Abstract
Decades ago, some doctors used to smoke with their patients. Although it seems almost unbelievable to ponder that fact—it is true. Fortunately, we have come a long way in our understanding of the impact of lifestyle behaviors on health, and today, research affirms that physicians who follow their own healthy advice create a win/win situation for themselves and their patients. By choosing to adopt healthy lifestyle behaviors, doctors improve their own health and serve as a role model for their patients who are then more likely to return. Physicians who practice what they preach also learn directly about the challenges, obstacles, and rewards that their patients experience when making healthy change.
A study by Frank et al. demonstrated that physicians and medical students who practice healthy lifestyle habits are significantly more likely to counsel their patients about such habits. 1 Specifically, results of the study showed that, compared with physicians who did not engage in preventive practices, if physicians engaged in preventive screenings, their patients were significantly more likely to also have engaged in preventive practice. The authors concluded, “We found a consistent, positive relation between physicians' and patients' preventive health practices. Objectively establishing this healthy doctor–healthy patient relationship should encourage prevention-oriented health care systems to better support and evaluate the effects on patients of improving the physical health of medical students and physicians.” 1
Patients Look to Doctors as Role Models
Health care clinicians are human beings before they are professionals and, therefore, struggle with many of the same issues that any person may struggle with, such as being overweight, experiencing high rates of stress, sleep disorders, high cholesterol, addictions, and many other challenges. But emerging research reports that it is especially important that clinicians strive to address their own health issues—many of which are linked to lifestyle behaviors. Experts encourage physicians to adopt the same healthy attitudes and practices that they so readily want their patients to embrace. In other words, clinicians are encouraged to “walk their talk” or “practice what they preach” for the benefit of all. By doing so, research suggests that physicians improve not only their own health, but interestingly, also the health of their patients. Cameron et al. noted that “primary care physicians who practice healthy behaviors are more likely to monitor and modify patient health behaviors than are specialists or less healthy physicians.” 2
It is a simple and noteworthy fact that patients look to their physicians and health care providers as role models. Puhl et al. reported that, in fact, physicians' personal health behaviors are linked to patient perceptions of credibility. 3 They stated, “Physicians who disclose health, diet, and exercise habits are perceived as more believable, healthier, and more motivating by patients compared with physicians who do not disclose health behaviors.” 3 Puhl et al. also conducted a survey among ∼360 patients regarding impressions of doctors who were overweight, obese, or normal weight. 3 Results showed that, compared with normal weight physicians, patients reported greater mistrust of physicians who were overweight or obese and were less likely to follow their medical advice. Patients reported “higher trust, more compassion, more inclination to follow advice, and less inclination to change doctors when the physician was presented as normal weight.” 3 It is interesting that although prior research suggests that physicians may have negative bias toward overweight patients, this study suggests this bias may also be true in the reverse.
Leading by Example
Caldwell B, Esselstyn Jr., MD, a Cleveland Clinic surgeon for 30 years and Olympic Gold medalist in rowing, is the director of the Cardiovascular Disease Prevention and Reversal Program at the Cleveland Clinic Wellness Institute, Cleveland Clinic, Lyndhurst, Ohio. In an interview, Esselstyn commented that it is essential for physicians to lead by example. He stated, “The patient immediately takes their cues from who they are sitting across from. If a person's physician smokes or is obese or doesn't exercise, this sends a terrible message to the patient.” Esselstyn added, “In my work, my colleagues and I have learned that the degree of compliance with whole food plant-based nutrition is wholly proportional to the belief that the person has in the conviction of their doctor.”
At 86 years old, Esselstyn reported that he has always exercised and likes to bike, walk, or swim and has followed a plant-based diet for the past 35 years since he initiated his first study on the beneficial effects of following a plant-based diet on coronary artery disease (CAD). 4 Today, Dr. Esselstyn leads seminars once a month for people with CAD and empowers them to halt and reverse their disease. In such seminars, Esselstyn includes presentations by patients who have success stories to share.
Esselstyn said, “Leading by example is so impactful for the patients.” He stated that physicians' obstacles to wellness may be similar to what patients report as obstacles such as “I'm too busy” or “I get home late” or “I don't have the energy.” Esselstyn reported that physicians need to be trained in wellness and healthy lifestyle behaviors and added that many clinicians have not received proper education about the true causation of chronic illnesses and are not taught about the significant role of nutrition, for example, in treating chronic illness. He said, “We need to start with wellness education in medical schools and residency training and beyond. But also, as clinicians, we have to personally prioritize health and wellness. If a person can't take care of themselves, they will pay the price.”
Esselstyn commented that he believes that chronic illness has typically been very poorly treated in the United States partly because to effectively treat chronic disease, one has to help establish significant lifestyle change for the patient. Esselstyn commented, “In a 12- to 15-minute office visit this is an invitation to failure. So clinicians have to be able to put together a clear road map for how patients can make the lifestyle change that will restore their health. To that end, Esselstyn said it is critical for clinicians to share examples of their own successes in adopting healthy lifestyle habits and also share success stories of other patients who made important lifestyle change. He advised, “Clinicians must demonstrate the link to patients between lifestyle and chronic illness and then provide a clear road map that empowers patients to improve their choices.”
Recommending that a patient engage in vigorous aerobic exercise or attend a yoga class three times a week is one thing; however, personally practicing this recommendation takes the understanding of the patients' experience and faced challenges to a new level. Experts recommend that clinicians engage in or at least try out the activities they recommend to their patients to gain a better understanding of the effects and potential benefits of engaging in wellness and making lifestyle change.
On a cautionary note, although leading by example is highly recommended, Howe and Monin warn that physicians who act with a superior attitude toward their patients regarding lifestyle changes can leave some patients feeling worse or even scare them away. 5 They reported, “Physicians who adhere to fitness and nutrition regimens also have to be careful to avoid a holier than thou attitude that can off put patients who then feel worse about themselves.” 5 The authors recommended utilizing compassion and sensitive strategies for sharing their own successes regarding healthy lifestyle habits.
Making Doctor's Health a Priority
Strangely, one would think that in the field of medicine, the health of its workers would be a priority. Unfortunately, Frank et al. noted that “Physician health is rarely systematically promoted anywhere in the world, suggesting that policy-makers believe that physicians are already adequately supported.” 1 It is only recently that the health of health care professionals is becoming a priority within the field of medicine. As Hull and colleagues pointed out, there are many challenges around this prioritization. 6 They commented that the directive “Physician, health thyself” in fact, “presents a significant challenge for persons entering the field of medicine.” 6 These authors stated that, for example, “Acculturation into the profession includes tacit inculcation of many beliefs, including the idea that physicians should not become ill, and if they do, that they should continue working anyway.” 6 Hull and colleagues stated that physicians are, in fact, less likely to take sick leave than others and are also less likely to have their own personal physician and/or engage in preventive screenings. These facts and significant rates of physician burnout are part of the driving force behind a broader recognition of the need for wellness policies and programs for physicians and other health care workers, which will ultimately also help their patients. Howe et al. reported that although physicians do attempt to counsel their patients regarding healthy lifestyle behaviors, it appears few are confident in their counseling skills. 7 They suggested that “Further research regarding provider-related health behaviors and training in counseling related to lifestyle is warranted in order to improve prevention counseling for patients.” 7
Teaching clinicians more about self-care along with system-wide wellness initiatives are important first steps to help improve physicians' health and well-being. The healthier a clinician can be, the less likely they are to suffer from personal burnout and other physical ailments, and the more likely they are to effectively influence their patients.
Conclusion
Experts are calling for physicians to take their own healthy advice and engage in self-care by practicing healthy lifestyle behaviors to improve their own health and the health of their patients. Experts also affirm that programs within the health care system are currently needed to help clinicians learn more about wellness, engage in wellness activities, and feel more confident about counseling their patients regarding healthy lifestyle behaviors. Hull et al. concluded, “For the sake of both doctors and their patients, it is essential to address the importance of wellness, prevention, and self-care measures for physicians during medical training and throughout their careers.” 6 ■