Trying to stay healthy can seem like a full-time job sometimes. Especially during a pandemic. But I’m here to make that goal a little easier. Welcome to the Nutrition Facts podcast, I’m your host Dr. Michael Greger.
Here’s a question: ‘How much do doctors actually know about nutrition?’ I have done a lot of research on the subject and concluded that more doctors should take the Hippocratic oath a little more seriously. Here’s our first story.
“A poor diet now outranks smoking as the leading cause of death [on the planet, as well as specifically] in the United States.” In the U.S., the #1 killer of Americans is the American diet. So, if diet is humanity’s #1 killer, then obviously it’s the #1 thing taught in medical school, right? Sadly, “medical students around the world [are] poorly trained in nutrition.” It’s not that medical students aren’t interested in learning about it. Medical schools just aren’t teaching it. “[W]ithout a solid foundation of clinical nutrition knowledge and skills, physicians worldwide are generally not equipped to even begin to have an informed nutrition conversation [about nutrition] with their patients. . .”
How bad is it? One study “assessing the clinical nutrition knowledge of medical doctors” found the majority got 70 percent of the questions wrong. And they were multiple choice questions, so they should have gotten a fifth right just by chance. And the “wrong answers…were not limited to difficult or demanding questions.” For example, less than half could guess how many calories are in fat, carbs, and protein; only 1 in 10 knew the recommended protein intake; and only about 1 in 3 knew what a healthy BMI was. I mean, this is like super basic nutrition knowledge.
And what’s worse, not only did the majority of medical doctors get a failing grade, but 30 percent of those who failed had “a high self-perception of their [clinical nutrition] expertise,” meaning not only were they clueless about nutrition, they were also clueless that they were clueless about nutrition, a particularly bad combination given that doctors are trusted and influential sources of healthy eating advice. For those majority of consumers who get information from their personal health care professional, “78 percent indicate making a change in their eating habits as a result of those conversations.” So, if everything the doctor knows they read in some checkout-aisle magazine, that’s what the patients are going to be following.
“Only [a quarter of doctors surveyed] correctly identified the American Heart Association[’s] recommended number of fruit and vegetable servings per day, and fewer still…were aware of the recommended daily added sugar limit[s]…”. So, how are they going to counsel patients on it? Yet, again, of the doctors who perceived themselves as having high nutrition knowledge, 93 percent couldn’t answer those two basic multiple-choice questions.
“Physicians with no genuine expertise in, say, [brain surgery] are neither likely to broadcast detailed opinions on that topic nor to have their [quote-unquote] ‘expert’ opinions solicited by media. Most topical domains in medicine enjoy such respect: we defer expert opinion and commentary to actual experts. Not so [with] nutrition, where the common knowledge that physicians are generally ill-trained in this area is conjoined to routine invitations to physicians for their expert opinions on the matter. All too many are willing to provide [their opinions], absent any basis for actual expertise,” or worse, “made on the basis of…bias and personal preference, [sometimes] directly tethered to personal gain such as diet book sales.” That’s one of the reasons all the proceeds I receive from my books are donated directly to charity. I didn’t want the appearance of any conflicts of interest.
“In a culture that routinely fails to distinguish expertise from mere opinion or personal anecdote, we physicians should be doing all we can to establish relevant barriers to entry for expert opinion [on diet and nutrition], as in all other matters of genuine medical significance.” I mean, we’re not talking celebrity gossip. Lives are at stake, and there are “[e]ntire industries…devoted to marketing messages that may conspire directly against well-informed medical advice in this area.”
“Medical education must be brought up to date. For physicians to be ill-trained in the very area most impactful on the rate of premature death at the population level is an absurd anachronism.” “The mission of medicine is to protect, defend, and advance the human condition. That mission cannot be fulfilled if diet is neglected.”
Maybe one place to start is for “physicians and health care organizations [to] collectively begin to emphasize their seriousness about nutrition in health care by practicing what they [at least should be preaching]. Is it appropriate to serve pizza and soft drinks at a resident conference while bemoaning the high prevalence of obesity and encouraging patients to eat healthier? A similarly poor example exists in medical conferences, including national meetings, where some morning sessions are accompanied by foods such as donuts and sausage.”
In our next story, we look at how more of us might be open to changing our diet and lifestyle if we knew how little modern medicine has to offer.
Yes, an ounce of prevention is worth a pound of cure, but a pound isn’t that heavy—why change our diet and lifestyle when we can just wait and let modern medicine fix us up? Previously, I noted that patients tend to wildly overestimate the ability of cancer screening and drugs like cholesterol-lowering medications to prevent disease. So much so that if patents were told the truth about how little they’d benefit, 90% said they wouldn’t even bother taking them.
The reason we should eat healthier, rather than just counting on a medical technofix, is that same over-confidence may exist for treatment too. In a massive study of more than 200,000 trials, they discovered that yes, pills and procedures can certainly help, but genuine very large effects with extensive support from substantial evidence appear to be rare in medicine, and large benefits for mortality, making people live significantly longer, are almost entirely non-existent. We’re great for broken bones and curing infections, but for chronic disease—our leading causes of death and disability–modern medicine doesn’t have much to offer, and, in fact, can sometimes do more harm than good.
Side effects from prescription drugs kill an estimated 100,000 Americans every year, in effect, making medical care the sixth leading cause of death in the United States. But that’s just for the deaths from taking medications as prescribed. Another 7,000 deaths occur from getting the wrong medicine by mistake; 20,000 deaths from other errors in hospitals. Hospitals are dangerous places. An additional 80,000 of us die from hospital-acquired infections, more recently estimated at 99,000 deaths.
But can you really blame doctors for these deaths? You can when they don’t wash their hands. We’ve known since the 1840s that the best way to prevent hospital-acquired infections is through handwashing, yet compliance rates among healthcare workers rarely exceed 50%, and doctors are the worst. Even in a medical intensive care unit, even if you slap up a contact precautions sign, signaling particularly high risk, less than a quarter of doctors washed their hands. Many physicians greeted the horrendous mortality data due to medical error with disbelief and concern that the information would undermine public trust. But if doctors still won’t even wash their hands, how much trust do we deserve?
So, we could go in for a simple operation and come out with a life-threatening infection, or not come out at all. And 12,000 die from surgeries that were unnecessary in the first place. For those keeping score, that’s 225,000 people dead from iatrogenic causes, meaning death by doctor, death by medical care. And that’s mostly just for patients in a hospital. In an outpatient setting, adverse effects can send millions to the hospital and result in perhaps 199,000 additional deaths. And this is not including all those just non-fatally injured, like oops, we just accidentally amputated the tip of your penis. And these estimates are on the low end. The Institute of Medicine estimated that deaths from medical errors may kill up to 98,000 Americans. That would bump us up to 284,000 dead, but even if we stick to the lower estimate, the medical profession constitutes the third leading cause of death in the United States. It goes heart disease, cancer, then me.
One respondent pointed out that it was misleading to call medicine the third leading cause of death since many of those we kill also had heart disease or cancer. Doctors aren’t out there gunning down healthy people. Only people on medications are killed by medication errors or side effects. You have to be in a hospital to be killed by a hospital error. Exactly! That’s why lifestyle medicine is so important, because the most common reasons people are on drugs or in hospitals is for diseases that can be prevented with a healthy diet and lifestyle, as I’ve covered before. The best way to avoid the adverse effects of medical care is to not get sick in the first place.
Finally today, we look at the medical community’s reaction to being named the third leading cause of death in the United States?
Previously, I profiled a paper that added up all the deaths caused by medical care in this country. The 100,000 deaths from medication side effects, plus all the deaths caused by errors, etc., concluding that the third leading cause of death in America was the American medical system. What was the medical community’s reaction to this revelation? After all, it was published in one of the most prestigious medical journals, the Journal of the American Medical Association, by one of our most prestigious physicians, Barbara Starfield, who literally wrote the book on primary care. When she was asked in an interview what the response was, she replied that her primary care work has been widely embraced, but her findings on how harmful and ineffective healthcare could be, received almost no attention.
Recalling the dark dystopia of George Orwell’s 1984, where awkward facts are swallowed up by the “memory hole” as if they had never existed at all, report after report has come out, and the response has been a deafening silence both in deed and in word, failing to even openly discuss the problem, leading to thousands of deaths. We can’t just keep putting out reports; we have to do something.
The first report was in 1978, suggesting about 120,000 preventable hospital deaths. The response? Silence for another 16 years. You know if you multiply 120,000 by those 16 years, you get 1.9 million preventable deaths, about which there was near total doctor silence. Silence meaning no substantial effort to reduce the number of those deaths. The Institute of Medicine then released its landmark study in 1999, allowing for another 600,000 deaths to take place.
Now, some things were changed. Work hour limits were instituted for medical trainees. Interns and residents could no longer be worked more than 80 hours a week, at least on paper, and the shifts couldn’t be longer than 30 hours long. May not sound like a big step, but I started out my internship working 36-hour shifts every three days, 117-hour work weeks. What’s the big deal? When interns and residents are forced to pull all-nighters, they make 36% more serious medical errors, five times more diagnostic errors, and have twice as many “attentional failures.” That doesn’t sound so bad, until you realize that means like nodding off during surgery.
The patient is supposed to be asleep during surgery, not the surgeon. Impairing performance as much as a blood alcohol level that would make it illegal to drive a car, can still do surgery. So, no surprise, 300% more patient deaths. Residents consider themselves lucky if they get through training without killing anyone. Not that the family would ever find out; doctors, with rare exceptions, are unaccountable for their actions.
The IOM report did break the silence and prompted widespread promises of change, but what they did not do is act as if they really believed their own findings. For if they really believed that a minimum of 120 people every day were dying of preventable deaths in hospitals, you would draw a line in the sand. If an airliner were crashing every day, you’d expect the FAA would step in and do something.
The Institute of Medicine could insistently demand that doctors and hospitals immediately adopt at least a minimum set of preventive practices (for example, bar-coding drugs so there’s no mix-ups—you know, like they do for even a pack of Twinkies at the grocery store). Rather than just going on to write yet another report, they could bluntly warn colleagues that they would publicly censure those who resisted implementing these minimum practices, calling for some kind of stringent sanctions, but instead we get the silence.
Dr Starfield didn’t stay silent, but she is unfortunately no longer with us. Ironically, she may have died from one of the adverse drug reactions she so vociferously warned us about. She was placed on aspirin and the blood-thinner Plavix to keep a stent she had to have placed in her coronary artery from clogging up. She told her cardiologist she was bruising more, bleeding longer, but that’s the risk you hope doesn’t outweigh the benefits—until she apparently hit her head while swimming, and bled into her brain. The question for me is not whether she should have been on two blood thinners for that long, or had the stent inserted in the first place, but whether or not she could have avoided the heart disease in the first place, which is 96% avoidable in women. The #1 killer of women need almost never happen.
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To see any graphs, charts, graphics, images, or studies mentioned here, please go to the NutritionFacts.org podcast landing page. There you’ll find all the detailed information you need –plus links to all of the sources we cite for each of these topics.
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