American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, May 9, 2013

Skin in the game

Knowledge, alas, is not power. Knowledge may be necessary for power. Knowledge may be prerequisite to power. But knowledge is not sufficient for power. The gap between what we know, and what we do with what we know, belies the wishful thinking the expression espouses.

My field, health promotion, and no doubt many others just as well, handily illustrates the gap between knowledge, and the true power of its effective application. We have known for the past two decades at a minimum how to eliminate fully 80% of all chronic disease, and just look around to see the use to which that knowledge has been put. During those same two decades, chronic disease rates and their public health toll have only escalated, and dramatically at that, globally, and especially in the U.S.

It was in 1993 that we were first, most clearly told in no uncertain terms of the opportunity to eradicate 80% of all chronic disease. For it was in that year that McGinnis and Foege published their seminal paper in JAMA: "Actual Causes of Death in the United States." We learned then what perhaps should have been obvious all along: Diseases were not really causes. Diseases were effects.

McGinnis and Foege asked, and answered: Effects of what? What was causing the diseases, heart disease, cancer, stroke, diabetes, dementia, that were in turn causing premature deaths? What was causing the diseases that were taking years from life, and life from years?

The answer was a list of 10 factors, most of which are under our potential personal control. But for our purposes here, the salient finding was that fully 80% of the action was just the first three items on that list: tobacco use, dietary pattern, and physical activity. I have long summarized this as use of feet, forks, and fingers.

Since 1993, a whole series of publications (1, 2, 3, 4, 5, 6, 7) has served to reaffirm the link between those same few behaviors and the epidemiology of premature death and chronic illness, and even control over the expression of our genes. And perhaps more importantly, to establish the reverse connection as well: We could, with good use of feet (routine physical activity), forks (optimal dietary patterns), and fingers (no cigarettes) eliminate fully 80 percent of all chronic disease. That is incredible, but certifiably true.

Archimedes famously said: Give me a lever long enough, and I can move the whole world! Feet, forks, and fingers are levers long enough to move the whole world of modern epidemiology to a dramatically better place. And they are accountable, and in principle accessible, to each of us.

But just as knowledge is not commensurate with power, will is not tantamount to way, despite cultural platitudes to the contrary. We may have the will to be healthy, but in a world of willfully addictive junk foods, ingenious labor-saving technologies, and cultural ambivalence, we may not have, or know, or find the way.

Where there's a will, there may or may not be a way. And so that way must be paved. One approach, accessible to us as individuals, is to align will-power with skill-power. There is a way to the summit of Mount Everest, but only those with genuine mountaineering skills can take it. The climb to eating well and being active is, fortunately, not nearly that arduous, but in our obesigenic environment, it's no walk in the park, either. Taking the path to health in our culture requires skill. Will-power alone will not suffice. Will-power plus skill-power certainly can.

But better still is shifting health from the road less traveled, to a path of vastly lesser resistance. And that, in turn, begins by acknowledging that some of the best defenses of the human body reside with the body politic. Only by taking collective action, through the implementation of programs, policies and practices; the dissemination of tools and resources, can we pave that path of lesser resistance so the pursuit of health is more accessible to all, and less dependent on skills so many at present do not have.

But until or unless we more effectively disseminate the skill-power we all need to disease-proof ourselves and our families, or escape to some island where health is less elusive, or change the world around us so we can get there from here, then far too much is lost in translation. Namely, for decades we have failed to translate our knowledge of disease prevention into the power of routine action.

And this should evoke genuine passion, because we all have skin in the game: the skin of people we love. An 80% reduction in all chronic disease may sound remote, anonymous, statistical. But if you love someone touched by heart disease, cancer, stroke, diabetes, and/or dementia, it means 8 chances in 10 that would not be so, because they would be healthy instead. This is not about some statistically anonymous public. It's about you and me, and the people we love. It's up close, and very personal.

And so a status quo that squanders the opportunity, year after year, to keep heart attacks, cancers, strokes and such out of our homes, and away from our own families, is just not acceptable.

Gertrude Stein famously said a difference, to be a difference, must make a difference. It makes no difference that we could prevent 80 percent of all chronic disease, if we don't. And frankly, I'm tired of just talking to you about it. I want to do something, together.

And so today, in a departure from my standard modus operandi, I would like to ask you for something. My federally-authorized non-profit (501c3), Turn the Tide Foundation, helps to disseminate programs and tools in the service of building "skill-power" and paving the way. We offer free programs that teach food label literacy to children and their parents, that enable schools and worksites to provide 30 minutes of physical activity daily, and more.

Our latest offering is a program built around music videos, intended to raise awareness among tweens and teens about the forces in the modern world manipulating their health away from them, mostly for profit, and what they can do about it. Our plan is to bring in charitable funds to develop a library of these videos, attach to each relevant readings, and develop (with the input of experts in education) associated teacher materials so the program can be formally incorporated into curricula in health, civics, science, marketing, economics, home economics, physical education, and more.

Views on YouTube are a new-age currency, and they, in turn, help generate the age-old kind. So here is my ask:

1) Please click here and watch our latest video, "The Process."
2) Please share the video with your contacts, kids in particular, and request the same.
3) Feel free to share opinions, either about "The Process," or even better, specific suggestions for subsequent efforts- - as the spirit moves you, online, or with me directly at
4) And if willing, please directly support this and our other efforts with a fully tax-deductible donation to Turn the Tide.

Note that unlike most foundations, Turn the Tide does not use money to go looking for answers we don't have, and might find. Rather, every dollar donated to Turn the Tide is used to turn the knowledge we already have into immediate action we can take. Every dollar supports programming you and your children can feel, and hold, and apply right now, where the rubber hits the road, feet hit the pavement, and forks hit the plate.

Knowledge could be power. A way to health, for us, and our kids, could be allied to the will we have for it. But only if we come together, and do something.

The only effective way to fix what's the matter is by taking action, together. Exchanging ideas, sharing opinions, and sharing opinions about opinions is all well and good. But taking meaningful action, based on the opinions we share, to make a real-world difference by fixing what's broken, is really what matters.

Thank you very much for giving this the serious attention it deserves. Because with years of life, and life in years at stake, this is no game. And we all, very literally, have skin in it.

David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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