The previous blog was written somewhat tongue-in-cheek, but a judicious application of financial rewards and penalties would undoubtedly work to make patients give up unhealthy habits and take up healthy ones. Just think how the percentage of drivers who used seatbelts increased once tickets were issued for being unbuckled. In the same vein, if the penalty for jaywalking were a $1,000 fine, we would certainly see less jaywalking and, pari passu, fewer pedestrian deaths. In Arizona motorcyclists wear helmets, but in Utah, where there is no such law, most "donorcycle" riders do not. So how can doctors reach patients, to educate them and to change their habits, bearing in mind that most patients with unhealthy habits (e.g. smoking) know that the cigarette habit mitigates against a long or a healthy life, and will further cause them to be a burden to their loved ones and their relatives?
I have long been convinced that our human brain is geared to avoid immediate (in the next 10 seconds) threats rather than time-distant threats. Hence "a bird in the hand is worth two in the bush", but "a stitch in time saves nine" is less frequently quoted. No one thinks that cigarettes are good for you. Even before the current studies directly linking cigarette smoking to an increased risk of heart disease, chronic emphysema and lung cancer we called them "coffin nails". But no cigarette smoker thinks that the cigarette that he or she is smoking right now will kill them, and that is precisely the problem.
In a similar vein, no overweight patient fails to notice the increase in weight, or thinks that that overweight is healthy. I have repeatedly told my overweight diabetic patients that they could cure their diabetes or at least diminish the amount of medicine they take by losing weight, but to no avail. Why doesn't the average human, after noticing an increase in belt or dress size go on an immediate diet? The majority of dedicated dieters in my practice are men after their first heart attack, which is really locking the barn door after the first horse has left.
If there is an immediate reaction to improper eating, then of course patients are careful. So patients with a peanut allergy, or lactose intolerance or celiac disease (gluten sensitivity) are very careful eaters. But even with the posting of the amount of calories in a given serving (this study was done in Taco Bell in Los Angeles) patients do not decrease the total amount of calories they eat. Why?
When patients measure their blood pressure or blood sugar at home, they usually repeat the measurement several times to get a "good" number to show the doctor. Many patients swear that they eat nothing and can't understand their failure to lose weight, but when I ask them to write down everything they eat in a daily diary and then tally up the calories for them, they are invariable surprised. Maybe that is why the only proven method of sustained weight loss is surgical: stomach bypass surgery or stomach banding.
Whenever I poll my medical residents, more than half of them stopped taking their antibiotic prescription before the bottle was empty. One study showed that 25% of patients who leave the doctor's office with a prescription never fill it, and of those who do dill it, 25% place the bottle in a drawer and never even take the first pill. The majority of patients believe that the more medicine they take, the sicker they are, so they try to taper or omit their doses of medicine, a habit that can have tragic results in an asthmatic or a hypertensive patient. What I am driving at is that it is not the lack of patient's disease knowledge or lack of patient education by the physician that is the problem, nor is it a lack of government guidelines. Rather, people just don't seem to think that the medical advice applies to them, or that failure to follow their doctors' advice will have negative consequences.
We all have had patients who have suddenly decided to give up smoking, or to lose weight, or to exercise, and we can certainly help them in this task. But no one, not even even the patients themselves, knows what made them "throw the switch" and adopt a healthier life style. This is the real problem facing public health: how to motivate the population to act in healthier ways, and neither blaming the patient population for being ill-informed nor simply telling to give up unhealthy habits seems to be the answer.
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Your piece shows perception and common sense, as usual. Humans will move through the Stages of Change model sequentially, and in my experience as a primary care doctor, the only stage you can shoot for at a given time is the nearest one in the direction you want to go. If they're thinking about it, you can help them move to planning it. If they're planning it, you can encourage them to put the plan into action. In the absence of a motivating heart attack, you just can't move a patient from ignorance and denial to action, skipping all the steps between. I would use "turning the dial" as a better analogy than "throwing the switch". Best wishes.
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