A patient once sat across from me in my exam room, glanced at the bookshelf behind me, and said, “Doc, I just don’t have your discipline.” He was looking at a copy of one of my first books, Dr. T’s Drop the Fat Diet, which features a before-and-after photo on the cover. The “after” image shows a six-pack I built through years of focused effort. To him, that cover was proof of some inherent difference between us, a determination or strength of mind he assumed he simply didn’t have.

He had no idea how wrong that assumption was.

He only saw the well-built physician with a six-pack. What he couldn’t see was a kid who grew up believing he wasn’t built for this, and that this level of fitness would never be his. I came from a family that never valued exercise, where movement was an afterthought and carrying extra weight was simply accepted as a fact of life. Nobody around me was chasing fitness, or even interested in it. For years, I believed the message baked into that upbringing: I hadn’t been dealt good genes for physical fitness, and any effort I put in would be a fight against my own nature.

That patient looked at the cover and saw evidence of an innate disability in his own life. What it actually represented was decades of unlearning deeply ingrained beliefs about my own body. It has taken me 35 years in interventional pain medicine, and even longer in my own personal transformation, to understand that both of us had misread the real forces behind our different outcomes and self-images.

In three decades of practice, I have never once met a patient whose health outcome came down to a simple lack of discipline. What I have met, over and over, are people who quietly gave up their sense of agency, attributing their situation to genetics, bad luck, or the belief that “this is just how I am.” Medicine often reinforces that resignation without meaning to. Terms like “noncompliant” and “nonadherent” get used clinically, but they carry a moral undertone, the implication that failing to change is a failure of willpower.

I don’t buy that. Discipline was never the missing piece. Agency was.

That distinction matters more than it might seem. Discipline is usually treated as a fixed trait, something you either have or you don’t. Agency is different: It’s the recognition that, whatever your circumstances, you still get to choose your next action. Discipline hands down a verdict. Agency offers an opening.

This isn’t just a reframe I find useful in the clinic. The research backs it up. A six-month exercise intervention in previously sedentary men found that sustained training reshaped DNA methylation patterns across thousands of genes in human fat tissue, altering the activity of genes tied to metabolic function. A broader review of physical activity and disease prevention reaches the same conclusion: Exercise modulates gene expression through epigenetic mechanisms linked to metabolic syndrome, diabetes, and cardiovascular disease. And a recent synthesis of lifestyle-driven epigenetics found that diet, movement, and even mindfulness measurably shift the epigenome in ways tied to long-term disease prevention. Genes load the gun; behavior pulls the trigger, and the newest evidence shows that the trigger gets pulled at the molecular level, every single day.

I know genetic fatalism firsthand, not just as a clinician watching it in others. For years, I believed my family’s patterns of weight and inactivity were simply my inheritance, a script already written. Patients tell me some version of the same story all the time: “My grandfather smoked and drank and lived to 100, so what’s the point?” I understand that logic, because I lived by it myself for a long time. But epigenetics offers a more useful frame: Inheritance sets the context; it doesn’t dictate the ending. Neither that patient nor my younger self failed because of our genes. We simply didn’t know we still had the power to write our own story.

Over the years I’ve built a simple framework I now walk patients through, not a discipline boot camp, but an audit of agency.

First, find a motivation that is specific and personal. Instead of “I should lose weight,” I ask patients to name what actually matters to them: keeping up with a grandchild without getting winded, walking a daughter down the aisle without needing pain medication, having the energy to travel, to garden, to walk the dog every day. Vague goals produce vague effort. Specific motivation creates ownership.

Second, name the inherited beliefs running the show. Many patients are operating on assumptions they never actually chose: “I’ve always been the heavy one in my family,” “exercise isn’t for people like me.” These beliefs feel like facts, but they’re usually just habits of thought, absorbed rather than examined.

Third, deliberately choose new beliefs to replace them. This is agency in its most clinical form: actively selecting a self-concept instead of passively inheriting one. A patient who believes their genetics and choices can work in their favor behaves differently from one who believes they’re destined to struggle.

Fourth, commit to the process without treating it as a temporary experiment. Discipline tends to fade the moment it’s treated as a mood-dependent state. Agency is different: It’s a decision that has to be renewed daily, whether or not motivation shows up. Setbacks are guaranteed. Hard days are universal. Choosing agency doesn’t make the struggle disappear; it just means coming back to the process again, especially on the days it would be easier not to. You don’t need to feel ready. You just need to be willing to choose again.

None of this replaces medical care. Chronic pain and structural injury are real, and I treat them with the full weight of interventional medicine. Agency doesn’t substitute for treatment. It works alongside it, alongside therapy, alongside every intervention and every follow-up. It gives patients a real stake in their own recovery. Every plan I build rests on both clinical expertise and the recognition that how a patient sees their own capacity for change is itself a clinical variable, one that can move the needle on outcomes as much as any procedure or protocol.

If that same patient sat across from me today and nodded at that book on my shelf, I’d answer him differently than I might have years ago. I’d tell him about the “before” picture he never saw, the home where exercise didn’t exist and extra weight went unremarked. That cover was never proof of a genetic advantage. It was proof that where you start doesn’t determine where you end up.

None of us chooses our genes, the home we grow up in, or the beliefs about our bodies handed to us as children. But every one of us gets to choose our actions, today and every day after. That’s not discipline. That’s agency. And unlike a diagnosis or an inheritance, agency is the one thing that can’t be taken from you.

After 35 years in practice, I’ve stopped asking patients to find their discipline. Instead, I ask them to recognize the agency they’ve had all along, and to use it as the path back to a healthier self.

Francisco M. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine and can be reached at Florida Spine Institute and Wellness. 

Dr. Torres was born in Spain and grew up in Puerto Rico. He graduated from the University of Puerto Rico School of Medicine. Dr. Torres performed his physical medicine and rehabilitation residency at the Veterans Administration Hospital in San Juan before completing a musculoskeletal fellowship at Louisiana State University Medical Center in New Orleans. He served three years as a clinical instructor of medicine and assistant professor at LSU before joining Florida Spine Institute in Clearwater, Florida, where he is the medical director of the Wellness Program.

Dr. Torres is an interventional physiatrist specializing in diagnosing and treating patients with spine-related pain syndromes. He is certified by the American Board of Physical Medicine and Rehabilitation and the American Board of Pain Medicine. He is a prolific writer and primarily interested in preventative medicine. He works with all of his patients to promote overall wellness.