This comment of Will’s got me thinking about how the medical profession sometimes comes across. On the subject of whether women should give up drinking because it may raise breast cancer risk a bit, he says:
The thought of taking out wine from dinner, if one enjoys it, seems tragic absent rather compelling evidence. We’re always finding out new things. New dangers and occasionally new benefits.
I try to avoid pronouncing on such abstractions as “the medical profession.” I have an insider’s view of American medical care, it’s true, but that perspective is still very limited. I have a pretty decent grasp of what taking care of kids is like, and because of the various places I’ve trained and practiced I have a somewhat broader base of experience than some. But it still feels kind of ludicrous for me to hold forth on “medical care in America today!” or some such.
That said, I have a sneaking suspicion that when people think of medical providers as a category, a large part of the mental picture is a humorless scold in a white coat. We are constantly finding some new thing that people should be doing (often something they don’t like, such as eating more kale or elevating their heart rates) or should give up (often something they enjoy a lot, like sex with attractive strangers or smoking cigars). By the time they’re teenagers, even my own young patients seem braced for a lecture when they come in for check-ups.
Some of this is simply unavoidable. I really do want my patients to be as healthy as possible for as long as possible, and certain things make that less likely. Certain very fun behaviors (getting tanked, sleeping with lots of people, playing video games until 3 AM every night) carry the risk of various unpleasant health outcomes. I don’t want my patients to become obese, or get infected with herpes, or develop a substance abuse problem. I would be shirking my duties to ignore risk behaviors or fail to counsel against them.
However, I do worry sometimes if medical providers, viewed as a whole, don’t conflate “health” with “absence of disease.” While the latter certainly is a large part of the former, it doesn’t comprise the whole. There are many things that may compromise or complicate a person’s physical well-being that add enough quality of life to make it worth it anyway. The best example I can think of from my own practice relates to sports injuries. I get lots and lots of athletes who have some kind of orthopedic problem, either from overuse or related to trauma of some kind. Almost all of them are relatively benign, and will heal on their own with time. From the perspective of preventing further symptomatology, the best recommendation is relative rest. For many of these kids, the impact on their quality of life of missing some major sporting event is catastrophic. (Yes, yes. They’ll get over it. But it serves the patient better to acknowledge the real distress they’re feeling than to patronize them.) Assuming that the injury won’t destabilize from further sports participation, I talk about costs and benefits of further play. If they’re willing to accept that their injury may hurt worse and for longer than if they opt out of play, I let them play. For a lot of kids, it’s worth it to have pain if it means they can participate in an activity that significantly enhances their quality of life.
No matter how enjoyable some things are, they’re harmful enough that people should never do them (like, say, crystal meth). But there are doubtless lots of people whose enjoyment of food keeps their weight out of the “healthy” range but whose quality of life is such that it’s worth it on balance. I wonder if there’s enough accommodation for that kind of thinking in medicine, and if we’d have better relationships with our patients if we allowed for more.