Why are doctors so stupid?

particularly about nutrition

Since I’ve been writing this blog for the past 12 years, I’ve received innumerable comments and e-mails all containing the same words: Why are doctors so stupid about diet? statins? fat? saturated fat? carbohydrate restriction? low-fat diets? and on and on. I’m not sure stupid is the right word – the right word is probably ignorant. But there is some stupidity involved, especially in those docs who have blown it off as a fad despite having been exposed to the benefits of low-carb by their patients who have done so well on it, or even by other doctors who have given it a try. Since I have had so many people write me or comment using the word stupid, I decided to Google the term “why are doctors so…” just to see what would come up first. As you can see from the screen shot below, stupid is the numero uno word, so I went with it.

Since Google ranks the responses in terms of how many people make the query, it looks like doctors in general are a pretty sorry lot. Along with stupid, people want to know why doctors are so mean to nurses, why they’re so important, why they’re so slow and so unhappy. No one asked the question – or at least not in the top five – why are doctors so busy? Having been one for a long time, and having been married to one for almost as long, I can tell you that doctors in practice are really busy.

When you go to see a doctor for a sore throat, the doc comes in, asks a few questions, listens to your heart and lungs, looks in your ears and throat, and probably gets a strep screen. After the results come back from the strep screen, he/she comes back in, tells you the result and gives you a prescription, shot, whatever. It all seems pretty calm. But the physician probably has a kid with a cut lip that needs suturing, a person having chest pain, an elderly patient with a bag full of medicines needing to be sorted, someone with vague abdominal pain, etc. All in a day’s work for a typical primary care doc. And always, always, always something comes in that’s emergent, that totally screws up the schedule and throws the doctor behind.

Since these things always happen, you might ask, how come you don’t just schedule for them? We did. It was called lunch. It was a rare day that either MD or I got to actually sit down and eat lunch, because that was catch up time. You couldn’t schedule for these unexpected situations because you never know when they’re going to happen. And when they do, and you get thrown behind, then all the patients left waiting are aggravated, and you (at least we did) try to spend a little extra time with each to make up for it, which keeps you behind. Then, invariably, right in the middle of all this chaos, in comes a drug rep to see you.

Since you want the samples, you rush in to see the rep for a minute to hear the spiel about the latest new pharmaceutical. You get loaded up with samples and head back out to see more patients. (Incidentally, we love the samples because we would always give patients a starter dose, so they could get started on their meds before they schlepped to the pharmacy to get their Rx filled.)

This frenetic activity goes on all day long. MD and I always had patients waiting for us when we showed up at the clinic and were usually still seeing them till 6-7 PM at night. Most hardworking primary care docs do the same. We didn’t have a hospital practice, so we kept later office hours, but those who did ended up heading to the hospital to make rounds on their patients both before clinic hours and after.

Such a schedule doesn’t leave a lot of time for reading the medical literature.

MD and I tried to catch up when we did get a breather, but it wasn’t often. So, like most busy docs, we flipped through the throw-away journals (so-called because they were underwritten by drug companies and came for free), went to a conference or two a year, and listened to drug reps.

Now there are online sources that weren’t available when we were in practice that physicians can use to keep up with the latest. One such free source is Medscape, owned by WebMD, which comes in a multitude of varieties, one for each specialty. Though designed for physicians, most anyone can get a subscription to any of the versions of Medscape simply by signing up for it.

Which brings me back to why doctors are so stupid. Or ignorant.

Because of the nature of their work day, when they get a few minutes, many docs will slip away and hit their computers. A lot will look at Medscape. I’m not even in active practice any longer and I look at it every day as it arrives in my mailbox daily.

 

Here is an email I got from Medscape a few days ago.  Notice the very first article:

Were you to click on this link, you would be taken to a page showing the short one minute video below:

How about that? You’re a busy doc, you take a minute, and look what you’ve learned. All this nonsense about saturated fat’s not being harmful is just that: nonsense. You knew it all along.

The young doctor on the video says categorically that

The AHA emphasizes that well-conducted studies show overwhelmingly [my emphasis] that all saturated fats raise LDL cholesterol and increase the risk for heart disease.

If the same doc, who clicks on this Medscape article, happens to catch CBS’s This Morning, he’ll watch a cardiologist confirm the notion that saturated fat is best avoided. She tells viewers that if they replace saturated fat with

…polyunsaturated fat, which is things like corn oil [55% Omega-6], safflower oil [75% O-6], peanut oil [30% O-6], soybean oil [55% O-6], you can lower your risk of cardiovascular disease by up to 30 percent, similar to statins… If you replace it with monounsaturated fat, things like olive oil or avocado, that’s good too, but not as good as polyunsaturated fats, but it’s pretty good.

With great confidence, she says the AHA definitively links saturated fat consumption as a cause of heart disease.  Of course, we know she means that since saturated fat intake leads to increased LDL levels (so conventional wisdom would have it), and since they all believe that an elevated LDL is a risk factor for heart disease, then eating saturated fat increases risk for having a heart attack.  That’s called the lipid hypothesis, which, despite the latest AHA nonsense, is still an hypothesis.

But not according to the 2017 President’s Advisory from the American Heart Association.

Which is the by God American Heart Association, after all. They should know, right? If I follow their recommendations, I’ll never get sued for malpractice, thinks our busy doc. And, sadly, he/she is correct. If one of our doctor’s patients has a heart attack, and the doc can show on the patient’s chart that said patient was informed to reduce saturated fat and replace it with polyunsaturated fat as per the recommendations of the AHA, what court would convict? Especially if a statin were thrown in for good measure. That’s following the accepted protocol.

If, on the other hand, our doc had noted in the patient’s chart that it was okay to eat saturated fat and avoid polyunsaturated fat (which is what I would tell my patients), and the patient has a heart attack and sues, the doc is toast.

So, the path of least resistance (and legal safety) is to follow the crowd, not to think critically.

Plus, our busy doc is really too occupied to actually think. He/she just reacts: “I knew saturated fat was bad all along.”

But what happens if someone does actually think?

Well, Gary Taubes wrote a piece in response to this AHA idiocy that should – but won’t – be read by every doctor who is in a position to make nutritional recommendations.

In good science … cognitive bias is addressed … by deciding in advance of looking at the evidence (or doing a trial) what criteria will be used to judge the worth of the evidence (the results of the trial) without knowledge of whether that evidence supports our hypotheses. This is one reason why clinical trials are done double blind, and the data analyzed by researchers who are blinded to whether the subjects were interventions or controls, such that the biases of the investigators (or even the subjects) don’t bias the interpretation of the results.

For whatever reason, when it comes to heart disease and dietary fat, the investigators whom the American Heart Association chooses to determine what we should or should not eat have never been believers in this kind of, well, scientific methodology. This was the general conclusion of my first investigation into the dietary fat story going on 20 years ago for the journal Science. I’d like to say the situation has improved, but clearly it hasn’t. The latest Presidential Advisory from the AHA on saturated fat is the AHA’s expert authorities – what Inspector Renaud in Casablanca would have called “the usual suspects” – reiterating that they were right fifty years ago, and they were right 20 years ago, and they’re still right. And the techniques they used to come to those conclusions can be used again and again until someone stops them. Which is unlikely to happen.

He goes on to accuse the AHA of practicing what he calls Bing Crosby epidemiology. And he’s right. Read his essay, and be a lot smarter than your doctor. At least where nutrition is concerned.

What amazes me about all this is the ‘experts’ seem to agree, despite a ton of conflicting data, that saturated fats are not just nearly bad, they’re really most sincerely bad.  Yet these same experts equivocate on coffee.

On one last note, I’m headed to France in a few days. Once I get settled in there, I’ll put up a post showing some pretty amazing data showing that perhaps saturated fat really doesn’t drive LDL levels up.  And I’ll give you a method of getting your LDL down before your next doctor’s appointment, so you don’t get hassled to take a statin.

Till then, I’ll leave you with this.

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93 thoughts on “Why are doctors so stupid?

  1. Dr. Ancel Keys Ph.D. (physiology) was on the cover of TIME whenI was a 1st year med. student (1961). He was head of his own department in the school of public health, not in the medical school. I was at the school for 12 years and never knowingly saw him. He was in the AHA and an editor or on the e ditorial board of the AHA journal CIRCULATION. The AHA still has an annual Ancel Keys lecture. They are deeply invested in the chlesterol-lipid theory of CHD. General Mills and others pay $1M to put the AHA logo on their products.

  2. Personalities are different for docs like everybody else. Many get it and recommend best practice for their patients but, as you say, they’re lucky if they have time to fill out all their forms. Certainly no time to fight with the ADA. And then there’s the power of medicine which could predispose to a certain arrogance. If I had just performed a multiple by-pass operation I would be completely insufferable. That’s where there is something to learn from Bing Crosby. He said that he was popular because most people think that they can sing better.

    • You wrote:

      If I had just performed a multiple by-pass operation I would be completely insufferable.

      Nah, you wouldn’t. It would be routine. If you were a surgery resident you would be insufferable. I know because I was one, and I was insufferable. As were all my compatriots.

  3. So glad to see you posting again! France sounds wonderful.

    I recently went in for my annual physical. After about 9 months of eating a LOT of bacon, butter, meat, dark chocolate, cream, and coconut milk/cream, I knew I felt better, looked better, and was on the right track. But there is always that doubt in the back of your mind (or at least, in mine) the first time you have labs done after switching to LC. I’m pleased to say that my labs were exactly as you’d expect for someone keeping total carbs <50 per day. I had normal lipid/lab values to start with (though high HDL sometimes puts me over the 200 mark, ironically classifying me as "high cholesterol" when it's almost impossible for me to get CHD with HDL over 100). Given that my numbers weren't bad to start with, there were not huge changes in my values, but all of them improved slightly or moved slightly in the right direction. And I've lost 10 pounds of pure fat since my last annual. I'm also pleased to report that my own doc (herself very slender and fit) said she has no problem at all with me eating LC – so thank God at least one doc out there can see that she doesn't need to "fix" what isn't broken! As always, thank you for all you do. I'd never have switched (and I'd still be "always hungry") without your blog.

    • Thanks for the sterling health report! You’ll really be interested in the next post I put up.

      I’m delighted to learn you’ve done so well, and that you have a non-stupid doctor. Don’t let her get away.

    • Your experience sounds very similar to mine. It starts with a lipid profile. You get backed into a corner with the old statin ploy, and you either get smart and learn to fend for yourself, or just give in. That was about six or seven years ago. You spend much time reading books, watching You Tube, and finally learning how to interpret an NMR lipid profile, not to mention several other blood tests which you pay for out of pocket because much to your surprise your HMO is not really interested in your health and neither is your doctor.

      I finally ended up going ketogenic full time about three years ago. That was after a controlled slow reduction in carbohydrate reduction.
      Why ketogenic? Cancer, neurological diseases, type II diabetes and all of the diseases that are associated with it. Then there is also that endurance sports incentive, and the 50% reduction in recovery time. I am 70 and I still cycle 60 or 70 miles every couple of weeks. And I forgot to mention that 70% reduction in focal dystonia. I can go back to playing a musical instrument again. I lost ten pounds to, but that was never the driving issue. But it does happen to correspond to what I weighed when I was 30 years old.

    • Similar story. I had my annual blood tests in March. In January I had stopped eating sugar, bread and just about all refined carbs while increasing fats. When I eat out my friends are amazed that instead of eating bread and butter, I only eat the butter – it’s better than ice cream. All fats now taste wonderful. And my cholesterol?: 206.

  4. Paragraph 5: “shlepped/schlepped” defined as “to proceed or move especially slowly, tediously, awkwardly, or carelessly” is an inaccurate description of how I fill my wife’s presciptions. You would need a word that meant immediately, fearfully, obsessively, meticulously, and quite often foolishly. I’ve done this hundreds of times over 40 years and never once did I “shlep”, and if I had I would have chosen the “schlep” spelling.

    Paragraph 8: listed > listened

    Paragraph 13: We’re > Were

    • Okay, I added the c. I can’t think of a word that means “immediately, fearfully, obsessively, meticulously, and quite often foolishly.” You’ll just have to make do with the added c in schlepped.

      Thanks for the heads up on the other two. Can’t believe I missed the We’re right at the start of the sentence. Wow! Good thing I don’t make my living as a copy editor.

  5. How can you stay low carb in France? I’m in Germany for a 3-month stay and I feel like a junkie in a crack house.

    • It’s easy. Meat, cheese, prosciutto, tomatoes, and the occasional croissant, which I have analyzed in depth and found to be mainly butter.:)

      I do think it’s much easier to stay low-carb in France than it is in Germany.

      • Really? I’ve only been to Germany once, but the breakfasts were low carb (lunch meat, cheeses) and there were “sausages” everywhere. Of course, they came with potatoes and the like, but I didn’t eat those.

        In France, I had duck confit with vegetables and also a baked potato dish that was essentially a few potatoes swimming in cheese and butter. It was very filling. Also had horse-cheek stew, which was great, though again had a few potatoes.

        Had I known about the croissants, I’d have had one of those, although wheat and I typically don’t get along well.

        • Agree about the German breakfasts, but it’s the rest of the meals that are problematic. Don’t get me wrong. You can do low-carb just fine in Germany – it’s just a bit easier in France. And Italy.

      • Now I’m REALLY looking forward to your next blog post. I’ve been interested for a long time in the French/Mediterranean but more emphasis on French way of eating. Stopping by my local patisserie for coffee and croissant. Bon voyage!

  6. Dear Dr Mike – I enjoyed reading this post, it explains a lot. I was reminded too of Dr James Carlson’s book ‘Genocide, how your doctor’s dietary ignorance will kill you’ – he explained there that the way doctors are trained in medical school doesn’t lead them to think more independently. Thankfully there are a few doctors like you who do think independently !

    Looking forward to your next post – my cholesterol is always high and scares my doctors (usually around 8.7mmol/L or 336mg/dl) but my HDL is amazingly high at around 3.5mmol/L or 135mg/dl, and my triglycerides amazingly low at 0.4mmol/L or 35mg/d, which screws the Freidewald formula to calculate high LDL. Every time the lab computer comes up with some nonsense about patient needing referral to lipid specialist to investigate FH. This has been going on for ten years now since I adopted a very low carb Paleo diet. ! had a CT angiogram last month which showed my calcium score is zero and that my coronary arteries are completely clear !

    Hope you have a wonderful time in France. It is very hot there at the moment as there is a heat wave going on, at least in the southern half of France there certainly is. But that doesn’t stop one enjoying the wonderful French cuisine – not the nouvelle cuisine but good old fashioned French food !

    Bon voyage !
    Anne

    • We will be in the southern half. A little more than an hour north of Marseille. Hope we can tolerate it.

      Glad to hear your calcium score was clean.

      • Since you’re going to France, I recommend Michael Sander’s book “From Here, You Can’t See Paris: Seasons of a French Village and Its Restaurant”, particularly his essay on “How to Eat Well in France”. His solution – follow the men in bleu de travail! However, it may not work as well in Paris or similar tourist traps. Regardless, it’s a great read.

        • Thanks for the recommendation. The book sounds great and just like something I would love to read. I wish I could have it delivered to me here. I’ve got it on my list, and since I come to this tiny village in Provence often, I’ll read it before my next trip.

    • Anne, use the Iranian equation to get a more accurate LDL when you have such low trigs. The Friendenwald starts falling on its face heading below about 90.

      • Hi pzo – yes I use the Iranian equation always. My endo knows I have a different formula and mentioned it in one of his reports – I know that doc is getting on the right track as when he reports my lipid figures he always writes “calculated LDL” for the LDL.

        • Here’s interesting, the lab my doctor used to use actually measured LDL, it used to fall roughly halfway between Friedwald and Iranian values (high HDL but not as high as yours, and low trigs). Also she tried to catch me out once by ordering a non-fasting test but my results remained highly similar, unlikely to happen on a high carb diet I suspect.

          Here’s more interesting, a couple of years back I went hypERthyroid (Graves) which reduced my LDL by exactly the same amount as the statin I stopped taking, yet it was only then that my leg arteries became mashed up. When the thyroid was subsequently overtreated and went low, my LDL leaped back up but my arteries improved.

          Now I tinker with my Carbimazole dose according to symptoms or their lack – every so often the thyroid goes off on one, either higher or lower depending on I know not what – and one of the best indicators is how far I can or can’t walk before my calves start to ache. I no longer even bother to get my lipids checked. I no longer bother with the glucometer either, except for the occasional spot check. If my pee smells of ketones first thing but not during the rest of the day then I reckon I am using them at about the same rate I an generating them. Which is good.

    • Oh I remember you from elsewhere (I used a different identity then), great to see you are still doing well.

      “My” doctor is actually pretty good. After over 50 years of being told my symptoms were made up, and an abject failure to connect all my “made up” symptoms into a credible pattern, she was the first to identify me with “a touch of prediabetes”. Now the diagnostic cutoff for “diabetes”is set where you have lost at least 50% of your beta cells, I had probably “only” lost 49%. There’s more complexity, but still . . .

      . . . I was also fortunate to buy a house from a pharmacist who noted some of my symptoms and sold me a glucometer so I already had some “evidence” which prompted her to give me a Glucose Tolerance Test. NO previous doctor had ever done other than check my fasting glucose or do a preprandial urine dip, thus they all missed that my problems were strictly postprandial.

      Naturally she gave me the standard HCLF diet sheet – the exact same diet I had previously been given verbally which made me gain weight rapidly (first time ever) wrecked my already bad lipid panel, drove my BP inexorably up and left me semipermanently exhausted and constantly hungry to the extent I was accused of “failing to comply” with the diet.

      When I wised up, thanks to clueful patients with clueful doctors elsewhere, Richard Bernstein, Michael Eades and a few others, and ACTUALLY stopped complying with the diet, my BG soon fell into normal range, my BP came down, my HDL doubled and my trigs fell to 10% of what they were, not to mention that a whole bunch of symptoms improved or went away completely.

      I dumped the statins, antidepressants, h2 blockers and went from a highish dose of losartan to minimal amlodipine thanks to low carb/Paleo/keto (I have self-experimented a lot to fine things down).

      TWELVE years later and she told me she “would have expected me to be on two or three diabetes drugs by now, if not insulin”. She seems to be no longer scared by the “inevitable” consequences of LCHF, partly from my and other patients’ experience and that of some of the nurses. Give her another decade and she might actually start recommending it herself.

      The downside is, she is very busy, it generally takes three weeks to get an appointment and “the computer” disallows appointments further away than a month, so I often have to see her colleagues. One of them may well be, as I have been told, an excellent diagnostician and good with acute illnesses, but chronic disease not so much. He absolutely believes in “Evidence Based Medicine” which is frankly nothing of the sort, and has told me I was “not diabetic” and “never prediabetic” because “the only thing that is important is HbA1c”, so obviously I could not have improved what was never wrong. Cognitive dissonance is strong with that one, Luke.

  7. Your blog really says nothing. I could have written it with my limited knowledge but identical criticism and complaints about mainstream docs re nutrition.
    May I request good solid suggestions for action to correct the situation. There are others like you who share your approach to healthy nutrition.
    Barbara Schipper
    G. I. Counselor

    • Yes, it may seem obvious to those of us, like myself who has struggled with obesity all my adult life only to find a ketogenic life style is a way out, but the blog addressed WHY so many trained clinicians remain uninformed. Drs. Eades, Atkins, Phinney and dozens of others have addressed solutions for correcting these crippling viewpoints throughout their published work.

      Why not “suggestions for action to correct the situation” for World Peace as well?

    • Have you READ the Drs Eades’ books? How about Gary Taubes’ books? Teicholtz? Sisson? Wolf? Jimmy Moore? There are literally HUNDREDS of books: some great, some good, some useless, to provide you with all the information you’re asking Mike to put into a short blog entry! How about YOU searching (even just) this blog for “book review” — Mike has reviewed LOTS of excellent books specifically providing the information and direction / advice you’re castigating him for not spoon feeding to you in the (apparently?) the only blog entry of his you’ve ever read! Sheesh!

  8. I am a newbie to your blog in the UK. Labelled T2DB in 2013 (age 60) with most of all the other elements of metabolic syndrome. Got to LCHF after lots of self-study. T2DB in remission/reversed (depending upon how you look at it). Married to a retired GP. She followed my self-education in nutrition in her retirement. With the time available in retirement, she changed her views from the conventional medical view to a LCHF advocate.

    I note the same journey amongst various docs who get diagnosed with T2DB themselves. The conventional prognosis is so unwelcome, they spend time finding and using the more positive LCHF alternative.

    It may be the case that the only person with time to study a patient’s health fully is the patient themselves. In the UK, the NHS system dictates that the power lies with the doc, not the patient. If a patient kicks the traces and adopts an unconventional approach, do it low profile or the “system” will label you a troublemaker .

    • I’m from the UK too Skomer – I discovered low carb/Paleo soon after I was diagnosed with atypical Type 2 diabetes (I’m thin and not insulin resistant) when I read Dr Eades’ book ‘Power Protein’ – this was ten years ago. I still keep a low profile about the diet though I occasionally let a bit slip out to my endocrinologist – even he admitted last year that it was the carbs that messed diabetics ! And he doesn’t push statins on me. He and my GP must wonder about my cholesterol being so high yet my coronary arteries completely clear. I sometimes say “I eat high fat but the good kind of fats” – knowing that they probaly think I mean polyunsaturated fat when I really mean saturated fat. I have to adopt this way too towards my cardiologist (I was born with a heart defect). I would love to be able to tell them the truth but it could easily lead to problems as you say, so best to keep shtum, use the medics for what they can give, and keep healthy !

      • ” same journey amongst various docs who get diagnosed with T2DB themselves.”

        This is the info I always provide to people with thyroid / adrenal problems — the ONLY doctors ‘we’ (self-educated, usually self-treating people) have found to know pretty much ANYthing useful have been docs who — themselves or someone they love have also suffered the tortures of the damned on “standard treatment” — which has caused them to go looking for a real answer!

  9. “Which is the by God American Heart Association, after all. They should know, right? If I follow their recommendations, I’ll never get sued for malpractice, thinks our busy doc. And, sadly, he/she is correct.” ~ Hope people reading this will understand that this is the Take Away. It all comes down to protecting oneself from litigation. The Dr has no incentive to change their nutrition recommendations. And in fact is incentivised to toe the party line.

    I have found a Dr who is a concierge practitioner. I paid a fee to become a member of his practice for a year and I have access to him 24/7. I can see him with a days notice and, other than the membership fee, I don’t pay anything to see him. He does not take insurance but runs all sorts of tests which are covered by my insurance. He is on board with my “say no to stains” and has turned me on to a liver cleanse diet which I modified to be low carb and is helping me drop weight. He has taken me from being pre-diabetic to not at risk, and had me do a Carotid Artery Screening to show that I had zero plaque. So he’s not concerned about my “elevated” lipid panel.

    After reading this I wonder why he’s not worried about malpractice. Maybe there was something in the contract I signed that protects him. Just thinking out loud. As it is I cannot see going back to a main stream general practitioner after this.

    • Your doc sounds like a good guy. Keep him.

      For the most part, unless there is really a major screw up, most people don’t sue doctors they like. So, as a doc, you can go a long, long way toward avoiding a malpractice lawsuit if you are just nice to your patients. Which I always tried to be. I really went against the grain when I put patients on low-carb, high-fat diets at the absolute height of the low-fat craze, but I explained what I was trying to do and why and made myself available if there were problems. But it was a field I was knowledgeable in, so I had confidence. If I was treating something I was less knowledgeable about, I would probably go with the standard recommendations, which could well be as mistaken as the nutritional recommendations are. And I would qualify as being stupid as per the title of this post.

  10. The political economy of the USDA and the food industry whose massive investments in “lo-fat” food aside, the reasoning shown here reminds me of the old story about why travelers stop at truck stops for good meals, which is, “Must be good because truckers who’re always on the road, stop there.” A sociological survey done in the 50s among truckers asking why they stopped at a particular restaurant revealed that 8% said the waitresses had cute asses and short skirts, 6% said that the food was good but 86% responded that other truckers stop there and “you know what that means!”

    When asking one of my daughters why she was trimming off the small shreds of fat to some chicken breasts, her reply was, “Because it’s animal fat and not ‘healthy.’ ”

    Thanks again for an insightful assessment of our collective stupidity, Mike.

  11. Good post, much food for thought. Part of the “too busy” problem is obviously part academic culture and part business model health care. A class/caste system that rewards senior authority (regardless of how out-of-date or misguided it might be) and punishes young “outliers” who may be on to something new and helpful will be a tough one to change.

    It’s also interesting that the grip on patients has gotten stronger, with doctors outright refusing to treat patients who presume to go against their nutritional advice (where I am, “plant-based” is nearly a religion). Treating patients with respect, as persons who can make up their own minds as to what they will follow without being labeled “non-compliant” or “refused treatment” (and having to sign documents to that effect) when it’s used across the board, is a real worry.

    Myself, I think we need a new level of doctor. Maybe we could call them “general practitioners.” Maybe they would be the ones who focus on patient wellness, nutrition, and preventative care. And pay them for what they are worth (kind of like teachers), treat them with respect, and not burn them out before they have finished their residencies or with far too large patient loads. Kind of an idea, isn’t it?

    • It sounds like kind of an idea. And as idealistic as it sounds, most patients are not in the market for preventative care from their doctors. In all my years of practice, I’ve never had a patient come see me to tell me how great he/she was feeling and ask what could be done to maintain that feeling. If you ask people, they all want docs to practice preventative care, but they never come in asking for it. They go to the doctor only if they develop an illness. Sad, but that’s the way it is. And until the economics change, I doubt the situation will change.

      • I think you are quite right–money talks and then people walk. So it would have to involve a pretty massive educational endeavor. I remember the “We mind very much if you smoke” campaign. I wonder if something along those lines might be an in-road.

        Having said that, I work at a medical center that has quite an innovative health clinic that tries to combine all aspects of preventive health care, and most patients are next-door to indigent. It’s great training for the residents who are the primary docs, but how easily such a model would transfer to general medicine on a wider scale–I would have to agree with you that it’s an ideal, rather than a readily reproducible reality.

  12. Your piece is fun to read, and it does bring up the issue that doctors are so overworked that they have no time to delve into nutritional information that they think they already know. I’m pretty sure this was the case for my previous endocrinologist. I would give him lists of books and online references, but he would smile and nod and make the same sort of soothing noises you would make to someone who claimed they could predict the future by cutting open a chicken and studying the entrails.

    But then I experienced an endocrinologist who was actually sarcastic with me twice when I described my low-carb diet and my research that led to it. (And I had to pay a lot of money to receive this bad treatment!) I believe that there do exist overworked doctors who are simply ignorant about nutrition, but now I also believe that there are doctors who would do anything to avoid the cognitive dissonance they’d experience if they admitted they were wrong.

  13. Many years ago My wife and I had a Med student over for a few dinners. He had a PHD in physiology but when he tried to correct the MD physiology teacher he was told he was wrong. In fact he was right but the Doc. had older information. If an intern sees a great article in a medical mag that contradicts the MD on rounds, he quickly learns not to get out of line. Med school is a highly regimented educational experience that does not at all encourage independent thinking. Based your blog, things have not changed. That is a shame and it means that patients are not really getting the best care.

    • Having gone through medical school, I can confirm that it does not encourage independent thinking. There is so much information that needs to be learned in four short years that the profs basically hammer it into the fledgling docs, leaving little time for independent thought.

  14. As a rising third-year pre-med student, avoiding becoming one of the ‘ignorant’ or ‘stupid’ doctors is something I’ve thought about. I wonder if you wouldn’t mind further discussing (maybe in a future post?) your point of physicians sticking to outdated yet conventional practices for the sake of credibility. I sure hope things are a bit better by the time I’m practicing, but if the past 10 years are a guide hoping the big ‘official’ organizations will change their stance is wistful thinking.

    • I hope things are better by the time you’re practicing, but I doubt it. You’ll see how it all works when you start med school. The ossification process begins there. You may end up being lucky enough to go to med school at a place that has more enlightened views on nutrition than most, but there will be other departments that are way behind the times. It a function of the interest of the professors involved, so it’s just the nature of the beast.

  15. Thanks for the link to that Gary Taubes article. I’m prone to intellectual crushes on intelligent men who can think critically, including you. In my family, it’s more important to go along to get along, which rubs analytical ( and obstinate) me the wrong way. I look forward to your next article, as my LDL is always high and my HDL is always low, no matter what I do. But at least my triglycerides are low, so some comfort is to be had there.

  16. Also a newby to the post. Age 66 now, had a CABG at age 59 due to rupture plaque (ate carbs and sugar without thinking all my life. Time of bypass LDL was 136, HDL 39, Triglycerides high. Of course put on statins and LDL down to 70 but terrible muscle pains. HDL up a little. Took myself off statins and felt better. Diet change to meat, butter, vegetables but LDL went back up to 100 – of course cardiologist went nuts. Caught between a rock and a hard place. Agree with all you say but any suggestions on dealing with the medical establishment about statins and low LDL’s

  17. Dr. Mike, we very much appreciate your commentary which is always illuminating. Thanks for posting this piece.

    My comment about this particular subject matter would be as follows: Most main- stream physicians know (and should freely acknowledge to all) that they have never been interested in nutrition and have never studied it in depth. (Present Eades’ company excepted.) Therefore, it follows that they should always freely own up to and acknowledge this fact to all of their clients, (I hate the word “patient” in this context and prefer the word “client.”)

    Bottom line, all docs should focus on what they DO know something about and leave it at that. (Maybe the disclaimer should also be stated in writing on the door to the examination room and on their office stationery.)

    Finally, the docs should lose the arrogance of whatever “know-it-all” attitude(s) they may have developed at med school, or otherwise, over time. In my view, all docs should not only keep the Hippocratic oath upper-most in their minds, but also treat it as a form of fiduciary duty to their clients…….always……with no exceptions.

    Fondly and Sincerely:
    Wil / Judy B.

    • Problem is, many patients (or clients, if you prefer) are overweight or even obese. Every doctor knows (or should) that obesity is a risk for all kinds of problems, so does the doctor have an obligation to tell overweight patients/clients to lose weight? If so, then the patient/client will ask how to best do it. Then what does the uneducated doctor do? Find someone like me to refer to? Doesn’t generally happen that way, though it probably should.

  18. You get an Olympic gold medal for persistence Mike.In 1968 during a tutorial at Otago Medical School it was revealed to five students by Prof., John Hunter, a study he had completed in the Marshall Islands (I believe) and the early data from the Tokelau Islands Medical Study, that CHD nor its risk factors, was present in this adult Island population, that consumed no sugar, processed CHO and survived very well on all marine life and coconut ‘meat’. Saturated fat consumption was 35-50% from coconut

    As you know this population was followed after migration to NZ and within six months, risk factor indices rose and with time abdominal obesity, pre and clinical diabetes with hypertension and CHD appeared. Consumoption of saturated fat, marine life fell and was replaced with processed CHO and sugar. Gary Taubes recently gave the study some exposure

    Thirty years later I completed a study amongst over 800 Indigenous Australians, with the financial help of Dr. Tom Lynch where the lipid results showed the typical features of CHO- or Atherogenic Dyslipidemia. Total cholesterol and LDL medians were at the upper limit. This population existed in nutritional poverty, all being benificaries. With the aid of a dietician, it was clear animal fat was absent and processed CHO and sugar was the basis of the nutrition they could afford.Their life expectancy was 22 years shorter than caucasians, largely due to CHD!

    I obtained enough Gemfibrazol to treat 396 adults for three months from a generous US drug company and was then refused any further help from Queensland Health, who was responsible for their’health’ welfare!Its still believed in Australian quarters that should know better, that saturated fat remains a culprit. They have added sugar recently.

    The more things change, the more they stay the same. Lindsay.A.Green. Cardiologist.

    • Yes, indeed. The more things change… Once the idea that saturated fat was the culprit in heart disease got wedged into the brains of a lot of academics and the confirmation bias set in, there was no hope of seeing it any other way.

  19. MD’s are not ignorant of the facts.. It’s deeper than that. They’re ignorant of where to find accurate and reliable information. They have the facts – just the wrong ones. And the last place to go – is mainstream science, and authority establishments such as AHA, ADA, GMC etc. Generally speaking, MD’s (as well as government authorities) are on the pathway to negligence.

  20. The big hindrance to scientific progress in resolving the healthy fats debate is scientific consensus. Comment by Jorge Barrio:

    I recently reviewed a lecture on science, politics, and consensus that Michael Crichton—a physician, producer, and writer—gave at the California Institute of Technology in Pasadena, CA, USA on January 17, 2003. I was struck by the timeliness of its content. I am quite certain that most of us have been—in one way or another—exposed to the concept (and consequences) of “consensus science.” In fact, scientific reviewers of journal articles or grant applications—typically in biomedical research—may use the term (e.g., “….it is the consensus in the field…”) often as a justification for shutting down ideas not associated with their beliefs. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2719747/

    UBC researcher Sanjoy Ghosh found out first hand what happens when findings do not jibe with consensus.

    As a PhD student, Ghosh worked primarily in a cardiac metabolism lab under the supervision of Dr. Brian Rodrigues, who encouraged the graduate student to research the relatively new field of cell death in the diabetic heart. The goal was to expose the detriments of saturated fats. Instead, their findings revealed the opposite. Ghosh tried to publish the research findings in 2004 but the paper was rejected five times. He was shunned but not silenced, and the early rejection served as a valuable lesson, he says. “If people are not ridiculing you to some level—if they say what you’re doing is weird—if you are not getting rejected, then you are not doing fundamental research.”
    https://ourstories.ok.ubc.ca/stories/sanjoy-ghosh/

  21. Shhhhhh…….don’t tell the AHA that this 71 y/o man had recent blood and urine test and came back with:
    HDL: 81
    LDL, Friedenwald, 49; Iranian, 45
    Trigs: 67
    Total, Friedenwald, 143
    A1C: 4.9

    I eat 100-150 grams of starchy (tortillas, beans, potatoes, oatmeal, grits) and fruit carbs a day, I eat occasional wheat. My oils are olive, coconut, MCT, and butter.

    Correct me if I’m wrong, but even if SF raises LDL, doesn’t it usually raise the HDL much more, giving a better HDL/LDL ratio? Speaking of which, ratios that is, plug my numbers in and you will see that they are literally better than excellent. Trig/HDL, lower is better, actually goes negative!

    My genes will give me another 25-30 years of life. I want to be healthy as long as I can. Also, I’ll be the sexiest man in the nursing home! I’ll have my choice, ha ha.

    • Yeah, sorry about that. I’ve read a ton of books over the last few months, but have just kind of run of time.

      I’m gonna get back on the review track soon. I’m at least glad to hear you enjoy them.

      • Dr. Eades, Do you ever review older books? “The Reverse Effect: How Vitamins and Minerals Promote Health and Cause Disease” by Walter A. Heiby (1988) is 1198 pages long. Chapter 3 (95 pages) is about polyunsaturated fatty acids. That chapter alone was worth the $46.62 I paid for the book. It’s available through Amazon Books.

        • I do read and review older books. In fact, I’m reading an excellent one now written in 1975, but it’s not about nutrition; it’s about WWII. I keep up on the literature re PUFA, so I doubt there is anything major in a 30 y/o book that I’m not aware of now, but who knows? Thanks for the recommendation. I may purchase it just out of curiosity.

  22. Bon Voyage Dr. Eades! Eat a ton of stinky raw milk cheese for me. Vive La France!

    As an addendum to this wonderful post, I continue to wonder why doctors take it as a personal affront if I don’t acquiesce to the various screenings they recommend. When I don’t agree and push-back against their advice, I am often lectured, bullied, browbeaten. Made to feel I won’t make it another day/week/month let alone year if I don’t test/scan/screen – look under every rock to find trouble lurking somewhere in my body. I went to establish care with an OB/GYN and she didn’t even “see” me, all she cared about is that I have refused screening mammography for the past 2 decades. Did she even notice I am a healthy, fit & lean 60-year old? Needless to say I will never darken her door again. Maybe I should not put myself in that position, not take advantage of the annual “Well Woman” check my insurance covers.

    • Doctors are like all professionals. Some you’ll bond with – others you won’t. In my view, it’s best to scout out a few till you find one you’re comfortable with. The downside to this is that you might end up with someone who is totally simpatico with you, but incompetent. When I was in practice in Little Rock, there was a GP who had an enormous practice because he was a really personable guy with a great bedside manner. Patients flocked to him, but he was a joke within the medical community.

      The optimal situation is to find a doc who will challenge your beliefs, but that will take you seriously and allow you to challenge his/her beliefs. Hard to find.

  23. There seems to be a dichotomy regarding the association of dietary saturated fat and increased plasma LDL-c. LDL-c is unaffected by dietary sat. fat in most, but in a significant minority they are positively correlated.
    I am in the latter category and I know the reason why, having proven it by experimentation. Restriction of rich forms of dietary cholesterol, namely eggs and liver, reduced my own LDL-c from 340mg/dL to 160mg/dL! A statin has a very similar effect on me, which is atypical for so-called “hyperresponders” to dietary cholesterol.
    In my own case I have strong evidence that I have adapted epigenetically to upregulate blood LDL due to a severe form of genetic autoimmune deficiency. Hence, I make sure to include many eggs in almost every meal that I eat. When I am sick with flu my LDL-c drops considerably, which is consistent with all of the research into the powerful immunological role of human LDL.
    However, my condition is very rare and cannot possibly explain the size of the minority of hyperresponders. Nevertheless, I suspect that if many of these individuals were to perform the same experiment that I did, they would get similar results. In other words, there is a strong correlation between dietary sat. fat and dietary cholesterol in real foods. In most people on their ordinary diet, their bodies do not call for higher LDL-c than can be maintained primarily with de novo synthesis in small intestine and in liver. But in the minority, their bodies do call for this — they will utilize, rather than excrete, dietary cholesterol.
    Serious low-carb’ers eat a lot of eggs, usually according to my observation. There is also a reasonable amount of dietary cholesterol available in foods like cheese and fatty meat.
    Again relying upon myself as experimental model, plant foods (probably their fats) seem to have the effect of decreasing LDL-c. This effect may occur mostly by altering homeostasis of cholesterol (i.e. chylomicron) metabolism in small intestine, were I to guess. In someone my diet, the research indicates that de novo synthesis and catabolism (i.e. use) of cholesterol in the small intestine is dominant over that in liver.
    I would like to see the hypothesis that others are like myself tested. Do you have any insights, Dr. Eades?

    • I do have insights. You will love my next post. Now if only I can emerge from my wine-fueled sloth here in Provence, I’ll get it put up in the next day or two.

  24. P.S. I think that the increased catabolic load of plant-food fats imposed by the proportionate chylomicron metabolism, not being offset by any accompanying dietary-cholesterol supply, probably explains the negative correlation between LDL-c and plant foods in the diet of those like me, whose bodies call for more LDL than can be generated by de novo synthesis.
    There is also the natural reduction in animal-food intake that will tend to correlate with increase in plant-food intake.

  25. I’ve been dealing with Crohns disease for more than 15 years. It only recently occurred to me that in all that time, stretching over three states and four different medical practices, except for a few offhand warnings about spicy food and alcohol no practitioner has EVER asked me about what I eat. It’s as though what goes into one end of our digestive tracts is completely unrelated to what happens down the line. Last year I told my current gastroenterologist that eliminating grains had made a marked difference in my digestive health and his polite but obviously uninterested reaction was “Well, if it works for you …..”

    I didn’t even bother bringing the topic up again after my last colonoscopy, the results of which showed marked improvement. Cuz, naturally this has nothing to do with dietary changes; that’s just crazy talk.

    • I have found a very-low carb diet to be one of the most effective treatments for Crohn’s disease there is. Might be worth going beyond simply cutting grains and cut a bunch of other high-carb foods to see what happens. I’ve had patients go into complete remission on low-carb diets.

      • My late mother had Crohn’s, probably for much longer than she had *diagnosed* Chrohn’s. Standard treatment for more than a decade was to wait until it got really bad, hospitalise her, put her on steroids and sulphasalazine (?) then let her out with yet another different diet. The only one they never used was low carb, of course.

        When she was nearly dead, they removed the diseased length of bowel, and she went on to live another 30 years. Then they claimed because the disease “never recurred” she had never had it in the first place. Er no, the postmortem clearly showed she still had the disease but it just didn’t “flare”. AFAICR she was still on sulphasalazine but the dietary policies were lifted. I too wonder what a low carb diet might have achieved.

  26. Thanks for this article. People need to know that doctors have many considerations when they advise their patients. I used to feel guilty when my doctor came into the examining room a little short of breath from running from one room to the next. He was very thin. He has since gone into a concierge practice.

    Good luck on your trip.

    I believe in France, the dairy comes from A2 cows. In America, our dairy comes from A1 cows. Apparently, there are some who believe that there is a stronger correlation between A1 dairy and heart disease than tobacco and heart disease. Maybe that is the French Paradox.

    https://thebovine.wordpress.com/2009/03/20/the-devil-in-the-milk-dr-thomas-cowan-on-how-a2-milk-is-the-answer-to-the-mystery-of-why-even-raw-milk-sometimes-does-not-seem-to-be-enough-of-an-improvement-over-store-bought/

    Regards and bon voyage

    • Thanks for the link about A1-A2. I don’t consume that much dairy myself, so it hasn’t been a big issue for me. Still, I like to keep up on these things. And when I do get milk, for whatever reason, I try to get it from A2 cows. Because this has become an issue, many companies that do get milk from A2 herds list it on their containers.

  27. Further ironic thoughts – when I was a child and had what in retrospect were symptoms of diabetes and “conditions common in diabetics” my doctor “knew” I must be making them up (or maybe it was my Evil Mother) because I was obviously not Type 1 and Type 2 was an uncommon disease of fat old people, and MODY hadn’t been invented yet.

    So I was diagnosed with psychiatric problems. Over the next fifty years, whenever I reported new symptoms they just bolted on a new epicycle to the psychiatric diagnosis to explain why I was making up *more* symptoms.

    Irony one is that in retrospect most of my symptoms WERE epicycles, but to let’s say a disrupted insulin/glucose axis.

    Irony two is that now I am an Old Fart, i see so many of the symptoms of my fellow Old Farts also as epicycles on a disrupted insulin/glucose axis. Yet “modern” doctors have been trained to see them as separate diseases, mainly drug deficiency diseases, and fail to see the underlying pattern let alone treat it holistically.

    I would love to see more doctors aware of dietary factors, not just inculcated into HCLF, Holy Health Grains, the dangers of meat and sat fats and the necessity of statins. I suspect like you a working knowledge of engineering would also help, after all engineers are problem solvers and systems thinkers.

    Anyway, enjoy your N=1 attempt to study the French Paradox!

  28. Aren’t most of the Doctors on the AHA advisory panels also vetted by the pharmaceutical companies as well, and isn’t there a big risk of losing revenue from the sale of statins if the myth is broken?

  29. How commonly do fellow doctors argue with you about the lipid hypothesis, or against the successes people have had following _The Six-Week Cure for the Middle-Age Middle_, _Protein Power_ and such?

    Do people without medical nor nutritional training but with a heap of activism or orthorexia argue against you as often? Is your patience equal with both opponents?

    Do you ever think “if you read anything of the book you’re arguing about, we actually wouldn’t be arguing?”

    I’ve endured criticisms and accusations about low carb & high fat after losing the middle-age middle (five inches off the waist and hips! thanks! I wouldn’t do it without your book!) from longterm acquaintances and relatives, and it astounds me that for all the reading they know I do, they think I wouldn’t have read widely for cautions, dangers, corroborating accounts, medical journal abstracts, other doctors’ books, websites and social media accounts before attempting _The Six-Week Cure_. They have no nutritional nor medical background, but they have enough brainpower and internet access to research things, so I don’t understand why they think I wouldn’t, that no doctors would ever recommend low carb and high fat for reversing metabolic syndrome, insulin resistance and the “Middle-Age Middle.”

    • Strangely enough, I haven’t had a lot of arguments with other physicians because I can explain things to them in terms they can understand. But every now and then I do. Same with non-physicians, most of whom give me the old saw about all things in moderation.

  30. Any thoughts on the French Paradox possibly having anything to do with the cheeses they consume and the bacteria/gut interaction? With all the research going on regarding the gut, it would not surprise me if that and not the wine explained it

    • Could be, I suppose. But the French eat very little sugar as compared to folks in the US. And they eat more saturated fat, which, in my view, is protective.

  31. Hello
    I am very interested in seeing your quick “fix” for temporarily lowering cholesterol numbers to avoid any unnecessary comments by medical personnel. I have been plagued all my life with the curse of a total cholesterol over 200 (beginning at 210 at age 20 and averaging about 240 at the age of 55). I am and always have been very healthy, active, at a normal weight and LC for years now. All my other indicators of health are fab.
    But it’s that pesky guideline (based upon 0 science) that attracts unwanted attention that I’d just as soon avoid. Now, I know that 240 is perfectly healthy level: 240 was considered “normal” even just a few years ago in France where I live until they adopted the US guidelines of 200. I sometimes try to explain how the 200 guidelines came about (the original anecdote, which I found on Barry Groves’ site second-opinions.co.uk, comes from Mary Enig back in 1984 when the NHLBI wanted money from Congress to do a study. Leaving the guidelines at 240 wouldn’t allow them to get the money they wanted for the study. Disgusting! Millions of people are being unnecessarily medicated because of that)