Ep 30 Prevent Illness in the First Place

Heather (00:03)
It seems like a good health idea to do whatever you can to avoid getting cancer or dying from kidney failure caused by diabetes or suffering brain damage from meningitis. Avoid, right? So why aren't more people taking some steps to do just that? To try to avoid these really difficult health outcomes. Some of the steps they would need to take are part of what's called preventive healthcare.

Really, there are two basic ways to approach our overall health, either try to prevent problems or deal with them after they occur. Most doctors prefer that people choose the first method, since it's obviously easier to deal with no problem than an actual problem. It's also more efficient and cheaper for everyone involved to avoid getting illnesses. Just where healthcare organizations and insurance companies land on this debate,

is a discussion for another time. But most doctors, honestly, just want people to be as healthy as they can be. And that's where the concept of preventive medicine comes into play. This is certainly not a new idea. Hippocrates argued all the way back in the fourth century BC that diet and environment mattered to health. The Romans built sewers because they had a hunch that having excrement near drinking water was bad. The idea of quarantining arose during the plague.

Vaccines became a reality in the late 1700s with the smallpox vaccine. So there's a lot of history behind this idea of trying to prevent disease. In the 20th century, the concept was developed a bit further into levels, if you will, of disease prevention. Primary prevents disease entirely. Secondary detects disease early. And tertiary reduces complications

from existing disease. Or more simply put, primary means don't get it, secondary means find it early, and tertiary means try to manage it well once it's there.

As even more scientific advances arose like antibiotics, lab testing, radiology, et cetera, healthcare delivery became more complex along with it, and physicians started dividing into specialists versus general doctors. Finally, in the 1960s, that generalist type medicine was split even further into three distinct fields. Family medicine, which cares for people of all ages,

internal medicine, which is just for adults, and pediatrics for kids. In the late 70s, the World Health Organization and UNICEF both declared that primary healthcare is the foundation of effective health systems worldwide. So, dating back thousands of years, preventive healthcare has been increasingly recognized and proven through loads of research as the best way to stay healthy in your life. So given all that,

It is genuinely interesting to me that utilization of preventive healthcare is actually going down in the US, despite these thousands of years of irrefutable evidence as to its success in avoiding or curtailing disease. Looking at commercially insured adults in the US from 2008 to 2016, the proportion that skipped their annual primary care visit

rose from 38 % to nearly 46%. That's almost half of adults skipping their annual health visit. Meanwhile, Medicare recipients, people who are absolutely at the age when shit starts going wrong, showed a troubling pattern of their own. By 2019, nearly one third were seeing five or more different doctors a year, but with virtually no increase in visits to their primary care provider. I mean, maybe they didn't have time after all that.

But what it means is that the one doctor who's supposed to know the whole picture is being seen less while the specialists multiply. I'm not knocking my specialist colleagues. There is absolutely a time and place for them. But the job of the primary care provider is to see the whole picture, to consider every organ and all aspects of your life. Without them, it's kind of like an orchestra with no conductor.

Every musician is technically skilled in contributing, but nobody's making sure they're all playing the same song. So people are generally having less primary care visits. Why is this happening? Well, there's plenty of understandable and relatable objective reasons. Rising costs being one of the most common, lack of health insurance, time constraints, and sometimes an inability to even get an appointment in the first place.

There are subjective reasons as well, a distrust of doctors and the medical system in general, a fear of illness and its treatments. Perhaps there were poor past experiences and for some, not feeling that there is a need for care in the first place. Some of these reasons are unfortunately rooted in the influence of news and social media. And they put patients into a tough spot. For example,

If the Secretary of Health and Human Services for our country, currently Robert F. Kennedy Jr., tells us that vaccines don't work despite hundreds of years of hard, incontestable evidence that they do, what is one supposed to do? Is the average U.S. adult getting onto the internet or chat GPT and reading deeply about vaccine statistics and studies to figure it all out? And what if your doctor gives conflicting advice to the news story you heard

about fluoride in the water being bad for you, or that vaccines contain microchips, or that cell phones cause brain cancer. All of these are untrue, by the way. You, the patient, might be stuck in the middle between conflicting sources, both of which you want to trust, so the burden of making the decision of who to ultimately listen to falls on you. And if you don't have a relationship with the doctor that you actually do trust,

Are you equipped to decide whose advice to follow? Are you going to put in the time and intellectual energy to research each and every health decision? No offense, but probably not. So it comes down to who you trust the most. Though, if you're not having preventive care visits anyway, who are you even gonna ask? I believe that the best thing you can do for yourself is to get a primary care provider, whether that's a doctor or a nurse practitioner.

And research backs this idea up convincingly. A national analysis of medical spending found that adults with a primary care doc had substantially higher rates of preventive services completed. 95 % of those patients had their blood pressure checked compared to only 67 % of those without a primary care provider.

Similarly, 89 % of patients with the primary care doc received cholesterol screening versus 56 % of those without a regular doc. And patients who see someone regularly report greater trust and satisfaction with their providers. They're more likely to receive treatment for chronic conditions and they report fewer unmet health needs. The relationship works both ways too. A doctor who has seen you repeatedly is better at detecting subtle changes that might look

unremarkable in isolation, but are meaningful in the context of your personal history. That continuity isn't a luxury, it's actually how the system is designed to work.

So before we dive more deeply into reasons why people aren't seeking a relationship with a primary care doc in the first place, let's talk about just what prevention even is in today's healthcare system. Primary prevention, remember this is avoiding disease in the first place, consists of things like vaccinations, lifestyle counseling like stopping smoking, for example, nutrition counseling, exercise promotion, and might include certain medications.

Secondary prevention when you try to catch disease early on includes screening for cancers like a mammogram to detect breast cancer, a colonoscopy to catch colon cancer, and maybe even remove precancerous polyps during that colonoscopy, and PAP tests for cervical cancer screening. It also includes routine health checks in which a provider checks your blood pressure to screen for hypertension, cholesterol screening, and blood glucose testing for type 2 diabetes.

It may also include HIV or hepatitis C or other lab testing. Lastly, tertiary prevention, which aims to keep existing disease from getting too bad, includes good glucose control for diabetics, good blood pressure control for those with hypertension. It could be physical therapy after a stroke, cardiac rehab after a heart problem, or medications that prevent progression of disease like

ACE inhibitors for heart failure or insulin for diabetes.

If you're wondering just who decides when and what type of preventive testing you should receive, there are several entities. There's many specialist organizations like the American Heart Association, the American Diabetes Association, the American College of Cardiology, and on and on. Then there is the USPSTF, the US Preventive Services Task Force. And yes, you have to go through a medical residency to say it quickly and often, USPSTF, USPSTF, USPSTF.

which is the organization that provides the most evidence-based recommendations for preventive screening tests. And here, evidence-based means that there have been well-designed and reviewed scientific studies performed over time that prove an outcome. The vaccination schedule is developed by the Advisory Committee on Immunization Practices, ACIP.

which is made up of a wide swath of doctors, pharmacists, epidemiologists, and other experts in healthcare analytics. They make recommendations about vaccine to the CDC, the Centers for Disease Control, and to the director of the CDC, who adopts or occasionally ignores those recommendations. These guys have been in the news a lot lately.

So now that we've discussed what preventive healthcare is and what it might entail for you, let's come back to some of those reasons why people are not seeking preventive care in the first place or maybe don't have a primary care doctor.

I'm going to focus mostly on the two subjective reasons that I hear the most often, a distrust of the healthcare system and not perceiving that there's a need for a doctor visit in the first place. Reason one, a distrust of doctors and probably the medical system at large. The distrust is real and it's measurable and it's growing. The Harris Poll has shown a drop in people's confidence in the people who are in charge of medicine

from about 80 % in the late 60s and early 70s down to less than 40 % today. Similarly, Gallup has polled US adults on their confidence in the healthcare system as a whole, as opposed to the last study, which was looking at people in charge of the healthcare. But the data shows that the number is about the same. It hangs around 36 % most years since the 1990s with a quick rise to about 50%.

in 2020 during the time that people were calling medical personnel heroes. But then it dropped back to its baseline of 36 % in 2024 when people once again decided that perhaps they are not heroes for some reason, but they are. And that distrust is not evenly distributed.

Black and Hispanic adults report significantly higher levels of medical mistrust than Caucasian adults, driven in part by perceived but very real discrimination in healthcare based on race, income, and insurance type. Interestingly though, individual doctors remain in general the most trusted source of health information.

Even though their trust rating, as reported by US adults, dropped from 93 % in 2023 to 85 % in early 2025, that's still so much higher than people's trust in the other parts of healthcare, the system in general and those in charge of it. This makes me think that the antidote to this systemic distrust is not yet another talking head on the news or another article about what to do.

the antidote is to form a relationship. Patients who have an established primary care provider, someone who knows their name and their history are far more likely to trust and act on medical advice. However, let's acknowledge that you can't build that relationship if you never make the appointment in the first place. But you might say, feel great and take no medications and have no symptoms of any problems right now. So why should I even go to any doctor?

Well, I'm glad you asked. This is a reason to I feel fine, so I don't need to see a doctor. This is honestly perhaps one of the most dangerous assumptions in all of health care, because a long list of serious conditions feel like absolutely nothing until they aren't. On a personal note on this approach, I may or may not even be here if I had followed that way of thinking. When I had a mammogram in 2020 that showed breast cancer, I felt

perfect and had no detectable lump. This was just the screening test doing what it's supposed to do, catch disease as early as possible and it worked. I was lucky to catch it in the earliest stage, 1A, but that only happened because I followed through on my annual preventive screening test recommendations. Let's look at an example that affects about half of US adults, high blood pressure.

This condition typically gives no symptoms at all until it causes a stroke or a heart attack. And sometimes at that point, irreversible damage has been done to the heart and blood vessels. The story is similar for high cholesterol, type 2 diabetes, at least in its early stages, and several cancers. Damage is being done before symptoms arise. Glaucoma, a leading cause of irreversible blindness, also typically causes no symptoms until the condition's quite advanced.

by which point, again, much of the damage is already done.

In terms of screening for cancers, a study in the British Medical Journal in 2023 estimated that nearly 800,000 Americans become disabled or die each year because of a missed or delayed diagnosis like colon or breast cancer. These aren't people who ignored symptoms, many of them had none.

Feeling fine is not a clean bill of health. I mean, it's great, but it's simply an absence of obvious symptoms. And many of the most important early changes in diseases are such that only a blood test, a blood pressure check, or a colonoscopy can detect. Remember, the whole point of preventive care is to find the problem before your body gives you a reason to look for it. To be clear,

I'm not trying to scare anyone or turn you into a hypochondriac. I'm simply saying that getting checked out from time to time is a good idea for everyone, whether you're feeling sick or great. If you're interested in looking over the current list of recommended preventive testing that is suggested for you by the various groups that I mentioned earlier, I'm posting that in the show notes and on my website in the resources tab. There are other organizations and committees that may or may not agree with what's on my list.

So I've added a few links to read more about it all if you like. And you can bring it up with your doctor when you make that appointment. Look, I know that going to the doctor feels like one of those things you'll get to eventually, like organizing your closet or finally calling that friend back. Life is busy, and if nothing hurts, it's easy to put it off indefinitely. But here's what I keep coming back to.

Many people who end up in serious medical trouble are not people who were careless with their health. They just didn't know what they had. They didn't know their blood pressure had been quietly climbing for years. They didn't know a cancerous polyp was growing in their colon. They didn't know because they weren't seeking preventive care. That's what this kind of care is at its core. It's about being informed about your own body and what's going on inside of it.

It's about having someone in your corner who knows your baseline. That's what's normal for you. So that when something changes, you catch it early when it's still fixable. So here's my ask. If you don't have a primary care provider right now, make that your one health goal for this month. And know that it might be very annoying to find someone. It may take many phone calls to find someone taking new patients with your insurance.

It may be six or more months until that appointment comes, but that's okay. If you do have a primary care provider but haven't been in over a year, call and schedule an annual visit. Bring your questions. Bring your skepticism if you have it. A good provider won't be threatened by it. They'll welcome it. And if yours doesn't, find a different one.

I'll be coming out soon with a short episode on actually finding, choosing, and switching doctors, so stay tuned for that one. You don't have to be sick to get good medical care. You just have to show up.