When the research confirms specific lifestyle changes improve disease outcomes, are physicians ethically obligated to prescribe those changes to patients? Perhaps - but the reality is more complicated.
A 2018 study from the National Institute of Health looked at 112 cancer survivors in Tennessee who smoked. Despite high participation in smoker cessation programs, only 33% were ready to quit smoking and believed their smoking contributed to their cancer diagnosis. On a larger scale, the datum is more foreboding: the American Cancer Society reports one in 10 cancer survivors smoke, despite the fact that this habit may have caused their disease in the first place.
Smoking for cancer survivors can lead to poorer treatment outcomes and even disease reoccurrence. But doctors are finding it difficult to write prescriptions for the lifestyle changes––like quitting smoking––and not just because healthy food and exercise equipment aren’t available at the pharmacy. Physicians are up against a system that doesn’t train them in lifestyle medicine or allow them the time to educate their patients on adopting habits that may prevent them from needing lifesaving medicines down the line.
“It’s hugely important to do both,” said Arthur L. Caplan, PhD, director of the division of medical ethics at the NYU School of Medicine, referring to educating patients on healthy habits and medication that could help their health. “You want to get the condition under control. But you have to get at the underlying problem. If it’s being caused by lifestyle change, you want to go after that. It’s good medicine and common sense, but the system is not rewarding that.”
According to Caplan, the ethical obligation of doctors to practice lifestyle medicine is outweighed by the fact that it’s often impossible for doctors to do so adequately. Primary care physicians often only have 7 to 8 minutes of time with patients during appointments, which is not enough time to offer useful counsel. And often, it’s time consuming and difficult to develop these sorts of plans and have patients stick to them.
“Prescribing lifestyle is a really difficult thing to do,” Dani Pere, vice president of programs and education for the American College for Preventive Medicine (ACPM) told Cancer Network. “If someone is pre-diabetic, it is much more difficult to create a tiered plan for them around exercise, lifestyle, and food than it is to wait until they tip over into full-blown diabetes. Lifestyle is low-tech and very intensive...it is very difficult to do both for the physician and the patients.”
Going even further, medical research and academic settings do not tend to devote resources to studying and teaching future doctors how to approach the benefits of lifestyle modifications with patients.
The ACPM supported two pieces of legislation in the 115th Congress that would give grants to medical schools to develop or expand curriculum related to exercise and nutrition and ensure that government-employed primary care professionals receive continuing medical education related to nutrition. The former was reintroduced the following session, meaning across-the-board training for oncologists may be implemented in the future.
With the help of the American College of Lifestyle Medicine, ACPM also created a 35-hour online continuing medical education program to teach the core competencies of lifestyle medicine.
Pere said it’s difficult to get medical school programs to teach lifestyle medicine, as it is rarely included on exams that students have to take.
“If a student is not going to be tested on how to give a nutrition prescription or prescribe physical activity...there’s no incentive to teach it,” she said. “There’s already a substantial amount of material just to get through. You have to work with decision makers on the testing.”
On top of this, Caplan told Cancer Network that doctors are battling the hold of advertisements on patients, who often come in bombarded with ideas from commercials about medicines that will allegedly help them.
“We’re definitely pill-driven,” he said. “That’s where the reimbursements are for prescriptions and medical intervention. In primary care, time is being monitored, so you don’t have a lot of time to go over lifestyle issues with your patient. I hear it complained about all the time.”
However, the need for lifestyle medicine is more dire than ever before. According to a 2002 paper from the World Health Organization, by next year, the majority of global disease will be chronic noncommunicable diseases associated with diet. Tobacco use and lack of exercise are also contributing factors. And the costs go beyond diminished lifespans: According to the Center for Disease Control, obesity-related costs were estimated at $147 billion in the United States in 2008. This includes direct medical expenses and indirect costs due to loss in productivity.
“From where we sit in prevention, we know about 80 percent of chronic disease is caused by lifestyle,” Pere said. “That’s taxpayer money we could be saving and re-investing. We know from where we sit in the medical education world. Physicians are not getting the training they need to provide.”
Note: This article was updated to reflect the American College of Lifestyle Medicine's involvement in creating a program in lifestyle medicine.