Why American Medicine Manages Disease Instead of Preventing It

By Dr. Lena Suhaila, ND, FABNO

You've felt this for a while. The visit that ends before your real questions get asked. The medication added to manage the side effect of the last medication. The labs that come back "normal" while you don't feel anything close to normal. The recommendation to follow up in three months, six months, a year, while nothing structural about your situation actually changes. The sense that the system you're inside isn't trying to make you well so much as managing how unwell you are, indefinitely.

You haven't been imagining it.

There's a version of this critique that goes off the rails fast, and I'm not interested in that version. The doctors aren't conspiring against you. The nurses aren't part of a cabal. Most of the people working inside American medicine got into it because they wanted to help, and many of them are heartbroken by what they see the system doing to patients and to themselves. The problem isn't the people. The problem is the structure those people work inside, and the structure produces sickness as a byproduct of how it's funded, regulated, and incentivized.

That's what this piece is about. The architecture, not the architects.

What Gets Paid Is What Gets Done

American medicine runs on a reimbursement model called the relative value unit, or RVU. Every action a physician takes is assigned a value, and the physician's compensation, the practice's revenue, and the hospital's bottom line are all tied to how many of those units get billed. Procedures generate RVUs. Imaging generates RVUs. Infusions and surgeries generate RVUs. Long conversations about lifestyle, nutrition, sleep, stress, gut health, or the metabolic terrain underneath a chronic disease generate almost none.

The fifteen-minute visit isn't an accident. It's what the math produces when you build a system around volume of billable encounters and minimize the time each encounter takes. The oncologist who would love to spend an hour with you can't, because her clinic is built around a schedule that requires her to see four patients an hour to keep the lights on. The endocrinologist who knows your insulin resistance is the actual problem can't address it the way she'd want to, because nutrition counseling and metabolic coaching aren't reimbursed at a level that makes them clinically viable.

The reimbursement model is downstream of something larger. Conventional medical education isn't built around prevention. It's built around disease management. The physician is trained to identify a diagnosis, match it to a protocol, and deliver the protocol. There's no money in prevention. There's money in illness, and the entire ecosystem is shaped accordingly. The food we eat, the chemicals we're exposed to, the substances permitted in our bodies in higher concentrations than nearly any other developed country, all of it sits inside the same architecture.

What Doctors Are Trained to Know

The average US medical school requires fewer than twenty hours of nutrition education across four years of training, and most schools fail to meet even the modest twenty-five-hour minimum recommended decades ago by the National Academy of Sciences (Adams et al., 2010, 2015). Twenty hours, total, for a clinician who will spend the rest of their career caring for patients whose chronic diseases are largely diet-driven. They're trained extensively in pharmacology because the system they'll work inside is built around pharmaceutical management. They're trained sparingly in nutrition, lifestyle medicine, environmental medicine, mind-body medicine, or anything resembling root-cause work.

This is why patients hear things from clinicians that contradict the actual biology. The most common one in oncology is "sugar doesn't feed cancer." It's an answer patients get from oncologists, oncology nurses, and hospital dietitians, and it's wrong in every clinically meaningful way. Cancer cells have profoundly altered glucose metabolism, a phenomenon described nearly a century ago and reaffirmed across modern cancer biology (Vander Heiden, Cantley, & Thompson, 2009). The reason a PET scan can find a tumor is that cancer cells take up glucose at dramatically higher rates than surrounding tissue. The entire imaging modality oncology relies on is built on the fact that tumors eat sugar differently. Hyperinsulinemia and elevated IGF-1 activate PI3K/Akt/mTOR, the exact pathways cancer cells exploit for growth (Pollak, 2012). The American Cancer Society and the World Cancer Research Fund both name metabolic dysfunction and obesity as cancer risk factors. None of this is controversial in the literature. It's just not in the twenty hours.

When a patient asks an oncology team about diet and gets the "sugar doesn't feed cancer" line, they're getting bad information from a clinician who is uninformed about the metabolic biology of the disease they're treating. That's not a personal failing. It's what happens when you train a generation of physicians in pharmacology and barely train them in nutrition, then send them out to treat diseases that are deeply metabolic.

Continuing medical education, the ongoing learning physicians do throughout their careers, is heavily underwritten by pharmaceutical industry funding (Brennan et al., 2006). The result isn't that doctors have been bought. It's that the information environment they live inside is shaped by who's paying to keep it running.

The Regulator and the Regulated

In fiscal year 2025, approximately 77% of the FDA's prescription drug review program was funded by user fees paid directly by the pharmaceutical industry (Congressional Research Service, 2025). The agency that decides which drugs come to market gets the majority of its drug-review budget from the companies whose drugs it's reviewing. NEJMdescribed the dynamic plainly: industry now pays roughly 75% of the costs of the scientific review of drugs (Darrow, Avorn, & Kesselheim, 2017). The unintended effect of the user-fee model has been a regulator structurally dependent on the industry it regulates, with documented consequences for review timelines, post-market safety surveillance, and which drugs end up approved.

The United States is also one of only two countries in the developed world, along with New Zealand, that permits direct-to-consumer pharmaceutical advertising (Almasi et al., 2006). American patients are exposed to roughly $6.6 billion in pharmaceutical advertising annually, and the documented effects include increased prescribing of branded over generic medications, decreased patient interest in nonpharmacologic interventions, and pressure on physicians to prescribe drugs patients have seen advertised. The patient asking their doctor about a medication they saw on television isn't a random event. It's the designed outcome of an advertising apparatus that exists in only one other country on earth.

Who Writes the Guidelines, Who's in the Trials

Clinical practice guidelines, the documents that determine what your physician will and won't do, are written by expert panels with documented financial relationships with the industries whose products the guidelines address. The result isn't necessarily that guidelines are wrong. It's that the questions guidelines ask, the interventions they consider, and the alternatives they fail to evaluate are shaped by who's at the table. Lifestyle interventions, nutritional approaches, mind-body therapies, and root-cause work tend not to be on the agenda.

The clinical trials that establish whether a drug works, what dose to use, what side effects to expect, and which patients will respond, are also overwhelmingly conducted on White participants. A 2022 Lancet Regional Health analysis of pivotal FDA trials between 2015 and 2019 found that 78% of US trial participants were White, while White Americans make up roughly 60% of the population (Turner et al., 2022). Cardiovascular trials run as high as 90% White. Some FDA approval cohorts have hit 87%. Oncology trials run 73 to 78% White, with Black participation at 4 to 8%, Hispanic at 5 to 9%, and Asian at 3 to 18% depending on cancer type. In cancer-related genome-wide association studies, 92% of the samples come from people of European descent.

What this means clinically is significant. Drug metabolism varies by genetic ancestry. Disease presentation varies. Risk factors vary. Treatment response varies. When the evidence base is built on a population that doesn't represent who will actually take the drug, the dosing, the side-effect profiles, the efficacy data, and even the diagnostic criteria are calibrated to a body that may not be yours. If you're not White, the protocols your medical team is using were largely tested on someone else's biology. The system isn't required to know how those protocols perform in your body, because the data to answer that question wasn't collected. The "average patient" in conventional medicine isn't a neutral concept. It's constructed from a dataset that's demographically narrow, and everyone outside that demographic is being treated with extrapolation rather than evidence.

What This System Produces

Put all of this together and you get a healthcare apparatus that is, by design, extraordinarily good at certain things and structurally incapable of others. It's good at acute care, trauma, surgery, infectious disease management, and the deployment of pharmaceutical interventions for diagnosable conditions. If you're hit by a car, having a heart attack, or diagnosed with an aggressive cancer that needs immediate intervention, the American medical system is one of the most powerful instruments in the world. That's real, and I want to honor it.

It's structurally incapable of preventing chronic disease, addressing root causes, working with the metabolic and inflammatory terrain underneath illness, supporting nervous system regulation, helping patients change the lifestyle inputs that shape epigenetic expression, or doing the slow individualized work that complex chronic conditions actually require. The system isn't designed to do those things. The reimbursement model doesn't pay for them. The training pipeline doesn't teach them. The regulatory apparatus doesn't validate them.

So the patient with metabolic dysfunction gets a prescription for the symptom and a follow-up in six months. The patient with autoimmunity gets an immunosuppressant and is told there's nothing else to do. The patient with cancer gets a tumor-targeted protocol and is told that nutrition, stress, sleep, gut health, and the rest of their biology aren't really part of the conversation. Not because their physicians don't care. Because the system those physicians work inside doesn't have a reimbursement code for caring about those things.

And it can't be one size fits all, because you aren't. Your biology isn't. Your terrain isn't. Your history isn't. Your ancestry isn't. The system is built to treat the average patient with your diagnosis. You are not the average patient. No one is.

What's Possible Outside the Frame

The reason functional medicine, naturopathic medicine, integrative oncology, and root-cause work look different is that they're built around different incentives. The visit is an hour, sometimes two, because the questions take that long. The labs are comprehensive because the body is a system. The recommendations address the actual terrain, not just the symptom. The patient pays out of pocket more often than not, which is its own structural problem worth naming, but it also means the care isn't shaped by what an insurance company is willing to reimburse.

This kind of medicine asks why your body. Why now. What's underneath this. What's the inflammation coming from. What's the insulin doing. What's the microbiome telling us. What was your nervous system carrying for the last decade. What does your genomic individuality, through tools like the Nutrition Genome report, say about how your specific body methylates, detoxifies, handles oxidative stress, and responds to specific nutrients.

Those are the questions the biology says are relevant. They're outside the frame the system is structured to deliver, which is a different problem.

If You've Been Sensing This

You haven't been wrong. The thing you've been sensing about your care has structural roots, and naming those roots clearly is the first step toward doing something different.

This is the gap I live in. Individualized care, grounded in your specific pathology, your specific biology, your specific terrain, your specific life. The metabolic work. The microbiome work. The nervous system work. The genomic individualization. The questions no one else has had time to ask. These are the things that make the difference between surviving and thriving.

If you're ready to bring that kind of attention to your own care, I'd welcome the conversation.

References

1. Adams, K. M., Kohlmeier, M., & Zeisel, S. H. (2010). Nutrition education in U.S. medical schools: Latest update of a national survey. Academic Medicine, 85(9), 1537–1542. https://doi.org/10.1097/ACM.0b013e3181eab71b

2. Adams, K. M., Butsch, W. S., & Kohlmeier, M. (2015). The state of nutrition education at US medical schools. Journal of Biomedical Education, 2015, 357627. https://doi.org/10.1155/2015/357627

3. Almasi, E. A., Stafford, R. S., Kravitz, R. L., & Mansfield, P. R. (2006). What are the public health effects of direct-to-consumer drug advertising? PLOS Medicine, 3(3), e145. https://doi.org/10.1371/journal.pmed.0030145

4. Brennan, T. A., Rothman, D. J., Blank, L., Blumenthal, D., Chimonas, S. C., Cohen, J. J., Goldman, J., Kassirer, J. P., Kimball, H., Naughton, J., & Smelser, N. (2006). Health industry practices that create conflicts of interest: A policy proposal for academic medical centers. JAMA, 295(4), 429–433. https://doi.org/10.1001/jama.295.4.429

5. Congressional Research Service. (2025). FDA Human Medical Product User Fee Programs (Report R44750). https://www.congress.gov/crs-product/R44750

6. Darrow, J. J., Avorn, J., & Kesselheim, A. S. (2017). Speed, safety, and industry funding: From PDUFA I to PDUFA VI. New England Journal of Medicine, 377(23), 2278–2286. https://doi.org/10.1056/NEJMhle1710706

7. Pollak, M. (2012). The insulin and insulin-like growth factor receptor family in neoplasia: An update. Nature Reviews Cancer, 12(3), 159–169. https://doi.org/10.1038/nrc3215

8. Turner, B. E., Steinberg, J. R., Weeks, B. T., Rodriguez, F., & Cullen, M. R. (2022). Race/ethnicity reporting and representation in US clinical trials: A cohort study. The Lancet Regional Health – Americas, 11, 100252. https://doi.org/10.1016/j.lana.2022.100252

9. Vander Heiden, M. G., Cantley, L. C., & Thompson, C. B. (2009). Understanding the Warburg effect: The metabolic requirements of cell proliferation. Science, 324(5930), 1029–1033. https://doi.org/10.1126/science.1160809