people (doctors and trainers) need to stop opening their yap about stuff they don’t understand. Despite the intent to help, if you don’t know the area it can do more harm than good. I think that would be a fantastic first step.

    • BojanKostevski1 says:

      Thanks @Mark Young , appreciate your respons! I dont really believe that you can ‘blame’ the public in any way for being uninformed, I’m just trying to spark a much needed discussion here and turn the argument around. In the end I think just like you, that much of the problem lies in every single part of the triad understanding their limitations in expertice and not to forget LEARN TO WORK TOGETHER (it’s OK to ask for help…) and consult each others when needed. Like I said, in an ideal world – doctors learn what they have enough expertise to give advice about, trainers understand where they fit in this structure (and i definitely believe they have an imortant place) and where they can provide expertise AND the general public understands the limitations to the different roles these play and what you can and can not expect from the different professionals. Who provides the general public with this education? I don’t know,  but I do believe that discussions like these are helping to increase the awarenes and could provide a starting point…Once again, thank you.

  5. BryanC says:

    I’ll save most of my reaction for my own blog :) However, in short: 1) There are consensus guidelines for physical activity to guide physicians on how to advise their patients just as there are consensus guidelines for the management of DVTs. I would argue that medical students get less lectures on hand injury than they do on lifestyle/nutrition issues. 2) The intervention required for most individuals posing these questions is reduction in caloric intake–which as Bojan has so eloquently put it, is not information patients don’t already have access to, and definitely not outside the scope of practice of a physician to talk about with their patient (we do it all the time in our specialty). I can’t think of a single physician I know in real life (as opposed to Bojan, who I’ve only met on the Internet) that would start to actually coach a patient on how to lift, or run, or swim. That’s what kinesiologists, coaches and swimming lessons are for. 3) The ability of any given trainer to complicate both the problem and the solution to the point where it sounds like they know more AND that that complication is a required component to success is unparalleled.

    • BojanKostevski1 says:

      Thanks for joining the discussion Bryan Chung   1. I agree, and these consensus guidelines are what I call “basic knowledge” and at the level that the doctor SHOULD be expected to know if they don’t have any big, personal interest and are willing to themselves dig into the research. 2. And that is also why I think we need to consult each other when needed, and develope a system where it’s OK to call each other and use each others expertise. 3. Once again, like Mark Young said, guess that’s where bigger regulation migh come into play, I don’t know… | Thanks for your imput man, appreciate that! Looking forward to that blog post!

  6. Neil C87 says:

    Just a small thought on this, would be easier (and maybe better), rather than focusing on educating doctors how to advise people, educating them that treating lifestyle issues is not their responsibility (as you mentioned yourself) and they should refer out. The whole “if in doubt refer out” saying that is often repeated around coaches and therapists. 
    Doctors commonly refer to other doctors more specialized in various conditions and treatments, should this not be viewed in the same light?? There are a growing number of professionals from various backgrounds who are becoming recognised experts in the area of obesity, diet etc.

    • BryanC says:

       @Neil C87 I think it’s worth noting that the original focus of Gentilcore’s post was the HCG diet, which is generally physician supervised (whether scrupulously or not is a different debate). The point of the post was to state that there are physicians who claim they can help patients lose weight, when in fact, they don’t have the knowledge to do so, using the HCG diet as a case example. Personally, I think it’s a bit of an extreme example to then make the statement that your doctor isn’t trained to help you lose weight and that this is the sole domain of trainers/nutritionists. It’s equally ridiculous to suggest that the complex information that is available (that doctors are not trained in) is actually NECESSARY for a person to enact change. There IS a role for physicians in weight-loss, just as there is a role for them when it comes to smoking-cessation, and beyond just the counseling component (from both a pharmogological and surgical point of view). To be honest, I’m not sure where the idea that physicians AREN’T referring out comes from. And even if a physician wasn’t going to refer out, most patients are going to take those types of matters into their own hands, and join a Weight Watchers or equivalent program.
      The deeper issue (man, I’m not going to have a blog post at this rate…) is that there is virtually no quality assurance for a regular “joe-blo” physician to ensure that the recommendations to other “professionals” are valid. Yes, there are physicians and surgeons of varying quality, but we all have to pass very stringent exams and processes (at least in the first world). And just as a layperson can’t typically tell the difference between two qualities of surgeon, a typical lay-doctor can’t tell the difference between Tony Gentilcore and dude in the chain gym with a weekend course and a website.

  7. KellieHartDavis says:

    I know that both you and the original author come from a European medical community, so things are bit different over there. But in the US, there is a tremendous polarization between the for-profit and research-based medical communities. The for-profit arena looks at the bottom line. They administer treatment, build practices, forge alliances in whatever manner makes them the most money– this is especially true with cancer treatment. We now have a huge push for urologists to run radiation treatment centers so they have a one-stop shop. The more services provided the greater the profits.
    My husband, who works on the business end of medicine, was recently at a conference in California. A medical director did a presentation on a cancer treatment that cut the treatment time in half and was more reliable than methods currently being used. But the catch was it shrank the profit margin because fewer treatments meant fewer charges—decreasing reimbursement. When asked a show of hands who would opt to use the treatment that was better for the patient, 4 of 75 physicians in the room raised their hands.
    No, physicians are not required to teach people to eat well, how to exercise correctly, or how to reduce lifestyle risks. But Hippocrates told his fellow physicians, “Leave your drugs in the chemist’s pot if you can heal the patient with food.” Just like the forefathers of our nation, I think that physicians should take the words from the father of medicine to heart.
    When the CEO of a medical group owns 10 houses over 1 million dollars, you can’t convince even the most green patient that he bought them with every patient’s best interest in mind. Not all physicians fall under this scope, but having listen to the stories told by my husband who’s worked with hundreds of physicians over the course of 8 years, I can hardly feel confident in saying that all doctors show up to work every day to heal the sick.
    If a family doctor can put a liposuction machine in his office (yes, this is happening all over the country) to boost profits, I think he is perfectly capable of picking up a nutrition textbook and advising his patient on a proper diet.
    Maybe I’m a little jaded being that I’ve watched a close family member who’s been morbidly obese nearly her entire life spend ever single month of her life for the past 10 years in and out of doctors’ offices. She’s been prescribed countless medications, has had numerous surgeries, including gastric bypass, and has been on medical leave more in the last year than she has been at work.  Not one single doctor has looked her dead in the face and said, “You need to lose weight or we can’t help you.” Why would they when they have referral incentives?
    Unless you are part of the non-profit medical sector searching for the answers, medicine is big business in America. 

    • BryanC says:

       @KellieHartDavis I don’t disagree with you, but I think the same argument holds for private sector personal training/nutrition, possibly even more so. I’m not sure how this changes the discussion.

  8. paul d2 says:

    Hi Bojan,
    Excellent excellent article!!!! Having been a person who ate a lot of crap for 20 years, smoked, worked in a high stress job for many years and lived a very sedentary lifestyle, I was on my way to a very early grave, and at 5 foot 6, I cracked 85kgs (low muscle tone and very high fat) – someone say OBESE!!!!!. No matter what advice my Dr would have given me, I would have ignored it, and in fact, despite the damage I was doing, I never visited my GP, apart from a few times when I experienced acute issues that required immediate medical intervention. Maybe the story of many people in the general population you refer to. Why the fuck are Drs getting blamed, when they only see these patients in life or death situations, or under disease related circumstances. A 15 minute consultation with a Dr is like putting a used bandaid on five lethal gun shot wounds. Personal responsibility rests squarely with the general population, and if you think the information in the mainstream press is wrong, and eating a balanced diet and the food pyramid is stupid advice, than except that you are on your own, and you need to learn and understand what you can do to make things better for yourself via nutrition, calorie restriction and exercise. The info is out there, and it is up to you to find something that works for you!!!!!   
    Nothing irks me more than people writing in blog comments and smugly reporting how their Dr was “gobsmacked”, “stupified”, “dismissive”, “outraged even”, over their changes in blood profiles, their curing of medically “untreatable” ailments and reversal of long term disease conditions that their Drs “could do nothing about”, through diets such as “raw food veganism” or “paleo” and claiming this is a panacea for everything and everyone. Typical quote – “I am paleo, and my DR told me that saturated fat is bad, and I eat a tonne of saturated fat, and I am the leanest and strongest I have ever been etc. You should ignore your DR and in fact, avoid Drs like the plague, because they don’t know shit, and besides they still believe in the cholestorel thing, and big pharma with their conflicted interests and their grain pushing is making us all ill to make more money, and Drs don’t know shit about nutrition, and if you follow low carb paleo, you will be just like me and in perfect health”. “This guy on the internet, who by the way, does HIIT 6 times a week, is ripped at age 90y, told me I need to give up dairy and gluten, and eat 6 meals, and since then boy, I have never looked back!!!”   
    I think people need to work with their DR and where it is affordable, leverage diagnosis and medical testing and get blood work done regularly, particularly when undertaking lifestyle changes to try and reverse lifestyle based conditions such as metabolic syndrome and obesity associated hormone imbalances. The intervention is “eat less, eat well and move more” – it is up to you!!!!!!!
    My own experience and how I worked with my DRs …..  
    I started an active lifestyle about 18 months ago to reverse obesity and skin conditions, lethargy and breathlessness walking up a few stairs. All good for a long time. One morning about 9 months ago, on my way to the gym, I felt a mild pain in the lower left side and was also suffering a mild fever. Figuring it was just a gym injury, I thought I would train around it, but at the last minute, decided to stay home. Shot off to my DR, who to date was very encouraging of my decision to exercise and eat veges and fruit to reduce my waistline, and within 5 minutes he had diagnosed me with acute diverticulitis (he is a dam good DR)  which was confirmed by referrals and appropriate testing. We did a lot of blood work, and discovered my liver enzymes were trashed (really really off the charts). I lost a lot more weight, altered diet and removed foods I deemed I could not digest well, and did a lot of meditation etc. I went back, and over the course of months, my liver enzyme profile returned to normal (thank fuck) and I reversed some fatty tissue deposits. Recently, after a lot of heavy lifting and some joint pain, I decided to see a sports DR, who through our discussions, did a large blood test profile, joint assessment etc, and included B12 and Vit D in my tests at my request. I came back Vit D deficient. He was so friggin astute, based on my presentation, he tested me for lupus and specifically SLE due to the location of my inflammation in the peripheral joints. Thirty minutes, a few questions and away I went. Results were early but mild indications of SLE, which we are monitoring (no big deal as far as he was concerned, given many of the other inflammation indicators came up negative). Again, awesome outcome.
    A problem is that Drs can make it look too dam easy, and the internet with its raft of conflicting information (and diet and lifestyle trainers and dogmatic fucking lifestyle priests) combined with commercial interests, poor ad copy and associated diet dogma and fundamentalism are all bundled up with a few fitness models, shots of 6 packs and a set of empty promises. Their lack of accountability to their “clients” who buy their programs, and their failure to paint a realistic picture of the “not so successful” results ….. well enough said …… They can make it appear so dam easy, when none of us really understand the complexities of our own bodies, and someone writing a blog and offering you a panacea of products and supplements without knowing jack about you, including your name and medical history knows less about you than you know yourself, and far less than a Dr can work out about you after 15 minutes of meeting you.           
    I have just hit 64kgs and am the leanest at 41 that I have ever been. I started strength training about 6 months ago, and this morning I almost deadlifted 2 times my bodyweight . I eat alot of protein, a heap of veges and a lot of fruit and restrict my calories. Do LISS a few days as well, and even flap around and do yoga on the weekend sometimes. My 3 and 6 year old kids sometimes drink vege juice I juice for them, drink smoothies, eat their veges (often side servings of broccoli, celery, capsicum etc) eat a salad with dinner, eat a lot of diffferent fruit, snack on things like kale chips, seeds and nuts + fish oil, eat good dairy and a lot of organic meat, and have no sugar and salt laden cereal, no soft-drink and of course they eat cake, donuts, chocolate, popcorn and hot chips and other “unclean food” as well.      
    The engagement model is simple, get a tonne of blood work done and a full physical and tests from your DR after covering off family genetic history, alter your lifestyle (get off your ass and do weights and also cardio for its associated health benefits), eat at a calorie deficit, vary macros until you hit a sweet spot, and make sure you get your micros covered. Keep revisiting the DR to assess progress. The missing piece is personal responsibility and self-discipline. It is not easy!!!! Simple but not easy.
    Rant over.
    Keep up the great blogs Bojon!!!!
    Paul D

  9. Shane says:

    Aren’t doctors trained to understand the strengths and limitations of research? They also have a better science education, a deeper understanding of how the body works. Doesn’t this make them far more qualified to give advice about nutrition and exercise than the general population?

    When in doubt, aren’t they still the best people to ask?

  10. Renee Gingerich says:

    the medical doctors here in Greenville, Texas, are a real disappointment, and I’m not so sure, that their cures are any better, than the disease itself. I am not even going to bother to complain about any of the medical doctors, here in Greenville, Texas, or any of their toxic, clog me up (cures) anymore, I am just done with going to see any of these useless medical doctors, here in Greenville, Texas, anymore! (I have Government hand out medical insurance, but what’s the point in having and Government hand out medical insurance, here in Greenville, Texas, when all of the medical doctors I go to see here in Greenville, Texas, really don’t do any better for me, than me laying around in my bed for several weeks, or whatever, trying to get rid of all of my diseases naturally, to begin with anyways?)

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  2. […] .  His article was then responded to by Dr Bojan Kostevski, a practicing physician in Sweden http://www.lift-heavy.com/a-doctors-response-to-a-response-from-a-doctor/.  The issues brought up in the blogs challenged the […]

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