It's just easier
So, today, I read two really interesting articles on Medscape. It's a medical news site.
The first was an interview with a psychiatrist regarding Binge Eating Disorder (BED).
The article, if you're interested, is here: http://www.medscape.com/viewarticle/843620_3
The next was about how doctors tend to fail to prescribe lifestyle interventions for patients.
If you're interested in that article, you can find it here: http://www.medscape.com/viewarticle/843028
The reason I found both of these articles interesting and thought provoking (other than the topics themselves) was the comments. I know, I generally have a "don't read the comments" approach to the internet. However, on a medical news sites, the comments are not always the usual fights and flame wars and vitriol.
What I found was disturbing to me as a physician. Now, certainly on there were comments that congratulated the author on a great write up, agreed with the sentiments therein, etc. However, there are always those "people need to be responsible for themselves, stop telling them 'it's not their fault'" type of comments, and these were present on both articles. Here's one that is a bit harsh, but more or less sums it up:
Maybe if we didn't live in a country who's population had been indoctrinated with the mentality that everything is someone else's fault and the complete lack of personal responsibility is accepted, as well as nonsensical insurance and government rules and regulations of how we practice..... we MAY have something to talk about. And why is it a physicians responsibility to teach patients lifestyle changes? If patients spent 1/2 as much time using the Internet to educate themselves on a healthy lifestyle as they did jacking around on Facebook and candy crush this wouldn't be an issue...... But then again ignorant sheeple are so much easier to manipulate and control....
Wow, huh? Now, I get it about insurance and regulatory burden on physicians. Although I have yet to see any regulatory burden that prevents me from counseling my patients. When I was in a traditional office, having to see 28 to 32 patients per day, I used a system called wave form scheduling. It basically front loaded every hour, with two 30 minute appointments and four 15 minute appointments every hour. It also relies on having more than one exam room available (I had 3 or 4 at the time I was using this schedule):
9:00 30 minute complete physical (room 1)
9:00 15 minute sick visit/follow up (room 2)
9:15 15 minute sick visit/follow up (room 3)
9:15 15 minute sick visit/follow up (room 2)
9:30 15 minute sick visit/follow up (room 3)
9:30 30 minute new patient/sick visit (not a physical). (room 1 if it's available or room 2)
Did I always run on time with this system? No, of course not, but the nature of the types of appointments I was scheduling and controlling when they were seen allowed me to have a bit of a buffer each hour to catch up and never really run more than 20 minutes behind. It is possible. You just have to be willing to be flexible and creative with your time and schedule.
The point that I make here is that, despite being pressured to see more and more patients, I managed to create a schedule where I could see patients for more than 10 minutes if it was needed. I could spend a little extra time with counseling and lifestyle management issues for those who needed it. I was also willing to tell patients, "Hey, I think we should talk more about this, but we're out of time today, can you come back in a couple of weeks?" and make sure to put them in one of those 30 minute time slots.
Look, I'm not trying to brag that I am somehow a perfect doctor, I know that I am not. I know that I'm not the smartest or even the best, and there are plenty of things I can learn to do better. I also know that there are great docs out there who ARE counseling their patients about lifestyle choices. It takes 3 minutes to ask a patient if she feels out of control when she eats. It takes only a couple of minutes to find out what a patient routinely has for breakfast. It takes the willingness to ask the question and to hear the answer to open that door to lifestyle counseling with a patient.
I do not believe that this is about time or reimbursement. I think it's about perception: most of the docs I've spoken to who don't like to do lifestyle counseling don't like it because they believe that patients aren't capable of change. They don't like hearing excuses for why it's hard, or they don't like hearing patients say "I don't really eat that much" which is the lie that many of us tell ourselves. I once had a conversation with a cardiologist who said "sure you can tell them to lose weight, but they won't, I just refer them to a surgeon for gastric bypass. It's easier"
It's easier. Those 2 final words sum it up pretty perfectly: it's easier to blame the patient for being lazy and uneducated. It's easier to prescribe a pill or a referral to a surgeon than it is to be empathetic. It's easier to claim that there's not enough time in the day. It's easier to claim "I don't get paid for that." It's just easier.
Medicine isn't easy. It's challenging and constantly evolving. What doesn't evolve, though, is this: if patients see you take the time to listen, and if they really believe that you care, your words will influence their choices. Data have shown that patients are more likely to quit smoking if their doctor encourages them to quit. Patients are more likely to comply with their medications if the doctor explains how to take them appropriately. Patients are less likely to sue if they believe a doctor cares about them, even if the doctor makes a mistake.
So, to my colleagues, I say this: stop blaming falling reimbursements, stop blaming 'those fat, lazy patients', stop blaming full schedules. Take the challenge you signed up for. Listen to your patients, empathize with your patients, counsel your patients, and care for them. They will respond. They've come to you for help. Don't assume that they can't or won't take your advice. Be compassionate and caring and straightforward with them.
They can do it.
And so can you.