If You Think Doctors Don’t Do Prevention, Think Again

Prevention has long been a priority of conventional medicine.

One of the common criticisms we hear from alternative and integrative medicine proponents is that doctors don’t do anything to prevent illnesses and have no interest in prevention. They claim that doctors are only trained to hand out pills to treat existing illnesses. Sometimes they even accuse them of deliberately covering up cures and wanting to perpetuate illnesses like cancer so they can make more money by treating patients. Nothing could be more absurd. Every reputable doctor would rather prevent illnesses than treat them. In his book Heart 411, cardiologist Steven Nissen even said he would be glad to see his specialty become obsolete: “Don’t worry about us; we will gladly hang up our scalpel and stethoscope if we can find a better way to lead you to a heart-healthy life.”

Doctors own prevention. They invented it, from vaccines to clean water to preventive screening tests. Mainstream medicine was responsible for the greatest preventive achievement in history: the smallpox vaccine campaign succeeded in preventing anyone from ever getting smallpox again. I defy you to comb through historical records and find any doctor who ever said “Let’s stop vaccinating for smallpox so we can make more money treating its victims.”

Prevention is one of the six fundamental principles of naturopathy. Alternative practitioners pride themselves on prevention, but they don’t actually do a very good job of it. In fact, there is evidence that their patients are less likely to get immunizations and some of the standard preventive screening tests recommended by the USPSTF. Instead of rigorously implementing evidence-based preventive strategies, they tend to offer other speculative, untested recommendations.

Preventing Zika virus infections

The current Zika crisis is a case in point. Doctors are doing prevention. Mainstream medicine has responded with mosquito eradication programs, effective mosquito repellents, travel advisories, and public information campaigns. Two experimental vaccines have already been proven effective in mice, and human trials are already underway.

Meanwhile, what are the CAM folks doing? Recommending things like these:

Mike Adams of Natural News warns:

If the Zika virus spreads into a devastating pandemic, it will only be because natural cures that already exist in nature are being systematically suppressed or criminalized by our corrupt, criminally-run medical police state system.

No, I don’t think so!

Bottom line: doctors are doing real prevention; non-doctors are doing bogus prevention.

The medical literature

Anyone who thinks doctors don’t do prevention must not be reading medical journals. Much of the medical literature addresses prevention rather than treatment. A recent review article in the American Family Physician, the journal of the American Academy of Family Physicians, is a good example. The title is “Diet and Physical Activity for Cardiovascular Disease Prevention” and its six pages and 36 references contain not a single mention of statins or any other drugs. It provides evidence-based recommendations to follow a DASH or Mediterranean diet and to get at least 150 minutes of moderate-intensity aerobic activity, 75 minutes of vigorous-intensity aerobic activity, or an equivalent combination each week.

What do naturopaths recommend for cardiovascular disease prevention? They may make the same evidence-based diet and exercise recommendations, but they also recommend non-evidence-based interventions like avoiding dairy, eating organic whole foods, taking vitamins and arginine, and using herbal dietary supplements like gingko and hawthorn. Some recommend CoQ10, omega-3 fatty acids, green tea, pomegranate, magnesium and potassium. And others add cinnamon, ALA, lutein, and plant sterols.

There are pragmatic studies claiming that the addition of naturopathic care to standard care decreases cardiovascular mortality, but pragmatic studies can’t determine effectiveness. Many of those studies are flawed and not properly controlled. They fail to distinguish between the effects of intensive counseling and the effects of the natural remedies they added. And those natural remedies are all over the map, so it is impossible to meaningfully compare studies or to determine which elements actually worked. I have seen no evidence that a patient under the care of a typical naturopath is any less likely to have a heart attack than the patient of a typical mainstream clinician.

What the critics really mean

When they claim “doctors don’t do prevention,” what they really mean is that they don’t think doctors spend enough time advising patients about things like exercise and diet. They seem to think doctors should take a detailed diet history from each patient and provide detailed personalized recommendations for what to eat at each meal. But that is not the job of doctors; that is the job of dietitians. Doctors understand the principles of good nutrition and provide general advice, but refer patients to dietitians for the nitty-gritty details.

Critics often have an exaggerated idea of what diet and lifestyle measures can accomplish. Only about a third of cancers are preventable by diet. Some people believe that if you eat right you can’t possibly get sick, and a recent commenter on this blog claimed that even genetic diseases could be reversed in three years by proper diet! They are wrong.

The critics cite anecdotes about patients who say they were given prescriptions with nary a word about preventive measures: for instance, statins to prevent cardiovascular events but no advice about weight loss, exercise, or heart-healthy diet. That may happen, but I suspect it is the exception rather than the rule.

I question the reliability of patients who claim their doctor never once mentioned smoking, weight loss, exercise, or diet. Memory is fallible. Studies have shown that 40-80% of medical information provided by healthcare practitioners is forgotten immediately, and half of the information that is remembered is incorrect. And surely people are less likely to remember advice that they didn’t want to hear.

The official guidelines for statins have been widely criticized, but the critics rarely acknowledge this paragraph from the report:

It must be emphasized that lifestyle modification (i.e., adhering to a heart healthy diet, regular exercise habits, avoidance of tobacco products, and maintenance of a healthy weight) remains a critical component of health promotion and ASCVD risk reduction, both prior to and in concert with the use of cholesterol-lowering drug therapies.

We can do better

Instead of “doctors don’t do prevention,” a more valid criticism would be “doctors don’t do as good a job of prevention as they might.” That is something doctors acknowledge and are already constantly working on, looking for effective ways of getting patients to understand and retain information and effective ways of improving compliance. And doctors don’t carry the responsibility for prevention alone. As with horses, doctors can lead patients to water but can’t make them drink. Doctors can encourage their patients to exercise but they can’t stand over them with a whip and make them get up off the couch. Doctors can lead patients to a healthy diet but they can’t follow them around 24/7 and slap their hand away if they reach for a slice of pecan pie instead of a piece of fruit.

Saying doctors don’t do prevention is a vile, ignorant canard. Showing how they could do better would be helpful, constructive advice.

Dr. Hall is a contributing editor to both Skeptic magazine and the Skeptical Inquirer. She is a weekly contributor to the Science-Based Medicine Blog and is one of its editors. She has also contributed to Quackwatch and to a number of other respected journals and publications. She is the author of Women Aren’t Supposed to Fly: The Memoirs of a Female Flight Surgeon and co-author of the textbook, Consumer Health: A Guide to Intelligent Decisions.

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