Dept of Finger Wagging

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.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.


  1. I do think that *technically* the proper role of the expert (whether scientist, doctor, dentist, etc.) is to inform rather than advise. On the other hand, most of us generally do agree that health maximization is more important than fleeting pleasures, and so the person in the white coat is really just acting as a projection of our superego. We dread the visit because we know we’ve sinned.

    • Yeah, i’d rather see doctors say “here’s a few alternatives, and here are my rough confidence levels on whether or not I have actually diagnosed this properly” (the latter being critical because it will guide my judgement of how long I give the medicine before I show back up saying “wrong diagnosis doc?”)

  2. This post hits home. Our youngest boy, the athlete of the family, lives for the nonstop parade of organized teams sports that seem to make up all of his non-academic life. This past summer he started having knee pain; after taking him in he was diagnosed with Osgood-Schlatter.

    I didn’t know what it was, and was surprised with the doc’s declaring him OK to play through the pain if he was up for doing so.

    It doesn’t bother him all the time, but on those days where he’s running across the soccer field and you can tell by his running gate that it’s a bad day, it makes me feel like the worst father in the history of the planet.

  3. People just love them some Argument From Authority, and what’s a better authority than the doctor?

  4. I just saw on the news from CNN that according to a report from CDC, the number of gay people on the largest STD dating site SinglesHerpes. com has reached 310,000. This site seems to be powered by plenty of fish and most of the gay people on it are sexy and good looking.

    Personally, I have no objection to gay marriage. My concern is that more and more gay men get STDs. It seems that gay men is easier to get an STD and they even don’t know when they have it.

    • Hmmmm. Can’t seem to find that CDC report or the CNN story about it. Would love to see a link, so please do provide one.

      I find it fascinating that you are familiar enough with the hundreds of thousands of gay men on the “largest STD dating site” that you feel comfortable pronouncing on their physical attractiveness. Just out of curiosity, how many people in total frequent the site in question?

      And yes, some gay men have STDs. So do many, many, many heterosexual men and women, and a great many of them don’t know they have them. The problem is neither unique to gay men, nor are they disproportionately affected.

      Glad you don’t have a problem with gay marriage. Not at all sure what that has to do with anything.

  5. Herpes is one of the most misunderstood std’s out there. The simple truth is that 90% of the adult population has it but doesn’t realize it. If you ever get a fever blister you have herpes. The only difference between mouth herpes and the other kind is simply where it’s located. It’s the same virus, resting at the back of your brain untill something triggers it and you get an outbreak. There is no difference in oral herpes and the other kind, just the location, and there is no cure for herpes, though drugs such as Valtrax can stop an ourbreak once you get one. Odds are these wrestlers already had the virus and why the big to do here is beyond me. You may know more about herpes on the dating and support site POZloving. Good luck to you all!

  6. I appreciate you posting this. Sorry it’s taken me so long to participate.

    Truly, I haven’t much to add. I think your youth sports example is a fantastic one. When my wife and I debate risk management (as I put it) or taking needless chances (as she would), it’s actually one of the examples I came up with where I could demonstrate something she considers to be good and healthy but that comes with some physical risks that are worth it (if you’re a sportsy kind of person, anyway).

    I wish I could find it, but I read an article a while back about how weight-shaming and the stress it causes to the shamed could actually be more unhealthy than being overweight. I oppose weight-shaming primary because I don’t think helps, but it could hurt. (I know that we’ve discussed this issue and so it’s not directed at you. I actually think that most doctors are okay about this. The problem more generally lies elsewhere. But it seemed pertinent to the discussion.)

  7. 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.


  8. Exc, Dr. Saunders. My own internist has zero in the way of bedside manner, but has rather puzzled me out as a bon vivant and a reasonably clever fellow, so makes very little in the way of scoldings for what both he & I know are [duh] bad habits.

    I’ve decided to take a chance on a rather uncharming Stanford grad rather than a mediocrity who can’t wait to hold my hand and lead me through the maze of the conflicting studies that hit the media daily and then the resulting emotional crises.

    To yr point, there’s a fellow in my office who eats oatmeal all the time, and eats a steak mebbe once a year. I ask him, why would you want to prolong such a miserable life?

    Or, to consult the classics:

    “Health nuts are going to feel stupid someday, lying in hospitals dying of nothing.”—Redd Foxx (1922 – 1991), who got his fourscore and ten, more or less

  9. Well, actually, it is exactly the attitude of doctors that is one of the main things that has kept me away doctor’s offices for the last 20 years. (Modern drugstore medicine is amazing – my last bad cut was easily sealed with one of those new superglues, saving me a $1000+ emergency room visit.) I should get a checkup sometime, but there’s no doctor I trust not to 1) rip me off too much by charging me (paying personally) the same ridiculously inflated rates they throw at the HMOs (which pay only 20% of that rate), and 2) not to hassle me.

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