THE NUANCE

Not long ago , I wrote a piece about the “lab leak theory” and the origins of SARS-CoV-2. I knew I was handling delicate and controversial subject matter, and so I offered my sources anonymity in exchange for their candid opinions.

I’d never written a story like that before — a piece quoting anonymous sources — and I had some apprehensions before getting started. In the end, my worries were misplaced. Many of the experts I contacted said they were willing to participate only because I was offering them anonymity. (You can read that piece here.) After the story came out, the feedback I got from them was positive. “It’s nice to see the unfiltered discussion,” one told me. “You should do this again!”

I decided to take his advice. The following interview is my first attempt.

‘This is why you hear American health care being called American ‘sick care.’ We are incentivized to find problems, not to keep people healthy.’

I’m speaking here with a cardiologist and medical director at a major American health institution. He’s a practicing clinician who has published hundreds of articles in peer-reviewed journals, and he’s an expert in preventative medicine.

During our conversation, which we agreed ahead of time would be on the record but not for attribution (meaning I print what he tells me without including his name), he told me about the problems he sees with U.S. health care — namely the ways doctors are incentivized to perform as many tests and procedures on their patients as possible.

He also talked about the unprecedented and recent drop in U.S. life expectancy, the rise of non-communicable diseases, and the need to take control of our “toxic” lifestyles. I found the conversation enlightening and I hope you will too.

Markham Heid: When we emailed, you mentioned that you wanted to talk about the problems you see in American health care.

Yes, one of the biggest problems with the American health care system, in my opinion, is that the incentives are messed up, meaning they’re not always aligned with patient welfare. And one of the major things that generally goes unrecognized and unacknowledged is that most doctors are compensated based on something called relative value units, or RVUs. This is basically a standardized unit to measure the work a physician is doing. For example, you get so many RVUs for doing a surgery or reading an EKG or echocardiogram, and these correspond with pay.

So thanks to RVUs, what you have now are all these physicians who are being incentivized to do things to patients. More procedures, more surgeries, more imaging tests. And this creates a giant conflict of interest because these aren’t always going to be in the best interest of the patient.

Can you give me an example of how this might lead to harm for a patient?

Well for one thing it incentivizes a lot of testing, and the tests we have now are so precise that they find things we never would have noticed before, and that requires follow-up. So that means more imaging, more tests, a biopsy, etcetera.

Now I’m all for testing if it’s harmless and we know what to do with the results, but that’s not always the case. You can end up with a patient getting a lot of expensive tests and having things biopsied and maybe procedures performed, like having a stent put in, without clear evidence of benefit. And this happens all the time right now because capitalism is a powerful motivator, and doctors are paid to perform tests and procedures.

Do doctors talk about this? I mean do they acknowledge to each other that this might influence how they do their job?

Oh yeah they do. A lot don’t like to admit it, but I talk with them and they say they know it distorts their behavior with regard to tests or procedures. This is why you hear American health care being called American ‘sick care.’ We are incentivized to find problems, not to keep people healthy.

When I was in medical training, one of the axioms I was taught was that the best interests of the patient are the only interests to be considered. Now I always tell young doctors that medicine is not just a job, it should be more like a calling or a vocation where you have to think morally about what’s right for your patients, but I think it’s hard to do that today because the incentives for doctors are so distorted.

We know more than ever about preventing disease, but you see how things have gone in the wrong direction the last few years with things like average life expectancy reversing course and actually dropping, and part of that is because doctors aren’t properly trained in preventive medicine.

Why do you think the average life expectancy has fallen?

Partly it was Covid, and partly it’s been deaths of desperation, so overdosing on things like alcohol and fentanyl. There’s more suicide than there used to be. And also the obesity crisis in America is just a disaster. It’s so bad. When you’re eating the standard American diet, or SAD as it’s called, it not only promotes obesity but it makes you sad and depressed. And then you add in social isolation, poor sleep, etcetera.

And the frustrating thing is all of this is very preventable and reversible. We know which diets work. We know how to exercise for longevity — which is not how you train for peak fitness, by the way. But you ask the average doctor, and they are completely ignorant about most of this. It’s not taught in medical school. Diet and nutrition, sleep and stress management and emotional health, these are the things that are killing us. And we are taught zero about all this in medical school unless you specialize in one of these fields.

So does the average person have to educate themselves on all this?

Absolutely. The average person out there has to take ownership of their health. If you don’t, if you just go along with the flow of American culture, you’re going to be up a creek in no time. There’s just so much stuff now that is toxic and corrosive to long-term health. We’re meant to be active and social and outdoors and eating whole foods. All that stuff is not happening. We’re all sitting inside on social media, watching Netflix, eating fast food, and then we get sick and pretend, jeez, bad luck. It’s not. It’s the result of our toxic environments and a medical system that is happy to go along making a lot of money treating people who are sick because of their lifestyle.

Do you think it’s more difficult to stay healthy today than it used to be?

Yes. It’s a really difficult spot we’re in. We’re kind of at a crisis point. You can build a virtuous cycle of healthy behavior, but you have to start thinking for yourself. And maybe the most important one is taking care of your emotional health. Right now, if someone is depressed or suffering mentally, we just medicate them rather than trying to address these problems at the root, which are often lifestyle issues. You know, get off social media. Get a dog and go our twice a day for a walk. Take care of your sleep and eat a healthier diet. I know this is really hard. I’m not saying it’s easy. But this is what you have to do if you want to feel better.

I’m a preventive cardiologist, so I have a passion for this stuff. It’s so apparent to me that we’re in a health crisis — probably only behind the global climate crisis in terms of severity. People are miserable, and we need to start doing things differently.

Thanks for reading the Nuance. If you liked this piece, please share it with others. If you aren’t a Medium subscriber and you plan to join, please use my referral link. You pay the same thing but Medium gives me a portion. — Markham