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

Thursday, February 6, 2014

Health: know what, or no how

You doubtless know the old saw about Carnegie Hall: How do you get there? Practice, practice, practice.

We might invoke similar reasoning about a far greater prize, with far more universal implications: vitality. How do you add years to life, and life to years? Good old-fashioned knowhow.

Note that it isn’t good old-fashioned “knowhat.” The term “knowhow” is in the dictionary, sometimes hyphenated (“know-how”), sometimes not. But “knowhat” isn’t there, hyphen or no hyphen. And with good reason. Without knowing “what” there is no job in the first place. Once we know what, and the job is before us, knowhow gets it done. Knowing what provides purpose. Know-how provides a process for getting there from here.

Having a process with no purpose is like having a route with no destination; it makes no sense. Knowing what is prerequisite to the application of knowhow.

Perhaps that’s why I so often find myself frustrated. More often than not, I vent my frustrations in a column like this one. Sometimes I rant a bit. Sometimes I try to give myself (and others) a good laugh because it’s better than crying. But there are those occasional temptations to throw in the towel. What is the point of trying to share know-how for health, when we can’t agree we know what?

We carry on about health as if we didn’t know what cultivates it. We act as if any given theory about diet or exercise is as valid as any other. We actually seem to be disappointed when an effort to facilitate health reiterates what we already thought was true (e.g., vegetables are good for us) instead of blasting conventional wisdom to smithereens.

If we are truly so uninformed about what it takes to be healthy, we really have no business trying to get there. We can’t work at being healthy if we are genuinely clueless about what makes us so.

The obvious analogy is geographical. Imagine if you wanted to go to, say, Cleveland, but had absolutely no idea where it was. Imagine that for some reason, there was intense controversy about the location of Cleveland, and cartographic factions competed for attention, notoriety and presumably related profits by espousing different theories, and producing discrepant maps. On one map, it’s in Ohio. On another, it’s in Arizona. On another, it’s in Japan. And the blogosphere is alight with commentary by each faction’s legion of devotees, all hurling insults at the benighted nincompoops in all the other legions. You think it’s in Ohio? Moron!

Under such circumstances, what hope would there be of ever getting to Cleveland? Not much.

Of course, we do know where Cleveland is, and for whatever reason, it has not proven good fodder for controversy. At least not yet.

Would that it were so for health. From my perspective, having read thousands of articles, written numerous textbooks, published hundreds of research papers, and cared for patients for 25 years, I don’t find the fundamentals of good health any murkier than the location of Cleveland. I can find both.

The evidence indicating what is most likely to endow us with more years in life, more life in years, and the vitality that makes life better and more fun, is nothing less than staggering.

We have epidemiologic analysis showing, repeatedly, that roughly 80% of all chronic disease and related premature death is attributable to what we do with our feet, forks and fingers. Be active, eat well and don’t smoke, and close to 80% of your lifetime risk of any major chronic disease could go away. Add to that list 3 more: sleep (get enough); stress (manage it); and love (share some), and the benefits are even greater.

There are epidemiologic studies in diverse populations corroborating these effects again, andagain, and again, and again, and … Truly, the list of supporting studies is far too long to capture here. Prove it to yourself by going to PubMed and typing any variant on the theme of “lifestyle factors AND health” in the search box, and then perusing the thousands of citations retrieved. Yes, it will be thousands.

There is, as well, the Blue Zones project which gives us a window to the cultures and habits of the longest-lived, most vital and happiest populations around the world. The findings here correspond perfectly with a focus on feet, forks, fingers, sleep, stress and love.

To the extent that diet is the complicated variable on the list, we make it far more so than it needs to be. As long as we eat wholesome foods, mostly plants, we can eat relatively high fat or low, relatively high carb or low, relatively high protein or low, include or exclude dairy, include or exclude meat, include or exclude grains, and be healthy. We can also adopt any of these competing theories, populate it with highly processed junk foods, and eat badly. By ignoring the basic theme of healthful eating and fixating on details, we predictably risk losing the forest for the trees. Public health nutrition has for just this reason been lost in the woods for decades.

Having written 3 editions of an extensively referenced nutrition textbook for health care professionals, I know, despite appearances to the contrary, that we aren’t clueless about the basic care and feeding of Homo sapiens. But it doesn’t really matter, because the tendency to act as if we were creates a seller’s market for fad diets and quick fixes. There’s a sucker born every minute, after all.

But that doesn’t mean it needs to be you.

So let’s decide: Do we, or don’t we, know the fundamental “what” required to promote human health? If you think not, there’s no reason to try, or waste your money on the latest confabulated theory.

But if you are like me and know that we do know what, the obvious question is why aren’t more of us benefiting from that knowledge? The answer is: knowhat, but no how.

The definition of knowhow refers to expertise, skills, and the capacity to do something well. These are interesting considerations that collectively suggest knowhow is not about making it happen with iron will, no matter how poorly prepared we may be. The definitional details of knowhow imply preparation, and competency. Skillpower, in other words, rather than just will power.

I genuinely believe the luminous prize of vitality—more years of life, more life in years—is tantalizingly, almost agonizingly within reach. I believe the knowhow to get there from here is available, manageable, shareable and eminently applicable. I believe all of our efforts, attention and resources should be focused on the dissemination of just such knowhow, and on facilitating its application. I believe these just as fervently as I believe that Cleveland is, indeed, in Ohio -- and if you want to get there from here, your time is better spent choosing plane, train or automobile rather than choosing among competing maps that put it in different places.

I believe we know what makes human beings healthy. But until more of us can agree we do know what, there simply is no how.

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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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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