Over dinner with a non-medical friend they said, “Even though I will inevitably have a heart attack [in relation to their love of ice cream], I’d rather enjoy a short life than live a long miserable life.” They brought this up even though I hadn’t made any comments about health during our meal. I’ve noticed that since becoming a physician family and friends make comments like this about their lifestyle with a frequency that surprises me. It seems that they feel guilty or defensive because they think I might be judging or evaluating the healthfulness of the life they lead. 

Perhaps more important than highlighting that I don’t judge my friends’ lifestyles just because I’m a physician is pointing out that in my role as a physician, I also do not judge my patients’ lifestyles. Society likes to use guilt to control people and create hierarchies of worse and better. Many health and physical attributes have been used to define people as better and worse. The list of such attributes is long; several common examples are weight, cholesterol level, blood sugar level, and brain functioning. Despite this societal tendency, guilt and creating arbitrary lists of good and bad don’t help achieve health, so they are not part of my practice as a physician.  

My job, especially as a primary care physician, is not to make my patients feel guilty or inferior. My job is to help my patients increase their chance of living a long, healthy life. Health is defined, in my mind, as a physical and mental state where a person can do the things they want to do with as little suffering as possible. My goal is to help my patients avoid suffering, illness, and pain from medical conditions and physical injury. Especially in the primary care setting, I provide my patients with recommendations to optimize their health. But my recommendations are recommendations – they are not law, and they are nonbinding.

Science continues to investigate what the optimal lifestyle is to ensure that one avoids illness and lives a long time. Yet, while we know many things, we don’t know what the perfect lifestyle is. Further, research can not account for the complexity of human experience. It is absurd to think that all people can live the same lifestyle. Individuals have different access to resources, different preferences, different priorities, and different realities. There is simply no universal fit for lifestyle.

When I discuss lifestyle with my patients my goal is not to make them start a different life. My goal is to identify reasonable adjustments that have a high chance of improving their health. For example, I might ask a patient about their typical diet. As I learn about their diet, I might offer education tailored to specific goals – such as reducing salt to help control blood pressure, strategies to ensure a stable weight or weight loss, or adjustments to prevent diabetes. I try to identify realistic adjustments because unrealistic suggestions are not likely to happen (by definition). For example, some of my patients only eat out. In those cases, rather than telling them they need to start cooking, I ask about the menus at the restaurants where they frequently eat and offer suggestions to optimize their health based on the menu choices they have. I might ask patients about exercise, tobacco, alcohol, drugs, sleep, stress, and any number of other things. The process remains the same for each: 1) Where is the patient now? 2) Is there some optimization that can be done? 3) What are the small steps and adjustments that can help my patient reach that optimization?

As a physician I meet my patients where they are in terms of their health goals and health situation. I see our relationship as a partnership where I’m an expert and they are advice seekers. Just as people hire financial advisors as experts and planners for their personal finance, physicians are experts and planners for lifelong health. As a physician I relay what research has shown is important for health; help my patients make decisions about specific medications, procedures, and tests; and form a plan for how my patients might optimize their health.

To my friend who thinks everyone who eats ice cream will have a heart attack – that simply isn’t the case. To my friend who thinks a heart attack is trivial – I’ve met hundreds of people who have had heart attacks and even those who survived were changed forever. So, in a general sense my response is, why not consider a middle ground where one can have ice cream and not have a heart attack? Curious how to do that? Consult your primary care doctor; she’s an expert in health and you hired her to help you reach your health goals.