Taking your health literally but not seriously

Back when Donald Trump was first running for President, there’s a line made famous by Peter Thiel, but likely first coined by Salena Zito, about the difference between taking Trump seriously rather than literally:

“I think one thing that should be distinguished here is that the media is always taking Trump literally. It never takes him seriously, but it always takes him literally. I think a lot of voters who vote for Trump take Trump seriously but not literally, so when they hear things like the Muslim comment or the wall comment, their question is not, ‘Are you going to build a wall like the Great Wall of China?’ or, you know, ‘How exactly are you going to enforce these tests?’ What they hear is we’re going to have a saner, more sensible immigration policy.

I think about this line a lot when I’m taking care of patients.

A lot of people take their health literally, but what they really should be doing is taking it seriously.

Taking your health literally means paying super close attention to every single data point - every ache, pain, odd sensation, blood pressure reading, pulse oximeter oxygen saturation, lab test, etc - and being concerned that it means something is wrong or requires further workup and medical attention.

Taking your health seriously means doing the things that you actually can do to maximize your chance of having a good health outcome.

Too many people focus on the former in a way that comes at the expense of the latter.

Some things are in our control and some things aren’t

You may have heard of the Serenity Prayer before, originally composed by Reinhold Niebuhr, which was popularized by Alcoholics Anonymous:

God, grant me the serenity to accept the things I cannot change,
Courage to change the things I can,
and wisdom to know the difference.

This is a powerful concept - we can’t change everything, and sometimes it’s really hard to put the effort in to change the things that we can.

I’m a cardiologist, and I take care of patients with heart disease. Heart disease is a common problem that has common causes, only some of which we can treat.

If you’ve been reading this newsletter for a while, you know that I talk about a lot of the same topics over and over again when it comes to heart disease - metabolic health, blood pressure, lipids/Lp(a), exercise - because they’re the things that drive problems for most people.

When I counsel my patients on these topics, I tell them that heart disease has a number of different risk factors, some of which are modifiable, and some of which are not.

Put a different way: we can lower your blood pressure through weight loss and medications, but we can’t change who your parents are.

Spending your mental energy related to health on the stuff that you can fix is way more productive than spending it on the ones that you can’t.

Unfortunately, not enough of us always have the wisdom to know the difference.

There are two major problems here: too much testing and too much treatment

When you take your health literally instead of seriously, it’s very easy to end up getting too many tests done and getting prescribed too many medications.

This stuff isn’t benign. More testing means more stress, more radiation, more false positives, and more downstream testing.

It sometimes leads to invasive procedures, all of which have potential complications.

This can come in many forms.

I see patients all the time who come in because they are getting older and want to establish preventive care, which is totally reasonable. But sometimes patients come in requesting a stress test “just to make sure that everything is ok.”

On one hand, a stress test is a fairly benign test - you walk on a treadmill hooked up to an EKG and we make sure you don’t have any signs of high risk heart problems.

But what if that stress test comes up abnormal (and that false positive rate may be close to 20%)?

Do we send you for an invasive angiogram, where we stick catheter in your arteries to take pictures of your heart? Or should we just do the noninvasive test, where we send you for a CT scan to look at the blood vessels around the heart? The angiogram carries a 1/1000 risk of causing a heart attack or a stroke, and the CT scan may find a lung nodule that requires follow up or even biopsy.

The human body is weird and diagnostic testing is fraught with error

People have strange sensations all the the time. We develop aches and pains that come and go. This tends to happen more as we get older, but sometimes young people feel odd things too.

Most of these feelings don’t mean that something medical is wrong. Often, they’re just your body telling you that you need to move more.

Occasionally these odd feelings are real medical issues - and I am certainly not suggesting that you blow off a concerning symptom - but most of the time, an odd sensation isn’t a sign of concerning disease.

But often, what most people need is simply to get up and move and give themselves a bit of the tincture of time.

Medical testing is really good if you’re having symptoms. But if you aren’t having symptoms and you’re able to do the things you want to do in your regular, no amount of testing is going to make you feel better.

And there’s a good chance it’s going to lead to more medicalization of a situation that didn’t need it in the first place.

The other result of over-medicalization is too many pills that you don’t need and don’t make you better

Physicians are trained to treat ailments with medications. It’s what we do for a living.

But a lot of things we see don’t need medications - they need better nutrition, more activity, and more sleep.

Decades of inactivity, processed food, and lack of sunlight lead to stiffness, pain, depression, anxiety, poor sleep, and almost all of the other “symptoms” that people often consider to be part of normal aging.

The answer to chronic back pain isn’t muscle relaxants, just like the answer to poor sleep isn’t sleeping pills, and the answer to stress isn’t more antidepressant use.

But I often have patients asking me for these things, and the response I get when I decline to prescribe them is more surprise than anything else.

When I recommend to a patient who is having trouble sleeping that they get more physical activity or spend more time outside, I’m often met with a number of objections - the reasons that they can’t do what I’m suggesting - and sometimes with a request for a pill anyway.

Going to the doctor and asking for a pill when you’re offered a non-pharmacologic solution is taking your health literally instead of taking it seriously.

These medicines are overprescribed because it’s easier to just write the prescription than to spend 15 minutes objection handling from someone who doesn’t really want your professional opinion in the first place.

So then how do you take your health seriously?

I see a lot of different types of people in my clinical practice - I think that most people actually know the answer to this question, at least subconsciously, because no one is ever surprised when I talk about these things.

But it’s much easier to list the reasons why you don’t have time to exercise and the challenges with turning off your electronics an hour before bed than it is to take the steps to change the things that you know are important.

Taking your health seriously means prioritizing the things that we know lead to better health like sleep, exercise, and nutrition.

Taking your health seriously also means not looking for the signal in the noise of your repeated bloodwork or getting medical testing that you don’t need because you don’t have symptoms.

Taking your health seriously means applying the serenity prayer to your health: change what you can, accept what you can’t change, and don’t over-medicalize the rest of it.