People

Disguises for a Deeper Problem and Walking in Your Patients Shoes

MedCrunch: Can you tell us about your current project at Nutrition Science Initiative (NuSI)? How you are taking new approaches to this specific medical field?

Peter Attia:  Think about it this way: imagine 40 years ago, 2% of the population gets a diseae and dies from it – pneumonia, for example. The medical establishment develops a vaccine to prevent the population from getting pneumonia. For forty years everyone is given this vaccine. However, the contraction rate of this disease continues to rise unabated. Today, 10% of the population gets and dies from pneumonia compared to only 2% forty years ago. If you confront this problem without emotion and only logic, you can really only draw one conclusion: either the vaccine doesn’t work – and it doesn’t matter if people take it or not – or the vaccine does work but most people simply don’t take it.

Now, the conventional wisdom might say that the vaccine works but here are 10 reasons why people won’t take it: they are too lazy, they are distracted, the environment doesn’t support them taking it, or some other excuse.  I would argue maybe it’s true that people aren’t taking the vaccine, which explains the treatment failure.  But what if the vaccine itself doesn’t work and is part of the reason why so few people don’t take it?  Or what if there is some side effect that is so unbearable that –despite the efficacy– very few people are able to take it?

The simple fact that either the vaccine doesn’t work and/or so few can actually take it, suggests that we need a better vaccine.  Period.  No more blaming people for not taking a pill (especially when there is such a paucity of evidence that the pill even works). That’s really the nuance and difference to our approach. We’re trying to go back to the beginning and say, “look, for forty years we have been unsuccessfully and ineffectually trying to treat a condition. Rather than to continue to berate the people who we are trying to treat, maybe we ought to question whether our treatment is correct as opposed to whether people are too lazy or otherwise uninspired to try to follow the treatment prescription.”

MedCrunch: Right now you are trying new approaches in the field of diseases that are associated with obesity. Do you think that you can, through your research, build a framework that can then be applied to other illnesses as well?  Is that your goal?

Peter Attia:  Yes, that’s part of it. I like your choice of words around obesity.  I don’t really consider obesity a disease and I think we do more harm than good by labeling obesity as such.  Obesity is a condition that in many cases –though not all– is predictive of increased risk for several diseases through an underlying process of metabolic dysregulation.  The diseases that cluster around this metabolic dysregulation –diabetes, heart disease, cerebrovascular disease, Alzheimer’s disease, and cancer– collectively account for the deaths of two out of every three Americans.  But there are common metabolic problems to all of these diseases that have to do with how energy is partitioned in our bodies. Obesity happens to be a symptom of this process in some of us, although not all of us.

MedCrunch:  In your talk at TEDMED you spoke about how your attitude towards patients has changed over the years. Can you describe the old and new you in terms of your relationship with patients?

Peter Attia:  I think the difference between Peter today and Peter seven years ago, for example, is that I’m just better at recognizing when I am being judgmental. I’m better able to take steps back and examine my beliefs and behaviors, and try to adjust my actions accordingly. I guess I’ve also had the privilege of walking a mile in someone else’s shoes.  In fact, today I look for opportunities to walk in the shoes of folks I disagree with or feel some tendency to judge. 

MedCrunch: Can you talk about the moment in which that change took place? Do you think that every doctor has to go through a certain journey to come to the point where you are to be more aware of the biases? 

Peter Attia: Part of it is just the journey of getting older and more experienced. That goes along with having had the personal experiences that made me realize what it was like to being on the receiving end of these judgments and how important it is for all of us to approach the experience of others with compassion and empathy. There are specific examples in my life beyond the one I talked about at TEDMED. I’m not sure I can speak about the process for others, though.

MedCrunch:  We think that the patient-physician relationship is difficult because of the what is expected from the physician. This creates an imbalance of power.  While it’s very important for physicians to stay empathetic, don’t you think that the patient sometimes expects too much from the physician given the fact that they have such busy lives and such huge responsibilities? Do you think that the problem is also on the patient’s side?

Peter Attia:  Could you give me a specific example?

MedCrunch:  As a patient, you go to the doctor expecting him or her to heal you right away?  But at the same time you also want them to show you empathy. Given the choice, you would probably prefer to be healed rather than to feel well treated.

Peter Attia:  I see your point.  I don’t believe that those are mutually exclusive features and I don’t think this patient-physician dynamic is a zero sum gain. If you’re asking me my personal opinion, I don’t think it’s asking too much as a patient that your doctor not only have the skill and knowledge to treat your condition but they also have the empathy and compassion to treat you as a person.

I’ll give you an example. My research background is in oncology, specifically experimental immune-based therapies for metastatic melanoma. The most important thing that I was ever taught by my mentor Dr. Steve Rosenberg was the need for this compassion. Because of the nature of the disease we were studying and trying to treat, most of our patients were going to die despite our best efforts, perhaps seven or eight out of every ten.  He said something that was very profound which was, “Peter, we can’t heal most of these people, but remember something: when we’ve done everything we can and our treatments have failed, we still have a responsibility to help our patients die with dignity and never abandon them.”

It is very tempting as a physician to move away from a patient when the patient is suffering or when the treatment isn’t working, perhaps because on some level as doctors we think that we have failed and it is a reminder of the failure. Our failure, that is. In fact, this is really at the root of much of the well-documented judgment physicians often have toward their obese and diabetic patients. The treatment fails. We assume it’s because they won’t comply. We don’t consider the possibility that the treatment might be incorrect, and we abandon them. So I really disagree with the premise that a patient can only expect one or the other, either a doctor who knows how to treat them or a doctor who treats them well. Patients deserve and should expect both.

MedCrunch:  Could you list a few things that you think should be changed in the current medical culture?

Peter Attia: I don’t consider myself an expert in this field and I don’t feel really qualified to speak about it at length. What I can say, though, is that physicians should be asking themselves the question, “Am I treating this patient with the best care I can?” both from a knowledge and technical standpoint and also from a human standpoint. As physicians, I think we have to ask ourselves if we would be treating the patient the same way if that patient were a relative or a friend. If I look back at all of the times that I was not empathetic and not compassionate towards patients, I can assure you that in that moment I was not at all treating that person the way that I would have treated them had they been a friend or relative.

MedCrunch: If you could give some advice to young physicians embarking on their careers and choosing their medical specialty, what would your advice be?

Peter Attia:  I think whatever path you choose, find a way to walk in the shoes of your patients. At least for me, I have found that to be the most powerful tool at my disposal to overcome the urge to judge.  If your patients understand that you are making every effort to see the world through their lens –and not just impose your lens on them– then you’ll be a better and a more successful doctor. Not necessarily because you’ll have more medicine or knowledge at your disposal, but because you’ll have a special relationship with your patient.

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