I was driving in a neighboring town last week, and I noticed a sign on an office building:

Metropolis Primary Care and Counseling: Your Medical and Psychological Resource*

I chuckled to myself. Brilliant! Of course, why not put it right out there. Possibly 75% of my job as an M.D. is psych. I don’t know if this Metropolis practice is one doctor, or a group that provides both services, but it makes total sense to me either way.

At the root of so many primary care office visits are depression, anxiety, insomnia, stress, addiction… Of course we internists do a lot of basic prescribing, counseling, and referrals around these bread-and-butter psychiatric issues.

But, I feel like I need to wear a therapist hat even when dealing with “pure” medical issues.

Let’s take heart disease, the number one cause of death in the US and the world. Per the CDC, 50% of Americans have at least one major risk factor: smoking, high blood pressure, high LDL cholesterol. For most patients, these major risk factors can be improved or even cured without using medications at all. The other risk factors: diabetes, obesity, inactivity, excessive alcohol intake- same thing.


Lifestyle changes.

We can safely and accurately tell most of our patients with one, two, three, or more of these diagnoses that they can reduce or reverse their heart disease risk by simply quitting the smoking, cutting down on the drinking, eating a heart-healthy diet, exercising, and losing weight.

It sounds so easy. Just tell people what will likely happen to them if they don’t change their ways, and they’ll change! All they need is information, data, facts, and the the right meds, resources, followup.

Yeah, right. We all have the patients who still smoke/ eat fast food three times a day/ don’t move at all, and don’t take their Statin/ antihypertensive/ insulin despite their stroke/ MI/ grafted arteries.

It can be depressing. And though I know change is hard, I believe we docs can help make it happen.

Yes, some of it is in providing drugs and data. We can prescribe medications to help people quit smoking or drinking or binge-eating (they’re called antidepressants), and lower the cholesterol, blood pressure and blood sugars. We can offer referrals to various resources: psychiatry, therapy, nutrition, preventive cardiology. We can talk diets. Me, personally, I LOVE talking diets. I believe in the low-carb high-fiber plant-based diet. I know this diet, I live this diet, I lost fifty pounds on this diet. I can write it out for people, show them the apps I use to help me maintain, offer  followup appointments for weigh-ins, give suggestions for staying motivated…

But, to really delve into where a patient is at, to understand and connect with the patient, in order to help them take the next baby step towards a positive health goal… that is really hard.

I think we internists can absolutely help people make significant behavior changes. I think it takes a lot of skill, time, long-term followup, and belief in the process. Kind of like good psychotherapy.

I am most definitely NOT a therapist, and in my four years of residency and three years of fellowship, I never expected that this would be the bulk of what I do. I remember that in training, we had some instruction in effecting lifestyle changes; I even remember a module on motivational interviewing.

But I feel like I need a lot more… like a PhD in counseling psychology.

I have patients who have made amazing life changes. A few give me some of the credit, and this is SO professionally satisfying.

And, this is one reason why we docs need more time talking with patients, and less time typing everything into the computer or struggling with horribly designed lab ordering and billing software. But, that’s a whole other post…


*Not the real name of course.