Lifestyle Medicine: Overcoming Systemic and Cultural Barriers to Better,More Affordable Care

Abstract

The 6 pillars of lifestyle medicine have strong scientific backing and plenty of supportive evidence to validate their integration into routine clinical practice. However, two barriers stand in the way of their widespread adoption: the system of healthcare and the culture of medicine. This article describes changes necessary to overcome these systemic and cultural obstacles and outlines steps necessary to achieve what traditional healthcare has so-far failed to deliver: higher quality, lower costs, and greater access to care.

“Providing education to patients, implementing modern technology and addressing mental-health issues would make medical care more convenient and lead to superior clinical outcomes.”

Context shapes perception and changes behavior. These 6 words explain practically everything that is right and wrong about American healthcare. And they highlight both the opportunities and challenges lifestyle-medicine practitioners face.

In healthcare, context includes both the formal system—made up of insurers, doctors, hospitals, and drug companies, along with the written rules and policies that govern medical care. Context also includes the culture of medicine—comprising the values, beliefs, norms, and unwritten rules that medical professionals learn in their training and carry throughout their careers.

Two Snakes of the Caduceus

Like the twin serpents that coil medicine’s iconic symbol, the system and culture of medicine are tightly entwined. It’s impossible to separate them. Each shapes and influences the other.

In the United States, these forces have contributed to exorbitant medical costs and lagging clinical quality. Americans today spend nearly double what people in other nations pay for care and, yet, clinical outcomes (as measured by longevity, maternal mortality, childhood death rates, and more) rank at or near the bottom ¹ when compared to 12 of the world’s wealthiest countries.

To improve our nation’s health and lower spending, both the system and culture of medicine will need to evolve. Lifestyle medicine can play an important role.

Decades of research have proven the positive health benefits of lifestyle medicine and its 6 pillars of better health: (1) a whole-food, plant-predominant eating pattern, (2) physical activity, (3) restorative sleep, (4) stress management, (5) avoidance of risky substances, and (6) positive social connections. Examples include the connections between plant-based eating and reductions in inflammation ² among adults and a declining threat of cardiovascular disease ³ among obese children, along with the importance of prescribing fresh foods in the home and structured exercise to improve lifestyle behaviors and fight obesity ⁴ in children. Researchers have also demonstrated the effects of physical activity on mental health status ⁵ and the cognitive function of patients with Alzheimer’s disease. ⁶ Pandemic-era studies showed the importance of restorative sleep and rest-activity rhythms, ⁷ along with lifestyle-medicine solutions for patients with diabetes. ⁸ Researchers have also integrated lifestyle medicine and preventive care recommendations into approaches for reducing or avoiding breast cancer. ⁹ They’ve found Further research shows the economic benefits ¹⁰ of lifestyle medicine—an important consideration for a healthcare system on the verge of bankruptcy.

And yet, despite the proven advantages, lifestyle medicine remains undervalued and underutilized in the United States, both among patients and the larger medical community. To understand why, the best place to begin is with a closer look at the broken healthcare system and its outdated medical culture.

Two Forces: The System and Culture of Medicine

The U.S. system of healthcare most closely resembles a 19th-century cottage industry. It’s fragmented with doctors and hospitals scattered across communities, disconnected from one another, and unable to communicate effectively. Like laborers of old, clinicians are paid on a piecemeal basis. They’re rewarded by quantity of services provided, regardless of whether they add value. Moreover, many of the technologies used in healthcare is clunky, cumbersome, and held over from the last century. In fact, the most common way that doctors exchange vital patient information is via the fax machine, ¹¹ an 1834 invention. And while there are many medical-technological wonders that look impressive and cost millions of dollars (from surgical robots to proton-beam accelerators), not one has meaningfully moved the needle on patient health. And as a result of the profession’s obsession with shiny, expensive technologies, many of the simpler technologies that can move the needle (information technologies that power better data and evidence-based medicine) get overlooked.

Finally, like the cottage industries of yore, healthcare lacks a centralized leadership structure and the kind of defined accountability required to improve the entire U.S. system of care and its culture.

Seeing What’s Invisible

The challenges of the American healthcare system (i.e., expensive, difficult to access, and hard to navigate) are visible problems, both to those who provide medical care and those who receive it. Culture, by contrast, is more like gravity. It is invisible, but poses grave danger when ignored.

I first recognized the immense power of medical culture in December 2019, when the federal government released a projection that healthcare costs would rise 5.5% a year ¹² for the subsequent decade. Compounding that percentage and applying it to $4 trillion in healthcare spending, I realized that medical care would cost an additional $2.5 trillion per year by 2030 without the promise of better clinical outcomes or more-convenient access for patients.

I waited for leaders of various national medical associations and societies to protest the hefty increase in spending—or at least point out better ways to spend the money. Certainly, our nation could improve the health of Americans by investing in chronic disease prevention or addressing the social determinants of health, which studies indicate have a three- ¹³ to six-times ¹⁴ greater influence on individual health than traditional medicine.

But the industry’s silence was deafening. In the culture of medicine, the belief is that doctors and hospitals already do their best to provide medical care. Therefore, any further improvements in clinical outcomes must require additional resources.

To better understand the role medical culture plays in healthcare today, I researched and wrote “Uncaring: How the Culture of Medicine Kills Doctors & Patients.” ¹⁵

Future doctors become ingrained in medical culture—learning its values, norms, and beliefs—not in lecture halls or from textbooks, but by observing the behaviors and listening to the words of senior residents and attending physicians. By the time they graduate medical school, they know which specialties rank highest in the clinical hierarchy, which treatments are most valued, and which approaches will be dismissed as inconsequential—even those that produce superior clinical results.

They can see that primary care doctors who rely on their cognitive abilities are accorded far less esteem than physicians who focus on procedures and operative interventions. And if they desire greater pay and recognition, newly minted physicians know to apply to a surgical or medical subspecialty.

Medical Culture: Then and Now

To better understand the immense power of culture—and how its long history continues to influence medical practice today—let’s go back in time to Vienna, Austria in the 19th century. There, Ignaz Semmelweis has been appointed the head of the maternity ward in one of Europe’s leading hospitals. And he is appalled at what he sees.

The labor and delivery service at this facility is run by esteemed academic professors. And the maternal mortality rate is 18%. Semmelweis isn’t just appalled, he’s also embarrassed because the mortality rate at the maternity ward next door, run by nurse midwives, is one-third lower.

The leading cause of death associated with childbirth at the time is Puerperal Fever, an infection that begins in the uterus of the women before spreading throughout their entire body. And the etiology, according to the leading academic minds of the era, is believed to be miasmas, tiny particles wafting up from the putrid streets below. But Semmelweis can’t figure out why the women in his hospital are dying so much more frequently than the one run by midwives. They’re all breathing the same, stinky air.

Advances in medicine often come from serendipity, and so it is in Vienna. One day, a colleague of Semmelweis’s nicks his finger while doing an autopsy on a woman who has just died from puerperal fever. The doctor develops an identical clinical course to all the women dying after childbirth (local infection, systemic sepsis, death). Semmelweis concludes that there must be something these doctors are carrying—either on their hands or the leather aprons they wore to protect their three-piece suits—that is to blame.

Semmelweis institutes a policy that anyone entering the delivery suite has to dip his hands in chlorinated water and put on a clean leather apron. Within a month, mortality drops from 18% to less than 2%. He writes up his experience in the leading medical journal and sends letters off to the directors of the largest maternity units across Europe. And he waits. And he waits. And nothing happens. Those who don’t outright dismiss his claims simply ignore him. Not one maternity ward adopts his life-saving approach, which raises an obvious question: How can a solution that lowers mortality by 90% be universally ignored?

Leaders often assume that time and money are the biggest barriers to change adoption. But in the case of Semmelweis, it took no time at all to dip one’s hands in chlorinated water. And there was no added cost to donning a clean leather apron. Standing in the way of saving tens of thousands of mothers’ lives was the culture of medicine.

Doctors in Semmelweis’s day saw themselves as healers, not as people who caused harm. The idea that they could be the source of the infection seemed preposterous. Acknowledging it would have lowered the prestige and esteem of the entire profession. And those leather aprons, the ones covered with blood and pus, were symbols of expertise. The more gore, the greater the doctor’s experience. Semmelweis’s colleagues would no sooner put on a clean apron than doctors in academia today would trade their long-white coats for the short jackets worn by interns.

Fast forward to the present day: Hospital-acquired infections are now the leading cause of death for inpatients. The most common infectious agent is Clostridium Difficile (C. diff). Unlike the coronavirus, this bacterium doesn’t travel through the air, but only on the hands and clothes of people. It can be killed with soap and water. And yet, research from hospitals across the country has demonstrated that physicians fail to wash their hands 1 in every 3 times they enter a patient’s room. ¹⁶

Skipping this step isn’t logical or rational. As in Semmelweis’s time, it’s cultural. Today, when a patient develops a hospital-acquired infection, physicians assume it had to be someone else’s fault. That is the power (and danger) of culture.

Context Shapes Perception

Psychological research demonstrates how powerfully context shapes perception and changes behavior. In healthcare, context (including the medical system and culture) has a profound impact on the way doctors perceive themselves, their colleagues, and the places they work.

A research experiment from Stanford ¹⁷ illuminates how this neurobiological process occurs. Notably, the study had nothing to do with medicine. Instead, volunteers were placed in brain scanners and asked to compare two bottles of wine. One bottle displayed a $5 price tag and the second a $45 one. What the participants didn’t know was that each bottle contained the same wine. Nearly all of the research subjects rated the more expensive wine as the better of the two. Although that outcome could have been predicted, the brain-scans produced shocking results.

The scans showed that the pleasure centers of the brain lit up intensely when the participants tasted the expensive wine—but not with the $5 bottle. The context (a $45 label) changed their perceptions, even when people’s taste and olfactory nerves were stimulated by an identical liquid.

This shift in perception wasn’t logical. It was subconscious. This helps us understand why Ignaz Semmelweis’s colleagues refused to use proper hand hygiene—not for some well-reasoned cause but because their brains were affected by the context of medical culture at the time. Subconscious distortions of the mind—brought on by varying contexts—cause people to engage in behaviors that can seem illogical and even ridiculous.

Another manifestation of this phenomenon can be observed in the culture of medicine’s obsession with relative status. In the context of determining the pecking order, doctors elevate the importance of activities that only physicians perform over those that other clinicians can accomplish. As a result, doctors who unblock coronary arteries are accorded higher status and greater prestige than primary care physicians who prevent these vessels from occluding in the first place.

And as a result of their higher status, cardiologists and other interventional specialists are paid twice as much as primary care physicians, despite a research collaboration between Harvard and Stanford ¹⁸ that shows adding 10 primary care doctors to a community increases life expectancy 2.5 times more than adding 10 specialists.

For the same cultural reason, performing a surgery or doing an interventional procedure is perceived as more valuable than preventing complications from chronic diseases, which can be accomplished by clinicians without a medical degree, including dietitians, physical therapists, mental health professionals, and nurse practitioners. And since intervention is accorded greater esteem in the culture of medicine, it is more lucratively rewarded than prevention despite objective data on their respective impacts on mortality.

When Medical Culture is a Positive Force

Before assuming that medical culture is purely destructive and bad, it is essential to recognize which aspects of it shouldn’t be lost. Culture is what makes doctors heroes and allows them to save lives. The culture of medicine and the impact it has on perception allows physicians to subconsciously deny the personal risks inherent to the profession.

As an example, think back to when the coronavirus first traveled from Wuhan, China, to the United States. Scientists knew little about it. Although researchers had sequenced the virus’s genetic structure down to each nucleic acid, they didn’t know if the infection came from particles or aerosol, whether it passed on people’s hands or countertop surfaces. And there weren’t any vaccines or effective medical treatments for it, either. Covid-19 was estimated to be 10 times more lethal than the flu, which kills around 50 000 Americans most years.

To battle the virus, doctors cared for infected patients 12 and 24 hours at a time. When there were no gowns to protect themselves, they donned garbage bags. When they ran out of N95 masks, they used salad lids to cover their faces. And when the patient’s respirations grew labored and insufficient, they’d pass tubes through the mouth into the lung, knowing these individuals would often cough, spewing virus into the physician’s face.

These actions were made possible by a psychological defense mechanism that is ingrained in medical culture and is acquired through a decade of grueling training. Denial is what allows doctors to be heroes. The medical profession demands that doctors be able to exclude unpleasant thoughts and feelings from conscious awareness. By suppressing frightening thoughts—and by suspending the dangers of reality—physicians are able to put their patients’ lives ahead of their own.

Breaking the Traditional Rules of Medicine

Although denial turns doctors into heroes, it can also undermine patient care. As an example, in medical culture, clinicians believe they ¹⁹ “save a life at any cost.”

And while it’s true that doctors work as hard as possible to keep patients alive until the moment their hearts can’t be restarted, Covid-19 exposed opportunities for doctors to “save lives” long before patients had to be admitted to the ICU.

For example, chronic disease contributes to 70% of all deaths ²⁰ in the United States. These same medical problems increased mortality from Covid-19 greatly. Traditional medicine does a poor job preventing these problems (diabetes, hypertension, obesity, lung disease) and avoiding their complications (like heart attacks, strokes, and cancers). However, if our nation did a better job of avoiding and managing them, tens of thousands of lives and billions of dollars could be saved each year.

But because doing so isn’t glamorous nor does it require a doctor, preventive care isn’t well rewarded in the American healthcare system and remains undervalued in medical culture.

A New Context for the 21st Century

In 1998, soon after being selected as CEO in Kaiser Permanente, I was invited to give a talk at the Oregon Health Sciences building. When I finished my lecture, I explored the hallways. On a wall, I saw a sign that I can still envision today. Across the top in bold letters was written: “Quality, Service, Cost.” ²¹ And below in small font the words, “Pick Any Two.”

Prior to the availability of modern technology and current medical knowledge, that was the best that 20th-century doctors could do. Unfortunately, physicians continue to view the three as tradeoffs, rather than as synergistic. Medical culture is to blame.

Lifestyle medicine can prevent disease, keep people healthier, and lower costs by reducing the incidence of heart attacks, strokes, and cancer. Providing education to patients, implementing modern technology and addressing mental health issues would make medical care more convenient and lead to superior clinical outcomes.

Despite all the potential and promise, American healthcare will languish in the outdated views of the last century until the system of medicine and its problematic culture change.

As Upton Sinclair pointed out, “It is difficult to get a man to understand something when his salary depends on his not understanding it.” The first step to higher quality and better health will be shifting the payment methodology from fee-for-service to capitation.

Changing the Payment System and Innovating With Lifestyle Medicine

In a capitated healthcare system, doctors and hospitals are paid a set monthly fee to provide all of the medical care a population of patients requires based on the number of people enrolled, their age and their healthcare status. In a capitated model, the providers of care do best when patients stay healthy, avoid complications from chronic diseases and embrace the health opportunities afforded through lifestyle medicine.

In the context of capitation, primary care and specialty care become equally important. With capitation, the importance of prevention rivals intervention. Capitation aligns the personal incentives of patients who would rather not experience a heart attack with the economic incentives of providers and payers. In a capitated system, lifestyle medicine isn’t an afterthought. Instead, it is central to an organization’s success.

Capitation drives cultural change and encourages clinicians to break medicine’s outdated rules. It compels clinicians to embrace modern information technology, including artificial intelligence, and appreciate the contributions of highly effective multidisciplinary teams.

Numerous studies confirm that patients with diabetes, hypertension, and heart disease do best with a healthy diet and daily exercise. Those with asthma and chronic lung disease, benefit from quitting smoking and reducing air pollutants. Capitation rewards innovative approaches and the prevention of medical complications. So, rather than treating patients with chronic disease on a calendar basis, seeing them every 3 to 4 months in person, capitation incentivizes clinicians to focus on opportunities to help patients improve their health on a continuous and consistent basis.

Clinicians don’t have the time to assist patients in achieving all of their health goals every day, but technology does. Imagine an Alexa-like device, powered by a generative AI application like ChatGPT, that would engage with people each morning, remind them to take their medications as prescribed, and encourage them to get the preventive screening they need. Imagine if the technology safely linked them with other individuals, reducing their isolation, nudging them to put on their walking shoes, and encouraging them to eat more fruits and vegetables.

Generative AI could analyze data from patients’ wearable monitors, glucometers, and pulse oximeters, compare the information to their physicians’ expectations and update them each day on their progress. Capitation would reward all of these positive outcomes and relentlessly drive systemic and cultural transformation.

In a fee-for-service context, doctors from other specialties are seen as competitors in a zero-sum financial game. And other clinicians, including pharmacists, physical therapists and nurses, are viewed as threats. Capitation alters those perceptions, promoting teamwork and greater coordination of care.

In the current fee-for-service model, most doctors don’t value lifestyle medicine. In the context of capitation, the advantages become clear to all.

Beware: The Retail Giants

Clinicians, I believe, are the people best equipped to lead the process of contextual transformation in medicine. But the stark reality is that if they don’t, someone else will, probably one of our nation’s retail giants. These companies recognize the inefficiencies of healthcare today and would like to eliminate them. Not for selfless reasons, of course, but for a chance at capturing even a modest percentage of medicine’s $4.3 trillion annual spend.

Already, 3 of the largest retailers in the game—Amazon, CVS, and Walmart—are taking steps to lead the transformation. Each is assembling a suite of capabilities that can replace most current healthcare offerings as we know them today. Amazon recently acquired One Medical, a primary-care-first organization with 188 clinics in 25 geographies. That move, along with Amazon’s previous acquisition of PillPack and its licenses to dispense drugs in all 50 states, provides the foundation needed to offer capitated healthcare to self-funded businesses. Taken together, it is easy to see how the largest online retailer could disrupt the totality of medicine.

Similarly, CVS Health already owns the insurance company Aetna and has its own pharmacies and retail clinics. And, in a pair of multi-billion-dollar acquisitions, the retail pharmacy giant bought Signify, a company with 10 000 doctors who provide virtual and in-person home care to millions of patients, along with Oak Street Health, a huge primary care company with 169 centers in 21 states.

Finally, Walmart recently signed a 10-year agreement with UnitedHealth Group, the nation’s largest insurer. UHG covers 10 million Medicare Advantage members and directly employs 60 000 physicians. This partnership will combine Walmart’s pharmacies and clinics with United’s 60 million subscribers.

In the short run, these retail giants will conduct business as usual. But over time, they will focus on innovative ways to raise quality and lower costs. They will do so by expanding capitation, ²² first for senior citizens through Medicare Advantage, then in the commercial and self-funded markets.

The leaders of lifestyle medicine still have an opportunity to lead the way. But they’ll need to recruit clinicians from diverse disciplines, embrace capitation, and maximize group performance through operational excellence. And they must hurry. Time is running out. As the sage Hillel asked, “If not now, when?”