Ask Rip: Podcast #59: Doctors, et al

[Mark Rippetoe]

Ask Rip #59 | Starting Strength Channel

[George Christiansen]

I wonder if the anti-squat, anti-deadlift, anti-press attitude among most doctors (and the general population) stems less from them being too stupid and more from the "some things are so stupid you have to be taught them" side of things?

The Stress-recovery-Adaptation Cycle and it's theoretically application is actually rather intuitive IF you haven't been scared off by being "educated", but certain people. Applying it well definitely takes some education or a lot of trial and error, but it just makes sense to anyone who has not spent their whole life sitting on their ass.

I'd also be curious to know how this silly BS translated across cultures?

[Mark D]

I had two experiences with doctors which taught me not to take their word for things, event things they SHOULD know about.

First, a few years ago I had an infection with a rash (what they used to call Scarlet Fever), it happened on a weekend so I went to the local urgent-care center, got a broad-spectrum antibiotic and was told to take an antihistamine for the rash. A few days later I went to my GP for follow-up, he sent me for blood work which showed my liver enzymes where thru the roof (he actually asked if I'd started drinking very heavily, as in bottles of booze a day heavily). I asked if it could be the antibiotic which caused it and he said "No" and sent me for an ultra-sound on my liver, along with a referral to see a liver specialist. Mind you, we had this conversation in his office with an internet-connected computer on the desk. When I got home I googled the name of the antibiotic and "liver" and found information, on the drug manufacturers website, saying that those liver enzymes will go out of whack from the drug, and that they generally return to normal after the drug course is done. Had my doctor said "I don't know, let me look" and did just what I did I wouldn't have been bothered, no one can know every side effect for every drug, especially when he didn't prescribe it in the first place.

Second, a couple years ago my cholesterol was about 250. My doctor (different doctor from above) told me to lose weight and get the cholesterol down or he'd prescribe statins (which I told him I wouldn't take, if I'm going to destroy my liver I'll do so with single malt scotch, not statins). Over the next six months or so I lost about 30 pounds and my cholesterol went up to 275, he prescribed statins (I didn't fill the script). Six months later when my weight had stabilized my cholesterol was 200, doc proclaimed the statins a success and was amazed when I told him I wasn't taking them. Further research showed cholesterol increase during weight loss is common, cholesterol is stored in fat in the body, reduced fat dumps it into the blood stream, to the liver and out. The upsetting part is the paradigm where you lose weight, cholesterol doesn't go down, you take statins, cholesterol goes down (which it probably would have anyway) and you end up taking stuff you don't need.

So yeah, if doctors won't be educated on actual medical issues which are supposedly their field, I don't expect them to know much about things that are outside their field.

[Will Morris]

I've gotten back to deadlifting just fine after tommy john surgery.

[Pluripotent]

I wonder if the anti-squat, anti-deadlift, anti-press attitude among most doctors (and the general population) stems less from them being too stupid and more from the "some things are so stupid you have to be taught them" side of things?

The Stress-recovery-Adaptation Cycle and it's theoretically application is actually rather intuitive IF you haven't been scared off by being "educated", but certain people. Applying it well definitely takes some education or a lot of trial and error, but it just makes sense to anyone who has not spent their whole life sitting on their ass

I'd also be curious to know how this silly BS translated across cultures?

I think that a lot of it has to do with the fact that most medical education is based off the American model.

A problem is medicine and probably in a lot of other fields, but especially medicine is that somehow everything is relevant. When you go to medical school, they don't really have a set curriculum for, say, the GI system. In my case (and the medical school I went to was by no means sub par), they give you a syllabus, which consisted of a poorly xeroxed set of lecture powerpoints for the whole module that was about 4 inches thick and bound by the printing department. You are tested at the end but the questions could literally be about anything, and step 2 was coming, which could also be about anything. So really all you can do is study multiple choice questions like mad and hope that you do well. This goes on for two years with lectures and then the next two years you spend in clinicals with another test at the end of each module. So really you're spending all your time just doing as many multiple choice questions as you can, because everyone knows that to be a good doctor you have to be really good at multiple choice questions, so the med schools, in their wisdom, decided to make multiple choice questions the most fundamental part of doctor training. You may never learn anything about the Stress-recovery-adaptation cycle in medical school, but you sure learn how to answer multiple choice questions. So if you want to have a good experience with your doctor, you should formulate your symptoms into a question stem and offer him a series of multiple choice questions that would lead him to your diagnosis. He'd be really good at that. The major controversy is always about answer C, however. Traditionally, if you didn't know, you were told to always answer C because statistically you'd always get about 1/4 of the unknown answers right that way. But then test takers began to suspect that test makers had caught on to this and would not make C a right answer for this reason. So, If your doctor is more old school, and you come in with a tear of your episiotomy scar and he has no idea what's going on, and you give him a multiple choice test with C being Bullous Pemphigoid and he tells you that you have Bullous Pemphigoid, then you know he's full of shit and just guessing. But if he's one of the newer types who thinks that C is never the right answer, then you just never know what to think.

Once you graduate, you are supposed to "keep up with the literature," which apparently means that you're meant to read the New England Journal of Medicine, JAMA and maybe Annals of Internal Medicine or The Lancet every quarter in their entirety, as well as two or three journals in your subspecialty. This, despite the fact that about 50% of journal articles don't stand up to further research in 5 years time and a remaining 25% are just completely irrelevant, and the other 30% are fabricated in their entirety. But somehow, everything is relevant.

Combine this with the fact that you have now just graduated with crushing amounts of debt and no place to live and you have to see patient's for 12 hour days at your understaffed hospital, the end result of this is that doctors are really just too busy to know anything about medicine at all.

But part of the problem with how we got into this mess in the first place... I think a lot of has to do with the Flexner report from the early 1900s. Back then, medical schools were wildly varied in how they trained doctors, and some were ok and some were appalling, but none were great, because it was 1910 and what the hell did anyone know about medicine then? But then Flexner came along and said, wow this is really appalling, this needs to be standardized! and so proceeded to take what was a big problem and make it worse by creating one solution, which even if it's a good solution (doubtful, but giving the devil his due, we'll say it was), it ain't gonna work for long. And so this is how medical school reform has worked ever since. We're constantly trying to find the one solution that will fix the problem, usually deciding on a poor solution that is uniformly adopted across all medical schools, and then immediately working on the next uniform solution as we toss the current one out of the nest and watch it smack a few branches on the way to the ground, break it's leg on a rock and get eaten by a snake before it can fly. But not to worry! There's always a new one to toss out the nest!

[Mark Rippetoe]

Study: European Guidelines Don't Drive Enough People to Statin Therapy | Medpage Today

Comments are pretty good.

[Keith Burnett]

I wonder if the anti-squat, anti-deadlift, anti-press attitude among most doctors (and the general population) stems less from them being too stupid and more from the "some things are so stupid you have to be taught them" side of things?

The Stress-recovery-Adaptation Cycle and it's theoretically application is actually rather intuitive IF you haven't been scared off by being "educated", but certain people. Applying it well definitely takes some education or a lot of trial and error, but it just makes sense to anyone who has not spent their whole life sitting on their ass.

I'd also be curious to know how this silly BS translated across cultures?

People do not tend to go to doctors for exercise prescriptions.....especially something that takes the commitment and the effort associated with strength training. Maybe go to IM or FP doctor and hear about "weight loss" or "sleep"...and perhaps get some information. Exercise has been totally dumbed down in the doctors office to "anything to get yo off your ass". It is a shame...I did not learn a damn thing about training physically in med school. A damn shame.

Furthermore, you have to cut the docs a little slack......if they send you home with a RX for strength training, somehow end up at 24 fitness, and learn cockamamie shit from the gym bros, or worse yet a personal trainer....and get HURT.....those docs don't want to meet up with an ambulance chaser and have to defend this in court.

I am just damned lucky to have stumbled over SS, when I finally arrived at the point that I wanted to train.

there is a still an all out surge in attempts to get people on statins. Some are opting for PCSK9 inhibitors. That stuff will send your LDL plunging......but what else it does...not certain. I told my cardiologist to fly a kite regarding both.

[Mark D]

there is a still an all out surge in attempts to get people on statins. Some are opting for PCSK9 inhibitors. That stuff will send your LDL plunging......but what else it does...not certain. I told my cardiologist to fly a kite regarding both.

My former doctor (the one with the antibiotics affecting the liver enzymes above) firmly believed statins should be in the water supply.

[George Christiansen]

Furthermore, you have to cut the docs a little slack......if they send you home with a RX for strength training, somehow end up at 24 fitness, and learn cockamamie shit from the gym bros, or worse yet a personal trainer....and get HURT.....those docs don't want to meet up with an ambulance chaser and have to defend this in court.

No. You don't cut people slack when they have no ability to utter the words "I don't know" when they should. And it isn't about expecting them to know how to prescribe an LP per se, but at least not running off at the mouth deterring people from doing basic human movements would be an improvement.

I guess I should be happy that the orthopedic surgeon I saw told me that it was ok to lift with what he called a "healthy as an 18 year old's shoulder", so long as I didn't lift "too heavy"....which considering that "too heavy" makes it impossible to lift....................

And certainly there has to be a class on how to give a personal opinion without making oneself vulnerable to a malpractice suit, no? I get that we live in, what often seems like a sue happy culture, but a large part of it, in regards to medical malpractice, comes from the medical associations trying to make themselves into some priesthood who alone has the right to an opinion about what someone should do about their condition and in opening the door to have a layperson sued for giving "medical advice" they get the same gun turned on themselves.

[Jordan Feigenbaum]

I had two experiences with doctors which taught me not to take their word for things, event things they SHOULD know about.

First, a few years ago I had an infection with a rash (what they used to call Scarlet Fever), it happened on a weekend so I went to the local urgent-care center, got a broad-spectrum antibiotic....

I'm not one to make apologetics for other professionals, but it is possible (probable, even) that the antibiotic prescribed to you doesn't typically effect liver enzymes in most folks, though nearly all antibiotics and antifungals have been associated with elevated liver function tests in small percentages of folks. That may have been the case, though a google search would result case reports or reported side effects on the particular antibiotic- even if uncommon. Should the provider have said, "I don't know" in this case? Maybe, but then again- a lot of the abnormal responses of this nature are just noise. Additionally, if you had trained within 7 days of starting this antibiotic- your liver function tests may have been elevated by themselves.

Further research showed cholesterol increase during weight loss is common,

Not really that common. There are two studies that show this relationship, but one actually did biopsies showing that cholesterol content within the body fat was unchanged. Additionally, most studies on rapid weight loss show decreased total cholesterol and triglycerides with increased HDL even during rapid weight loss. The main thing we're trying to evaluate with a lipid panel with respect to statins is what is your risk of a bad outcome and can that risk profile be beneficially altered with certain strategies.

The statin thing probably needs to be discussed in a different manner amongst the strength crowd. Lots of nocebo and misinformation going around, though I don't think they should be in the water supply.

Overall, I think the attitude towards most physicians is based on a stereotype that may or may not be accurate depending on the particular provider. The other issue is the time that most docs have to spend with their patients. 10-15 min (esp in an urgent care setting where you don't know the patient) isn't nearly enough- so that could be another contributing factor too. I spend an hour with each of my patients nearly every time and it's pretty nice feeling like there's a good exchange of information and shared plan

People do not tend to go to doctors for exercise prescriptions.....especially something that takes the commitment and the effort associated with strength training. Maybe go to IM or FP doctor and hear about "weight loss" or "sleep"...and perhaps get some information. Exercise has been totally dumbed down in the doctors office to "anything to get yo off your ass". It is a shame...I did not learn a damn thing about training physically in med school. A damn shame.

100% agree. I think that we pay lip service to providing adequate guidance here (especially to get reimbursed appropriately), but don't want to be held to a high standard with respect to what we're recommending, subsequent follow up, etc. If we are talking about exercise as professionals, we need to be well versed on the topic and have adequate time to counsel appropriately or refer appropriately (not to PT). That said, I don't think there are many in the medical field who share this view point given the current climate.

Furthermore, you have to cut the docs a little slack......if they send you home with a RX for strength training, somehow end up at 24 fitness, and learn cockamamie shit from the gym bros, or worse yet a personal trainer....and get HURT.....those docs don't want to meet up with an ambulance chaser and have to defend this in court.

I'd be interested to hear Brodie's thoughts on this for sure.