The Fall
I fell yesterday. Six miles into a jog on the American Tobacco Trail, down hard, arm bruised. It hurt. My first thought was to stop. My second thought: stopping would make tomorrow worse, so I kept going.
The path was unpaved, riddled with loose rocks. My foot caught on something, and I was down before I knew I was falling.
I fall once a year, maybe less. This might have been my longest stretch without one.
Part of the reason I kept running was practical. There is a public facility along the trail, and I knew I wanted to clean the wound right away, with soap, while the skin was still warm from the run. The cleaning was going to hurt, and I wanted to get it over with.
A half mile later, a different thought arrived. If I walked into a clinic in the next ninety days and they asked whether I had fallen recently, I would get a bracelet. Fall risk. Printed, wrapped, and attached to my wrist.
I knew this because it had already happened to me two years ago. I went to a cardiologist for a pre-marathon checkup, a visit I had scheduled myself because I wanted to be responsible about training. At intake, the receptionist asked if I had fallen recently, and I answered honestly that I had, because I am active and I fall sometimes. She reached for the printer and began generating the bracelet before I had seen the doctor and before anyone had measured anything about me. Later in that same visit, I scored in the top ten percent on a fitness test for my age bracket.
The moment I realized what the receptionist was doing, I changed my story. I told her I had not really fallen and that I did not need the bracelet. I lied. I lied to a medical professional, to my own chart, because the bracelet was not just an embarrassment. It was a symbol of something much larger than its original purpose, and I was not willing to wear it.
Pygmalion and Procrustes
There are two old ideas that have been rattling around in my head since that visit, and they explain why a paper bracelet felt so much heavier than it should have.
The first is the Pygmalion effect. The story comes from Greek mythology, where a sculptor named Pygmalion carved a statue so beautiful that he fell in love with it, and the gods eventually brought it to life. Psychologists borrowed the name in the twentieth century to describe something more ordinary and more unsettling: the way other people’s expectations of us shape who we actually become. When a teacher believes a student is gifted, the student tends to perform as though the belief were true. When a clinician believes a patient is frail, the patient tends to behave as though the assumption were correct. When a clinician sees a patient as the abstract average of a demographic, the patient tends to drift toward the mean. Expectations are not neutral. They reach into us and begin to shape us.
The second idea is the Procrustean bed, which comes from a darker corner of the same mythological tradition. Procrustes was an innkeeper who offered travelers a place to sleep and then made sure they fit the bed exactly. If they were too short, he stretched them. If they were too long, he cut off whatever hung over the edge. The fit was guaranteed because the bed was fixed, and the travelers were not.
When I sit in a clinic at sixty-three, I can feel both of these forces working on me at once. The staff carries a set of expectations about what a man my age is, and those expectations begin to sculpt me the moment I walk in the door. At the same time, the clinic itself is a Procrustean bed made of protocols, intake forms, and standardized questions, and it is not interested in whether I fit. It is interested in fitting me. The bracelet was one small example of both forces meeting at the same wrist.
Lived Experience
In my fifties, I used to watch people a decade or two older than me defer to their doctors, and I was puzzled by it. These were intelligent people, accomplished people, people who had run companies or raised families or built careers on the strength of their own judgment. And yet, when a man in a white coat told them what to do, they set their own judgment aside and did it. I thought, quietly, that I would never be like that. I told myself I would keep my own counsel as I got older. I believed that was a matter of character.
I was wrong. What I had taken for strength of character was the good fortune of never having been tested as a man in his sixties. The pressure does not announce itself. It leans on you slowly, and from every angle.
Now that I am sixty-three, I can feel it directly, and I understand why the people I watched in my fifties did what they did. The forms assume a version of you that is not quite you. The guidelines assume a trajectory that is not quite yours. The clinician assumes a baseline risk that does not account for how you actually live. If I defend my judgment, I do it alone.
The pressure shows up in specific ways. My cardiologist looked at my lipid panel, which was excellent by almost any measure, and recommended a statin. My LDL was higher than the guideline preferred, so the guideline said statin, and the conversation was effectively over before it began. I asked him to walk me through why a statin made sense given the rest of the picture, and he would not. When I raised the known side effects — the destabilization of blood sugar, the muscle soreness that has cost some men their ability to exercise — he was unmoved. We can adjust your prescription, he said, as if side effects were a dosing puzzle to be solved downstream rather than a reason to reconsider upstream. The protocol said what it said.
During the same stretch of visits, he also told me to stop eating eggs. The advice was built on an older chain of reasoning — that dietary cholesterol raises blood cholesterol, and that raised blood cholesterol is the same as cardiovascular disease. The first link in that chain has been quietly abandoned. The 2015-2020 dietary guidelines removed their long-standing restriction on dietary cholesterol because the evidence did not support it, and the American Heart Association’s own 2020 advisory acknowledged that observational studies do not show the association they had assumed for decades. None of this came up. The advice arrived as a pronouncement. Had I not already done the work to understand my own metabolism, I would have taken that advice. I would have walked out of his office and back toward the foods that kept me obese for most of my adult life.
And then there is the smallest and strangest of the pressures, which I have only recently begun to recognize. When I was younger, a doctor who learned I was on no medications would say something like, well done. Somewhere around sixty, the response began to shift. It is not usually spoken aloud, but the raised eyebrow is there. The nudge is there. The sense that a man my age ought to be on at least one thing, and that being on nothing is a kind of oversight rather than a kind of achievement. Wait a minute. Am I at the doctor’s office, or at a garage, after asking for a simple oil change? Would I like to add a cabin air filter? Would I like a statin while I am here? That was not a question I expected to be answering at my annual physical, but it has started to come up.
Fair Acknowledgment
All of that is the view from my side of the exam table. I owe the other side a fair accounting. I do not think the people in the lab coats are villains, and I do not think the system is designed to hurt me. The truth is more complicated than that.
First, the demographic shift is real. On average, a population of sixty-year-olds is less healthy than a population of fifty-year-olds, and a population of seventy-year-olds is less healthy still. The aggregate numbers tell a real story, and the clinicians who work with those numbers are not making anything up. The frailty curve bends. The chronic conditions accumulate. The medications multiply. All of this is observable, and a cardiologist who has been practicing for thirty years has seen it many thousands of times. I understand why the protocols exist.
What the guidelines struggle to see is the individual. An average describes a population. It does not describe a person. One sixty-three-year-old runs six miles a day. Another does not. The fall-risk screening question treats us as interchangeable. The statin guideline is calibrated for the population, and the man in front of the doctor may not fit it. The advice against eggs was written, at some point, for someone who was not me.
Second, the constraints on the clinicians themselves are real. A clinic runs on protocols because protocols are defensible. If a patient falls and the chart does not show a fall-risk screening, the clinic is exposed. If a patient has a heart attack and the chart does not show that a statin was offered, the clinic is exposed. Legal liability is part of this, but it is not the whole of it. Standardization is easier to teach, easier to audit, and easier to scale. A clinician who tries to treat every patient as an individual, in every encounter, will eventually be worn down by the volume. The protocol is, in some sense, a survival strategy for the clinician as much as it is a risk strategy for the clinic.
Third, there is the matter of lifestyle interventions, and here I have to be careful to be fair in both directions. Clinicians are skeptical of lifestyle interventions because they have watched patient after patient fail to follow through. That skepticism is not imagined, and it is not malicious. It is based on experience. If you have recommended dietary change to a thousand patients and seen a handful succeed, it is reasonable, in a bleak way, to reach for the prescription pad instead.
But the skepticism carries a blind spot. A great deal of what has failed has been the calorie-in, calorie-out model of dietary intervention, which leaves people hungry and therefore miserable and therefore non-compliant. When the interventions are designed around satiety instead — the low-carb approach I follow is one example — the adherence numbers improve. The research on this has been accumulating for years, though it has not yet fully reached the exam room. Which means the clinician’s honest experience of patient failure is partly an experience of failed methods. The patients may not have been the problem.
This is where the Pygmalion effect returns. If the clinician does not expect the patient to succeed, the clinician does not invest in exploring what might work. The conversation that might have opened a door never takes place. The prescription pad comes out, and the patient leaves with the slip in hand and a sense that the other roads were never real.
Arming the Reader
What follows is how I maintain my footing. I will not pretend it is a program, because it is not. It is a set of habits and instincts I have gathered over the last several years, and I offer them in the spirit of one man writing down what has helped him.
The first habit is a question I have trained myself to ask: What is the relative risk, in numbers, of doing or not doing the thing you are recommending? Categorical advice is easy to give and hard to argue with. You should take a statin. Numbers are harder to give, because they force the clinician to specify what the statin is actually buying me, and over how many years, and at what cost in side effects. Most recommendations sound inevitable when they are spoken as protocols. They sound much less inevitable when they are spoken as trade-offs.
The second habit is closely related. I ask the clinician to walk me through the reasoning. If the answer is some version of the guidelines say so, that is a reason, but it is a thin one. It tells me what the rule is. It does not tell me why the rule applies to me. A clinician who can explain the thinking behind the recommendation is a clinician I want to work with. A clinician who cannot, or will not, is a clinician I begin to look past.
The third habit lives outside the exam room. I have been building my own health literacy, slowly and through reading, because I have decided that I am not willing to be a passenger in decisions this important. The specific domain I have invested in is metabolic health, which means understanding what insulin does, how satiety works, and what the lipid panel measures and does not. The literature has moved a great deal in the last decade, and a good amount of what I learned growing up about diet and heart disease has been quietly revised. I have found that reading the research, even at a layman’s depth, changes the conversation I am able to have with a clinician. It also changes the conversation I am able to have with myself.
The fourth habit is a community. I belong to a low-carb group where the members think seriously about food as medicine, and the presence of people walking the same road has been more useful to me than I expected. I want to be plain about this: the low-carb approach I follow is controversial, and I know it. I am not here to argue anyone into it. I can only speak for what the last nine years have done for me, which is a great deal. I offer the approach the way I offer the other habits, as one man’s experience. If food as medicine is a paradigm you have not considered, it is worth considering.
The last habit, and the most important, is to find the right clinician. I am not advocating that anyone walk away from medicine. Medicine has saved my life more than once, and it will probably save it again. What I am advocating is the recognition that a clinician is a person, and people vary. Some will meet you as an individual. Some will treat you as a row in a table. You are allowed to choose, and it is worth the effort.
Close
After all of that, I still think about the bracelet. Not the one I refused at the cardiologist, and not the one I will refuse again the next time I am asked. I think about the bracelet as an idea, and what it would have meant to wear it.
If I had accepted it, I would have carried a small printed declaration that I was a man at risk of falling. Some part of me would have begun to believe it. The next time I set out on the American Tobacco Trail, I might have gone a little slower. I might have skipped the unpaved stretch. I might have told myself that a six-mile run was too much to ask of a man my age. None of this would have happened all at once. It would have happened the way the Pygmalion effect always happens, quietly, by degrees, without my noticing. Procrustes does his work while the traveler is asleep.
I am not willing to shrink. That is the whole of it. I am not rejecting medicine. I am not rejecting doctors. I am not rejecting the real wisdom that a careful clinician can bring to a long life. I am rejecting the Procrustean bed, the fall-risk bracelet, and the assumption that a man at sixty-three is the average of men at sixty-three. I am not the average. You are not the average. There is no such person. The average is a description of a group, and a group is not a body that walks into a clinic on a Tuesday morning with a bruised arm and a story to tell.
I fell yesterday, and I kept going, and I will keep going. The trail is still there. The pebbles are still there. And so am I.
PS
A note for readers curious about low-carb eating: I am a support admin for Adapt Your Life Academy, Dr. Eric Westman’s education platform. Dr. Westman was my physician when I started this way of eating in 2017. I am also one of the testimonials on their site — 65 pounds down, still there. If you want structured, clinically grounded support without the noise, Adapt Your Life Academy is where I would send you.