The Better the Doctor, the More Likely They Are to Be Forgotten: The Dangers of Preventive Medicine as Taught by the Anecdote of Bian Que

Sometimes, a patient who has overcome a serious illness will shake my hand with both of theirs and say, "It's all thanks to you, Doctor."

It’s not a bad feeling. It isn't, but while shaking their hand, I find myself thinking about something else in the back of my mind. I wonder if, by the very fact that this "thank you" is being born, I had already failed.

If I had taken action sooner, perhaps this person wouldn't have needed to thank me in this way.

When you work as a doctor, a strange thing happens: the moments you are thanked are the moments you feel most guilty. Being told "thank you" strongly usually happens after something has already fallen apart significantly.

This feeling was perfectly articulated by a Chinese person over 2,300 years ago.

Bian Que said he was the worst doctor of all

There is a legendary master physician named Bian Que. The "Records of the Grand Historian" and the "Han Feizi" contain dramatic anecdotes about him, such as reviving a dying crown prince or diagnosing an illness just by looking at someone's complexion.

There is a story about this Bian Que. King Wen of Wei asked him,

"I hear all three of your brothers are doctors. Which one is the most skilled?"

Bian Que replied immediately, "The eldest brother is the best. The second brother is second. I am the worst."

King Wen was surprised, as Bian Que was the only one known throughout the land.

Bian Que continued: The eldest brother cures illnesses before the symptoms even appear. Therefore, no one realizes he has done anything. His name does not even leave the house. The second brother cures illnesses while the symptoms are still very minor. Therefore, his name does not leave the village. I, however, pierce the blood vessels with needles, use strong medicine, and cut open the skin after the illness has become severe. That is why my name is known even to the feudal lords.

The more skilled the doctor, the more anonymous they become.

The moment I read that, I felt I understood a little bit where that guilt during a handshake comes from. The times I am thanked are when I have done the work of the "third brother" in Bian Que's story.

Modern medicine is almost entirely the third brother

In outpatient care, the work of the third brother is easily evaluated. When a patient with an HbA1c of 7.5 tries to improve their lifestyle and it doesn't go down, I prescribe medication. When someone with an LDL over 160 talks about their diet and it still doesn't return to normal, I use statins. When someone with blood pressure over 160 comes in, I have them measure their home blood pressure and adjust their antihypertensive medication. Of course, this is important work. I use medicine and tests without hesitation when necessary.

However, this is all work done to extinguish a fire after it has grown large. Ideally, I would have wanted to stop it before it caught fire.

If I were the eldest brother, I would have taken action before it reached this point. At a stage where even the patient themselves wouldn't have noticed. Even though that would be overwhelmingly better for the patient. So, am I properly acting as the eldest brother? This is where I lack confidence.

The day I couldn't become the eldest brother

A few years ago, I was looking at the health checkup data of a business owner and noticed that their blood pressure and lipids were gradually worsening. I noticed it. But I couldn't step in.

I said something like, "Let's be a little careful." But the person was clearly busy and kept checking their watch during the consultation. That day, the outpatient clinic was backed up, and there were still many people waiting behind them. I didn't have the courage to say, "If things continue like this, you'll be in danger in five years."

If I had been tracking the decline in the numbers, I should have proposed changing their lifestyle much earlier. But I made excuses for myself, thinking, "It's still barely within the standard range" or "The person themselves has no subjective symptoms."

Even Bian Que had a king who would not listen. It was Duke Huan of Qi, who appears in the Han Feizi.

Bian Que looked at Duke Huan's complexion and said, "You are ill. It is currently in the striae (the surface of the skin), but if you do not treat it, it will go deeper." Duke Huan replied, "I am not ill," and ignored him. After Bian Que left, he remarked to his attendants, "Doctors love to treat people who aren't even sick just to claim credit."

Bian Que visited two more times, telling him the illness had progressed from his skin and flesh to his intestines and stomach. Duke Huan only grew more annoyed. On the fourth visit, Bian Que looked at Duke Huan's face and left without saying a word. When asked why, he replied:

"If it were in the striae, herbal medicine could have cured it. If it were in the skin and flesh, acupuncture could have. If it were in the intestines and stomach, there was still a way. Now that it has reached the bone marrow, there is nothing more I can do."

Duke Huan died five days later.

In this anecdote, Duke Huan, who wouldn't listen, is portrayed as the villain, as if he brought it upon himself, but this isn't really a laughing matter. Bian Que spoke clearly three times. When I look back, I wonder if I have been able to speak clearly to those business owners three times. It's highly questionable.

I believe that about half of what happens in outpatient clinics is not a problem of "patients who won't listen," but of "doctors who cannot explain it well enough."

Was Duke Huan's suspicion really wrong?

However, despite writing all this, I cannot say for certain that Duke Huan's words were entirely wrong.

"Doctors love to treat people who aren't even sick just to claim credit."

The medicine of the eldest brother (the best doctor) has a weakness that is hard to put into words. If you take action before symptoms appear, you can never prove that you were right.

You intervene, and the person doesn't get sick. But no one knows if that was thanks to the intervention or if they would have been fine if left alone. Because a disease that never happens is invisible. It's tempting to end the story with the noble sentiment that "that is why the eldest brother is never thanked." But on the flip side, prevention always carries the risk of turning people who would have been fine on their own into "patients."

Therefore, drawing the line between good prevention and mere intimidation is harder than you think. Duke Huan's suspicion of Bian Que might have been a surprisingly reasonable precaution.

That is why I choose prevention that changes the environment

In the first place, a significant portion of illness, when looked back upon, is related to behavior. A 2024 analysis examining 88 risk factors across 204 countries found that over 41% of the global disease burden is attributable to risk factors, with the largest category being behavioral factors (smoking, diet, alcohol, lack of exercise, etc.). This means that over 40% of health damage could potentially have been avoided if behavior had been changed.

So, how do we prevent it? Instead of intimidating people and increasing tests, there is a form of prevention that changes the environment without forcing the individual to endure hardship.

Moreover, the evidence for this comes more from behavioral economics than medicine. A clear example is the Apple Watch study published in Science Advances in 2023. With over 160,000 people and over 76 billion minutes of behavioral data, a simple mechanism that "sends a notification after sitting for 50 minutes" increased the probability of standing up by up to 43.9%. I started doing this myself after seeing this, and I think all of humanity should do it. (I have summarized how to break up sitting all day while working inanother article.)

A single notification. Sometimes a watch vibrating once moves people more than a doctor lecturing for 30 minutes. It's frustrating, but I think it's quite true. If I were the eldest brother, I would definitely choose this. Not flashy medication or surgery, but setting up the environment so that the person feels like they "changed on their own"—that is just right.

The "prescription of the eldest brother" that I give to business owners

None of them are about prohibition; they are just about changing the first move.

Rearrange your refrigerator shelves.Put cut vegetables and boiled eggs at eye level, and place snacks in a spot that takes a little extra effort to reach. I'm not saying don't eat them. By just changing the order in which you reach for things, you barely feel like you're depriving yourself.

Turn off the color on your smartphone at 10:00 PM.Use iPhone automation to automatically switch to grayscale. When the color is gone, the pull of social media weakens. I'm not saying you must go to sleep. Just make the screen a little more boring. I suggested this to five people, and three have kept it up for over a month. Two dropped out, saying, 'I can still see it fine even in gray.' It doesn't work for everyone. (The data on 120,000 people showing that smartphones aren't bad for sleep because of blue light is something I wrote about elsewhere.)

Put your gym clothes out in the entryway the night before.Don't make yourself think about whether to go or not in the morning. The clothes are already out. It feels like more of a loss not to go after you've gone to the trouble of preparing. I haven't been training for 17 years through sheer willpower; I've just created a situation where it's more of a hassle not to go. ...Writing this, I realized that the eldest brother was probably like this too. He didn't even make his patients think he had 'cured' them.

All of these are modest. They aren't flashy treatments or superfoods. But the eldest brother's medicine is probably just like this.

The person who puts out the fire becomes invisible.

I think this kind of story isn't limited to medicine. In your workplace, too, doesn't the person who puts out a raging fire become a hero, while the person who made arrangements to prevent the fire from starting in the first place remains invisible?

The three brothers of Bian Que is a story about organizations and life, disguised as a story about doctors. The world is built to reward conspicuous interventions and make modest prevention invisible. The eldest brother is not unknown because he is unskilled. It is because humans are incapable of being grateful for things that never happened.

The value of prevention lies in 'usable time,' not medical expenses.

It is unreasonable to talk about the value of prevention in terms of 'lowering medical expenses.'

In reality, you cannot say that prevention will always lower medical costs. While some things, like vaccines, are clearly beneficial, expanding testing can sometimes increase the total cost. You cannot carelessly say, 'If you practice prevention, you will save money.'

That is why I use a different explanation for business owners: 'You will increase the time you can use in your 60s and 70s.' The response to this is quite good. Rather than whether you save a few hundred thousand yen in medical costs, it's about whether you can still go on business trips at 70. Whether your mind stays sharp in meetings. Whether you can travel with your grandchildren.

Health is not about reducing expenses. It is about extending the time you have available.

The best doctors should be forgotten.

When I was in elementary school, my father bought me Mitsuteru Yokoyama's 'Records of the Grand Historian' and 'Romance of the Three Kingdoms.' Back then, I just found the battles and strategies interesting. I never thought that decades later, I would be reminded of Bian Que's eldest brother in my own clinic.

I call myself a personal doctor for business owners, but my ideal is slightly contradictory. When someone doesn't have a heart attack 10 years from now, it's better if my name doesn't come up as the reason. It is best if no handshakes or 'thank yous' ever occur.

However, the eldest brother had a weakness. He couldn't pass his knowledge on to anyone. No matter how excellent the prevention is, if it isn't put into words and only reaches the one person in front of you, it disappears along with your name. That is why I write on note and X.

I want to deliver the move to make before getting sick not just to the one person sitting in the clinic chair, but to those beyond them as well. The work of the eldest brother that you can do today is nothing grand. Change one shelf in the refrigerator. Make your phone screen black and white at night. Put your gym clothes in the entryway. Try lining up your health checkup results with last year's numbers. That is enough.

A move that no one praises can sometimes quietly save your future self 10 years from now.

Thank you for reading this far.
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For those who want to know more deeply (Related articles)

I'll leave two articles here if you want to actually practice 'the eldest brother's medicine' with your own body.

▼ How to read your own health checkup results like the eldest brother
Why you shouldn't just end withall A'son your health checkup (Free) This is a method for making the move before you get sick using your own health checkup results. Even if you have all A's, if you line up your triglycerides and HDL next to your LDL and compare them with last year's numbers, you will see the breakdown of your metabolism before it happens. It is a story about re-reading a paper that you usually just circle items on once a year as your 'annual physical balance sheet'.

▼ Things that are truly effective are usually modest
The top 10 self-investments with the highest returnsthat a doctor who graduated from the University of Tokyo medical schoollearned over 17 years (Free)

It is no coincidence that my eldest brother's prescriptions (the refrigerator, the color of your smartphone, gym clothes by the door) are so understated. Looking back on 17 years of self-investment, the flashiest things were the most wasteful, and the things that actually worked later on were surprisingly mundane. Whether in health or career, the things that work all share the same face.

Announcement regarding the membership 'Dr. Mosari Lab'
I run a membership program called 'Dr. Mosari Lab.' In my free notes, I write broadly about the steps to take before you get sick. In the lab, I go a step further and write about 'what to start with in your own specific case.'

• How to read your health checkup results so they don't just end with an 'A' grade

• The order in which to check your blood pressure, blood sugar, lipids, and sleep

• How to fix your lifestyle, as I actually discuss in outpatient visits as a primary care physician for business executives

• Member-exclusive Q&A bulletin board

For 1,000 yen per month, you get unlimited access to all articles. You can cancel at any time if it's not for you.

Note: This article is intended to provide general health and medical information and does not constitute diagnosis, treatment, or medical advice for any specific individual. If you have health concerns, please be sure to consult a medical institution. The author cannot be held responsible for the results of any actions taken based on the information in this article.

References

[Classics]
'Heguanzi,' Shixian Chapter 16 (Anecdote of the three brothers of Bian Que) / 'Han Feizi,' Yulao Chapter (Anecdote of Duke Huan of Cai) / 'Records of the Grand Historian,' Biography of Bian Que and Cang Gong (Biography of Bian Que, resuscitation of the Crown Prince, etc.)

GBD 2021 Risk Factors Collaborators. Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990–2021. Lancet. 2024;403(10440):2162-2203.

Mertens S, Herberz M, Hahnel UJJ, Brosch T. The effectiveness of nudging: A meta-analysis of choice architecture interventions across behavioral domains. Proc Natl Acad Sci USA. 2022;119(1):e2107346118.

Nazaret A, Sapiro G. A large-scale observational study of the causal effects of a behavioral health nudge. Sci Adv. 2023;9(38):eadi1752.