wellness care: a manifesto

The vast majority of health care providers, surprisingly, aren’t adequately trained to promote health. Physicians, nurses, dieticians, physical therapists, and others learn how to detect, diagnose, and treat illness. And they (we, I should say— I am a nurse practitioner) are pretty good at it.

gettin' educated
gettin’ educated

It’s an essential science and skill with a huge body of evidence behind it, and a set of structures that support quality through training, testing, lisenceing, registering. If you see a board-certified physician, or a registered dietician, for example, you know that that person has a certain kind of training and meets a certain set of standards.

These health care professions are trained to evaluate, generate, and rely on scientific evidence, the gold standard of which is considered to be a randomized controlled trial. There is a huge push in health care now towards evidence-based practice. Overall, this is a good thing— it means using treatments and tests have been shown to work. Yet, there are limits to this system— including what kinds of intverventions are amenable to RCT testing, and who pays for the studies, and who is included in the sample, and what outcome is measured. It’s a good system, but it’s not perfect.

Health care professionals are who you want to see if you have an acute illness that might require antibiotics, say, or an injury that could be easily fixed with surgery. They’re also your first stop for early detection of things like cervical cancer or breast cancer, and for detecting and managing some aspects of chronic illnesses like diabetes or high blood pressure. It’s also the way to get some crucial preventive care, like vaccines.

BUT. But. If you are just not performing at your peak, you aren’t feeling great, you have some lousy habits or are stuck in lifestyle patterns that are harming your health, a health care professional may not have the solution for you. After they’ve ruled out some serious issues that might be causing you to feel lousy, they will usually throw up their hands and tell you you’re fine. Doctors are taught very, very little about nutrition, and very, very little about exercise, and almost nothing about managing stress. So, after your doctor tells you you’re fine, then what? You leave feeling bad, and you wonder why your doctor can’t help you to be truly well. What’s going on here?

Let’s take a step back and look at how we think about health. Let’s think of health and health care like a pyramid:

The little triangle at the top is the treatment of disease— health care professionals are great at this. Under that is early detection, another strength. Under that is prevention. And on the bottom is daily personal wellness practices: this is the biggest part, and the part that the rest of your health depends on. But most of the stuff that falls into this category isn’t taught effectively in medical school! Health care professionals don’t know how, or don’t have time, or aren’t paid to address the biggest, most influential piece of health. When you go to your doctor and your needs include things from this category, you might be out of luck.

Why? The things we do every day that contribute to our overall state of health are not, by and large, amenable to study in RCTs. There are too many variables, too many personal preferences, too much chaos and not enough order. There are no direct financial incentives. There are some studies here and there on diet and exercise and meditation and sleep, but most of what’s out there is observational and/or anectodal. And our health care system doesn’t tend to recommend things that don’t have science behind them, so these kinds of practices get short shrift.

Enter “Alternative Medicine.” Am I the only one who hates this term? These are practices that are largely dismissed or ignored by the “mainstream” medical world. Some of them are ancient and well-established, like acupuncture and ayurveda. Others are less codified, like certain diets or gratitude practices or execise programs.

And a lot of people who provide diet advice, exercise support, mind-body therapies, and more are trying to legitimize their work by making it sound science-y. And that’s where “pseudo-science” comes in, and it doesn’t do anyone any favors. If a practice is yielding good results for you, you don’t have to come up with a scientific-sounding explanation and insist that others will get the same results. You can simply say “this works for me,” and offer that it might work for others. This isn’t to say there’s no place for study and curiosity, but rather to suggest that there’s no need to make claims that there is science where no science be. We can get advice and support and direction— all of which is valuable— from lay people. It doesn’t have to be done the same way that medical care, or “illness care”, if you will, is done. But when we try to fit this particular square peg into the medical round hole, it just perpetuates the cycle of “real”medicine and “alternative” medicine refusing to cooperate.

So. . . now what?

How about a system where the illness care and the wellness care aren’t at odds with each other? How about a system where we see people together, under one roof, for both kinds of needs? Yes, let’s absolutely use blood tests and drugs and surgeries when they can help us. But let’s also look at other ways to promote wellness— ways that are not part of “illness care.” Let’s build in listening and support and individualized diet guidance and exercise classes. Let’s put in counseling and self-reflection and goal-setting. Let’s use therapies from other traditions.

There are movements seeking to promote integrative medicine, functional medicine, and others. There are practices that are working towards these models— some hire people called “health coaches” or “health consultants” or other things like that.

But these practices are still an anomaly, and they will remain that way as long as we pay for care (illness or wellness) in the way we do now. Having a health coach is almost exclusively something for wealthy people who can afford to pay the hefty price tag.

Are we ready to reimagine our health care system from an illness-focsused system to a wellness-focused system? We need some paradigm-busters here. Let’s go!

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