There is already an “official” field of medicine called “lifestyle medicine”, at least there is according to the American College of Lifestyle Medicine (www.lifestylemedicine.org).  It is a: “…national professional society for clinicians who specialize in the use of therapeutic lifestyle interventions in the treatment and management of disease.”

At its narrowest, lifestyle medicine is used to promote lifestyle changes necessary to achieve optimal results in post-acute treatment of conditions such as heart disease, or post-surgery in cases of bariatric surgery for weight loss.  In such cases, permanent lifestyle changes are needed to retain the benefits of the original intervention, and to prevent the recurrence of the original problem.

Lifestyle medicine is also an essential element of most chronic disease management efforts, since most require or at least benefit from patients’ lifestyle changes.  Compliance with medications, for example, is a lifetime behavior change, while compliance with self-monitoring such as daily or even more frequent blood glucose monitoring for diabetes, weight monitoring for congestive heart failure, etc. is equally essential.  Changes in diet, exercise, stress management, and other health-related behaviors are also recommended in most self-management efforts.

Specific lifestyle changes are also needed to reduce health risks, even before chronic or acute diseases arise.  Ending the use of tobacco, the abuse of alcohol and drugs, unhealthy diets, physical and mental indolence, are generally recommended for everyone.  Preventing or altering patterns of violent behaviors, unsafe driving, sexual practices, and behaviors in general, while adopting safe practices instead is equally a lifestyle approach to prevention.

Promoting healthy behaviors, such as those that promote physical fitness, mental acuity, social and spiritual health, can be equally included in lifestyle medicine.  Physicians and other clinicians have special influence with most patients, and can prompt lifestyle changes in cases where other approaches have failed. [K. Murphy “Teaching Doctors to Teach Patients About Lifestyles” New York Times, Apr 17, 2007]

On the other hand, physicians are rarely trained or experienced in the art or science of altering patients’ lifestyles.  While “medications” in the form of prescription or OTC drugs are often used in some lifestyle change efforts, such as nicotine replacement therapy for smoking cessation or drug antagonists for alcohol and illicit drug abuse, all lifestyle change efforts require “cognitive services” such as cognitive and behavioral therapy, motivational interviewing, for example.  Such services are currently not paid for by most health insurance plans, and are not usually included in medical school curricula.

There are physicians who are actively engaged in lifestyle medicine, particularly those who market proactive health preservation and improvement as part of their “concierge”/“boutique” practices.  Lifestyle medicine makes an almost ideal “extra services” category for physicians who are prohibited from charging patients more for normal primary care, and is attractive to large numbers of baby boomer generation patients who want to remain young, active, and independent as long as possible.  The 150 or so MDVIP physicians in sixteen states use lifestyle medicine as a major element of their retainer practices, and report dramatic reductions in sickness care use as a result. (www.mdvip.com)

A number of physicians also use a kind of lifestyle medicine that includes “retail” sales of nutriceuticals products and services, from herbal and vitamin therapy to massage, hypnosis, acupuncture and other complementary/alternative therapies.  The fact that these are not covered by insurance makes them ideal for retail purposes, while their widespread consumer acceptance helps make them popular as well.  And at least some have proven effective in treating specific conditions.

The biggest challenge in lifestyle medicine, however, is the fact that physicians generally value their time at an “outlier” level compared to other clinicians, such as nurse practitioners and physicians assistants, and non-clinicians such as trainers and health educators.  Where patients pay $1500 per year for retainer practices, physicians can afford to spend extra time with them, but most patients may, and certainly most employers and insurance plans would prefer lower-priced lifestyle coaches.

Large physician practices, and practices that are part of integrated health systems, or at least collaborate with hospitals in lifestyle medicine, can offer services through a team approach for providers, and group visits or remote communications methods for patients, in order to keep costs affordable.  They will still be handicapped by the fact that they will tend to have patients who are covered by a wide variety and large number of different insurance plans or employers, hence have to deal with a large number of payors, with varying interest in and willingness to pay for lifestyle medicine, as well as varying notions about what is needed and will be paid for.

When the Family Physicians of Western Colorado in Grand Junction embarked on a diabetes management program based on the Chronic Care Model, for example, this practice found only one local insurer that would pay them.  Though it paid enough to make the program a profitable one for those patients who were covered by that one insurer, only a minority of all patients were so covered, and the practice lost money on the program overall, since it chose to enroll all its diabetes patients in the program. [P. Mohler & N. Mohler “Improving Chronic Illness Care in a Private Practice” Family Practice Management, 12:10 Nov/Dec 2005 50-56]

Probably the best approach for physicians who are interested in lifestyle medicine to take would be to contract with or work for large employers who are willing to sponsor onsite medical clinics for their employees and dependents.  The onsite clinics, because of their convenient location, should prove attractive to employees, at least, and can include whatever lifestyle medicine employers are willing to pay for.  And since improving the health of employees returns as much as two to five times as much value to employers as it does to insurers, the revenue from such clinics may be significantly more profitable than is the case with insurer-paid sickness care, with far fewer hassles and overhead costs.

Of course, physicians may not wish to work for employers, though large numbers already function as employees of hospitals and integrated systems.  And even in onsite clinics, physicians will rarely be the most effective or efficient source of lifestyle medicine services, given the high cost of their time.  But for primary physicians who can bear the idea of being an employee, onsite practices for individual employers, or perhaps for groups of employers located in the same neighborhood, could represent one of the best opportunities to create true “medical homes” that combine proactive and reactive medical care, and the kind of medicine they want to practice.