Recently, when attending a medical talk about the connection of unhealthy diets to obesity, heart disease and cancer, I was caught by surprise.
“When I want to discuss this issue with patients,” the speaker, a physician, said, “I ask permission.”
Permission? I said to myself. Since when do doctors with proven strategies for improving health ask for permission?
I am well aware of concepts like patient autonomy, which reminds doctors that patients should be the ultimate decision-makers. And I am very careful to ensure that my patients give informed consent before embarking on treatments — particularly ones that carry risk.
But when it comes to informing patients about potentially healthy interventions, I am not shy. A former colleague of mine used to ask medical students whether there was any topic that a physician did not have the right to ask a patient about. “Who they voted for in the last election,” he ultimately concluded. But that meant that mental illness, substance use, sexual behavior — and diet — were fair game.
So after the session, I sent an email to the speaker to ask if I had heard right. I had.
She went on to tell me how she might broach the subject: “I’d like to share with you how your food choices can help lower your cholesterol, blood pressure and blood sugar so that you may be able to avoid taking more medicine and be healthier. Would you like to hear about this?”
My first thought was that she was bringing political correctness to the doctor’s office. I’ve seen how this can happen in my other job, as an undergraduate professor in bioethics and the history of public health, where discussing topics like race, gender, addiction and obesity from certain perspectives might be seen as “microaggressions.” Perhaps this physician was afraid of offending her overweight patients by raising the subject of food choices.
But she said no. Rather, asking permission was how she approached the topic of healthy behaviors in general. In practice, she added, most patients agree to let her go ahead. Indeed, her enthusiasm for doing so often makes her run late.
Still, it got me thinking. Shouldn’t doctors have free reign not only to raise whatever topic they wish, but also to suggest it needs “fixing”?
After all, the number of potentially fraught topics I can discuss with my patients is seemingly endless. In addition to the usual suspects, such as diet, smoking, binge drinking and unprotected sex, there are many others, among them spousal abuse, texting while driving and the use of bicycle and motorcycle helmets.
Perhaps the best recent example of a controversial public health issue that is entering the examining room is gun ownership and gun safety in the home. Florida has even passed a law, the Privacy of Firearm Owners Act, to prohibit physicians and other health practitioners from raising these topics. Montana and Missouri also have similar laws. To date, legal challenges have been unsuccessful.
The physician whom I heard speak is not the only one who defers to her patients. I spoke with a colleague of mine who is also studying the health ramifications of dietary choices, and she told me she also asks permission when discussing other potentially “sensitive” subjects like smoking, alcohol or depression.
This physician’s patients also almost always say “yes” when she asks, she told me. And perhaps getting permission is a good thing. Patients may be more likely to listen to recommendations if they’ve first been given the option of participating. Guidelines published by the National Heart, Lung and Blood Institute urge physicians to ask their patients if they “would be comfortable with discussing general health, including weight.” But there is little research in this area.
Still, it remains difficult for me to use this approach. Call me a traditionalist or a closet paternalist, but I view each patient encounter as an opportunity to improve both physical and mental health.
This is not to say I have all the answers or always know what’s best. To be sure, research into the connection of diet and disease often seems contradictory. One study might find that a certain diet is good for your health, another that it is not.
But this is what I learned from the talk that I attended. Changing one’s diet from one dominated by meats and other foods high in saturated fats to one that is essentially plant-based — full of legumes, whole grains, fruits and vegetables — can significantly lower a patient’s risk of getting diabetes, heart disease and cancer, and may even reverse heart disease. I am going to be very sure that my patients hear that message.
Barron H. Lerner, M.D., is a professor of medicine and population health at New York University Langone Medical Center and the author, most recently, of “The Good Doctor: A Father, A Son and the Evolution of Medical Ethics.”