Doctor, Judge Thyself
I feel that the best doctors are the ones who are truly nonjudgmental. They can meet a patient where they are, and gently but firmly guide them along, whether with little tiny baby steps, forward two and back one, or big sweeping steps, onwards towards a healthier place.
I am not one of those doctors.
I’ve made patients cry. Not because I delivered any bad diagnosis, but because of my “you can make positive change” approach. I would like to say these are my overly enthusiastic attempts to empower my patients, but I don’t think that’s all true.
The truth is, I often feel frustrated, fed up, and, frankly, judgmental of the people who come in saying “I can’t do it.” And, I hate this about myself.
“I can’t” drives me CRAZY. I want to jump up and down and scream at the top of my lungs “YOU CAN, so get over it and let’s START TRYING!”
I want people to be motivated by the cardiovascular risk statistics I emphasize to them. I want to see people who are ready to roll up their sleeves and get working on the project. I want people to take my nutrition advice. I want people to get up and move.
“I can’t lose weight no matter what I do.”
“I don’t have time to exercise.”
“I can’t quit smoking, I’ve already tried.”
These types of statements make my own heart rate and blood pressure rise. I feel myself getting worked up, ready to make my stand, and essentially, spend alot of their visit time on this one issue. This is a huge commitment when you’re a primary care doc with twenty minutes to cover this AND the Gyn-y stuff AND the psych stuff AND the health monitoring stuff.
But by and large, I do it. I don’t wade in, I jump. I say:
“Okay. Tell me why you think you can’t do this. Let’s go over what you’ve tried. I may be able to help.”
Which really means:
“Let me flush out all your excuses, and then, I will shoot them down one by one.”
Some people, realizing that all of their perceived obstacles have been effectively annhilated, will actually feel empowered to move forwards. But some will just emotionally collapse, I think because they are not ready to make changes. Changes are scary… and excuses are like security blankets. And it’s kind of cruel to yank someone’s security blanket when they’re not ready.
How have I become so evangelical about effecting healthy change? Over these six years as an attending, I have seen a few of my patients make real, lasting, positive changes.
A few of those few have cited my excuse-squashing-go-go-rah-rah-you-can-do-it approach as instrumental to their success.
This would be, very few patients.
But, those successes are intoxicating. I can help people to get healthy! This is what I went into medicine to do!
But, also…. Doing a little self-analysis, I suspect that I get all up in arms over these “I can’t“s because I have been there. I have struggled with weight: Hey, I lost fifty pounds of post-baby weight. I struggle with prioritizing exercise: Hey, I work, and I have two kids. I have quit smoking: Hey, I smoked for many years.
What I have to realize, or better yet, to process and absorb, is that we’re all different. I lost alot of weight gained during my pregnancies, but my pre-pregnancy weight was healthy. I work out, but I have alot of support from my husband and family. I quit smoking, but I never smoked more than a few cigarettes at night. So, the things I have learned from my own experiences aren’t always going to apply to someone else’s.
I’m sure other providers have had the same issues controlling their frustration or judgment as they try to help their patients.
Don’t they?
Maybe sarcasm can be motivating….
I think it’s supposed to be more effective when patients come up with something to try on their own. I would probably walk out of your office wanting to punch you if you took your standard approach with me. And I’m sorry, you can’t honestly think that the challenges you’ve faced are even remotely equivalent to what a lot of your patients face. Come on.
I know, that’s why I’m writing about it. See the title?
🙂
Yes, it’s frustrating. It’s deeply frustrating. When I did my primary care fellowship, I realized that I was less frustrated than my colleagues because I didn’t expect my patients to quit smoking. I grew up in a family of smokers (including my father the cardiologist), and I knew that knowledge of the risks is not enough to motivate change. I spent most of my fellowship learning how to help patients with behavior change through motivational interviewing – so my version of your experience is that I want to jump up and down with my colleagues and say “YES YOU CAN DO THIS DIFFERENTLY” 🙂
Seriously – have you had any experience with motivational interviewing and brief interventions?
Hi Jay- I guess not enough, because I’ve always thought that’s what I’m doing.
In my experience, it’s more effective to talk about what works than what didn’t. It’s also helpful to figure out where they are. If they’re not ready to change, then let it go. The most frustrating thing is when you’re working harder than the patient is. There are some great resources here http://www.integration.samhsa.gov/clinical-practice/sbirt/brief-interventions
What a great post! Thank you!!
Last year I attended a seminar called “10 minute CBT”. It was a fascinating approach to dealing with exactly the scenarios you described. Instead of focusing on what a patient “can’t” do, re-framing the question to explore how positive change can be made appears to be more effective. The first step is called “Goalification”. http://www.cfp.ca/content/56/12/1312.full The idea is to transform the patients’ complaints into goals. No longer are you focusing on the negative. I’ve tried it a few times and it defintely requires practice.
Hey Dr. Mom, Thanks to you for providing this link! The descriptor is really good reading, actually enjoyable to read, especially the sample patient encounter. Like many things that come out of Canada, this approach is logical, practical, and, I bet, effective. I’m so impressed, I plan to turn this into a post…
If you can’t access all the articles let me know. I can print them or create a PDF and email if you need.
You are truly the best kind of primary care doctor out there. It is so hard to approach these issues, especially related to weight loss with patients because they can be so incredibly sensitive about it. But, we have to do it. We have to do everything and anything we can to get out in front of the obesity epidemic in this country. It is truly wonderful to see a patient transform as a result of your encouragement and cheerleading. Many of our patients are not ready to face the reality of their serious life-threatening health issues, but it is our job as physicians to start that conversation.
Hey, many thanks for the positive encouragement! I agree completely that we as physicians are obligated to take more action on this front, and I’m open to hear ways in which to do this more effectively. You in OB/GYN are often called upon to act as PCPs- I’m sure you’ve had to initiate these discussions too- Have you found anything that works well?
Well, I’m not sure I am much better at this than anyone else is, but here is some of my techniques:
1. Patient relationship is so important. Sometimes I will bring a patient back for a second visit to revisit the issue, especially since I may not have time to cover everything in a 20 minute visit.
2. Use of non-threatening language- I have found that the words “obese”, “overweight” and “morbid obesity” are offensive to many of my obese patients. Their eyes will glaze over before the conversation starts and I’ve lost them. So, I’ve tried introducing the concept of discussing weight and weight loss with my patients with kids gloves, first. Words like “fluffy” and “extra areas to love”, “extra fluff” sometimes help open the door a bit more and get the patient to relax.
3. It starts with food- too often, patients will tell me, “Doctor, I eat salad everyday and exercise, but no matter what I do, I can’t lose weight.” I ask the patient to write a log of everything and anything they put in their mouth for two weeks – EVERYTHING, from water to wine, from cashew to steak – with quantity as well. Sometimes the problem isn’t what they are eating, but rather HOW MUCH they are eating. It adds up, especially when snacking.
4. Start with smaller goals. Rather than throwing out “you need to lose 50 pounds in order to reach your goal”, I may start with “improving overall wellness by helping you make healthier choices for exercise and food”.
5. Patients want their doctor to care about them- “I care so much about your wellness”, “How can I help you feel better about your body and your weight, what kinds of things can I advise you on so that you have a healthier weight?”
6. “I exercise all the time and nothing is happening!” – what kinds of exercise? How much? How many minutes? What is your max heart rate and for how long? Let’s talk about that and try to get an estimate of how many calories you are actually burning when you do that.
7. Start with one meal a day and work from there. Breakfast is the easiest and I have a protein shake recipe I use that is filling, tasty and a pretty easy sell.
Good topic, and I appreciate the links others have posted about effective methods of behavior/thought change. I know we have not been taught how to address these issues, its something I’ve been thinking about, and wanting to learn more about so that I can do this in a way that 1) works (more often than it fails) and 2) doesn’t leave any of my patients in tears/rage (I’ve been there, with an OB provider during my pregnancy and I was so so hurt & angry that I never saw her again, warned all my friends away, and complained to the head of the division when I saw him for my next visit. i.e. she would’ve been better off keeping her mouth shut).
I deal with a lot of patients living in dire economic conditions, poor family situations, unsafe environments and food scarcity so saying “I get it, I’ve been there, here’s what I did you can do it too” is only going to put up a huge wall between us because I so don’t “get it”. Spouting off the research is certainly not going to change their minds, nor is my evangelizing about the miracles of exercise & calorie counting. Those things take time/knowledge/money/energy/support. I’m not sure the answer, I really want to do better here.
Its commendable that you care enough about your patients to want them to do this for themselves, but if its not working it definitely is worth investing some time into learning different approaches.
Every one, therefore, gives what he sees fit–certain prices being only tacitly understood as proper for certain men. The doctor is supposed to accept what is offered, and it is contrary to etiquette for him to remonstrate against the sum.