Tuesday, January 18, 2011

Helping Patients to Improve Their Health ?

     There has been a lot of press and discussion about how giving patients more information about their health and healthy habits in general will improve their health, but I have never seen much evidence of this. In fact, a recent 13-month study of Taco Bell, which posts the calorie count of each item in its menu, showed that customers did not decrease their total caloric intake. It's somewhat similar to smokers smoking a greater number of low-nicotine cigarettes to get the same total nicotine effect, or people eating more of a low calorie food. I also can't see how having all their electronic medical records will give them healthier habits.

     Every adult knows (or at least is told by his doctor and government authorities) that he/she can become healthier by stopping smoking, losing weight, and exercising, with very little effect on their habits. In all my years of practice I have  never been able (even with the help of a nutritionist) to get any overweight new onset diabetic patient to lose weight, even after I told them that the loss of 20 pounds would probably reverse their diabetes. In fact the only patients I have ever seen voluntarily and efficiently lose weight is men after their first heart attack. The heart attack removes their denial that they could ever get seriously ill. Most of them immediately go on a diet whose major component is eating fish 7 days a week. This works, but after 6 months I have to check their blood for toxic mercury levels. The only healthy habit my patients willingly follow is that of having a glass of wine daily, fish oil twice a day, and dark chocolate. This is probably because two of the three taste pretty good, and none of it seems like real medicine.

     The basic problem is that the human brain seems to be geared to avoid a life-threatening problem only if it is perceived to be imminent, i.e. to occur in the next 10 seconds, but not if the threat is 10 or 20 years in the future. So not every driver belts in, every cigarette smoker (and they know cigarettes are also called "coffin nails") intellectually believes that cigarettes may be dangerous, but also believes that the particular cigarette being smoked at this minute will not be lethal. Every adult understands the dangers of unprotected sex, but 25% of my college student patients (male or female) have unprotected sex at least once during college, usually when they are having sex with someone who is not their usual partner.

     When I am medical ward attending, I poll my residents to see how many of them actually  finished the prescribed number of days for their last antibiotic prescription, and the answer is always fewer than 75% of them. I then ask them to sit down and talk with the next ward patient who refuses a test or a prescription and try to understand their reasons and motives, rather than immediately call for a psychiatry consult. Similarly, I have regular patients who have never had a mammogram, a colonoscope, a flu vaccine, etc. However, I can usually get them to take a tetanus shot every 10 years after I explain that tetanus is usually fatal. (The same applies to yellow fever vaccine, but not always to malaria prophylaxis.)

     Many patients also try to appear healthier than they are. I usually have my diabetic patients initially do fingerstick sugars fasting in the AM and 2 hours after dinner in the PM 3 times a week. Once the  HgbA1C blood test became available (for you non-doctor readers, this is a measure of the average blood sugar for the previous 3 months) it was immediately evident that most diabetic patients either wrote down a lower number for their blood sugar than the test showed, or kept on re-doing the test until they came up with a number they liked.

     We all have patients that try to reduce (on their own) the amount of blood pressure or asthma medicine that they take, because they think that the more medicine they take, the sicker they must be. I explain that the important aim is to achieve control of the problem, and it is not sensible to expose themselves to the possible side effects of any medicine unless they take enough medicine to achieve our mutual goal. Sometimes they will skip some of the medicine and not tell me, hoping that it will not show up on my examination.

     In line with the above, patients with unhealthy habits know that their habits are unhealthy, and that their refusal to alter their habits is illogical. It is precisely because their behavior is not logical that telling them more than once or twice to change their habits is non-productive, and only causes bad feelings on the part of the advisor or advisee or both. Confrontation never works in such situations. The only exception I have ever seen is when an alcoholic  man's boss tells him to go and dry out for 30 days or else he will lose his job, the man dries out and stops drinking. This is because his job is intimately entwined with his ego. 

     This subject will be continued in a future blog.


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