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Primary Care Provider/ Therapist

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.

How?

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…

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*Not the real name of course.

7 replies »

  1. My old chief of family medicine always maintained we’d all end up as shade-tree psychiatrists, and it turns out he was right.

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  2. I am curious – I also achieved/maintained great weight loss with a low carb (in my case, high fat/protein, not quite enough plant) diet. Have you shared this with patients and seen them take it up (or take on other changes)? Has your counseling helped anyone/many? … Just curious. … I had an interesting experience. I was told by my dentist I was a year away from seven cavities. We talked about what I ate and drank and he told me the single biggest thing I could do (besides increasing flossing) was cut the sugar out of my coffee. It’s not a lot of sugar, but I sip it slowly. … Anyway – it has been a few months and I don’t have sugar in my coffee and floss more. I am not sure he followed the scripted motivational interviewing. There was some scare tactics (in one year you WILL have cavities). But there was also give-and-take and open ended questions about what I do now. … Anyway, I am very sympathetic to the difficulty of lifestyle changes and the fact that the “pre-contemplation” phase can be quite long. I have fallen off the wagon and had to climb back on (dragging an extra 5-10 pounds) a couple times. … On the other hand, the relative ease with which I incorporated a simple change made me wonder. If we just offered one change (like cut out sugary drinks) would that be easier than a big lifestyle change? What is your experience with this?

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    • Thanks so much for the thoughtful comments! You know, you describe that the dentist spent some time talking to you; there was give and take and open-ended questioning; and based on the discussion you both had, he offered one potentially useful life change. I’d say the guy knows what he’s doing! How many dentists spend that kind of time? Or, maybe it didn’t actually take up alot of time.. I have found that it takes less time than I predict to review someone’s basic eating habits with them… I have seen patients take up the low-carb diet plan, and usually, they have some success. As you have experienced, maintaining is hard! I struggle sometimes as well, and am happy to share that with patients. Yes, I also think that offering one small easy change at a time is sometimes the best. I often suggest to someone that they cut out sodas first, if that’s what they drink. Or some other big easy target… But I am by no means any expert in this stuff. Love to hear what others do/ have experienced.

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  3. do you have a resource you give your patients for information on that diet? What takes time for me is to go through specifics, something I also don’t have the expertise to do (I am SO often asked “How many calories should I be eating/day”, which is so variable with kids, but even in adults should take into account current weight, activity level, pregnancy/nursing, age). I try to get a sense of what patients are eating and make 1-2 concrete suggestions for things to add or drop (drop juice/sodas/candybars, add 3 servings veggies) but an overall diet plan seems beyond what I can do. I wish I had a reliable source to send them to—there is a lot of crap out there that I don’t want them sucked into.

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    • I totally know what you mean. I avoid handouts and try to get a quick sketch of what someone is eating, what they like/ don’t like to eat, what their obstacles are, and what resources they have. If someone is really in need of alot of basic nutritional education I sketch out a sample diet plan and refer them to a nutritionist or to our cardiac prevention nutrition program (if they qualify- it’s kin dof like cardiovascular weight watchers, and very effective). Usually I just sketch out big do’s and don’ts (i.e. 3 meals/ 3 snacks; cut out all added sweeteners and flours; eat all plants, proteins, healthy fats, providing examples) . I often run into the limited-resource obstacle, but can even counsel around that (the frozen food section!!). The biger obstacle is the person who eats 3 fast food meals a day, has no idea how to grocery shop, and a phobia of preparing food….

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  4. Hi again. … Just to answer your question – you know what? That chat with the dentist took maybe 5 minutes. Probably less. Less than the time each of my future fillings will take, that’s for sure. And a laughably small fraction of the cost. If he saves me just one or two fillings I will be grateful. My dentist is nearing retirement. He is clearly in the mode of working to stay active and engaged and because he cares about oral health and helping people. I think it’s too bad that we have a system that pays us to do things 3/4 of the way. And that extra 5 minutes that very few health care providers spend would make ALL the difference. … How many times have I left a dentist office not really knowing how to brush and floss (he told me that too, also in a matter of a minute)? Every time. How many times has a dentist asked me about my diet before this? ZERO TIMES! And while my primary care doctors have generally taken a stab at lifestyle discussions it has always felt very perfunctory and check-list-y. Like, “okay, so you see a dentist, right?” – next question – … I think one open ended question would be great, maybe in addition to the checklist approach.

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