Me: (seated across from patient with BMI of 48%) So, tell me about your diet. What sort of things do you enjoy eating?
Patient: I don't eat anything really. Water in the morning, sometimes coffee. I have a salad with no dressing for lunch and maybe a carrot for a snack. Dinner is Lean Cuisine, more water. I never eat dessert. I drink water all day.
Me: ( smiling kindly) And tell me about what sort of exercise or activity you like and how often.
Patient: Oh, I walk for an hour every morning and go to the gym 3 days a week.
Me: I am confused here. That is a lot of exercise and not many calories- What do you think is going on with this 18 pound weight gain over the last month?
Patient: I don't know. I do every thing right... I just keep gaining.
Now, we all know that what this patient is saying is not likely true. Some of my colleagues would say that the patient is in denial. They are not aware of what they are eating and they mistake the intention to exercise with actually exercising. To some extent that may be true, but I think that the answer lies in their experience with their providers. I think most of the reasons have to do with what they expect to hear. Maybe they don't want to disappoint us. Maybe they don't want to hear from one more person what they already know. Maybe WE don't make it a safe place for them.
I will share some of the things that ARE working for me and my patients in some future posts, but today-I want to say that the trust and open communication that leads to changes in health behaviors and ,ultimately, outcomes does NOT happen in the 7 minute visit: It happens when I take the time to listen. It happens in the moments between the M.A. knocking on the door to remind me of my busy schedule and the patient understanding I believe they are important enough for me to listen to them.
That patient could be full of poop. It is the only explanation. Their bowels are obstructed. They are going to burst and they is going to get sepsis. They'll have to put her on a food pump and put their stomach into a coma. They won't be able to eat for years. Only food pump. I heard it on radio lab.
ReplyDeletehttp://www.radiolab.org/2012/apr/02/
That is an interesting explanation. I think some of us would agree that the patient is full of poop, but more figuratively than literally. I will have to listen to that radio lab, though. I don't get NPR well here in the desert. Thank you so much for reading and commenting!
ReplyDeleteI think that is universal in all fields, parenting included. We teach people to lie with the disapproving glances up from the chart and the superior attitude because we are wearing the "white coat". Really the professional is the GPS and the patient is the driver.
ReplyDeleteThis is a wonderful analogy, Stephanie. I tend to emote all over the place with facial expressions and other body language. I can walk in the room and say "Hello-I am Doe, a family nurse practitioner" with what I think is a smile, but my body language shows when I am hurried. Sometimes, I AM feeling judgmental. I look down at the 79 pound 3 year old with most of their teeth capped and I have an opinion. I have to breathe, say a silent prayer and ask myself if saying aloud what I am thinking is going to help that child. I have to watch my tone and when I don't- when I let it my annoyance show- that mother shuts down. So, I can direct us down a road to help that child, or I can run us into a dead end. I work hard on not having that "superior attitude" But I am a work in progress.
ReplyDeleteThank you so much for taking the time out of your equally busy schedule and to comment.
I was doing a play on words with the full of poop. I didn't want to use expletives on your blog though.
ReplyDeleteThank you for that Nico. I had wondered if it were Ramses posting. I look forward to all of your comments. I hope you become a regular here.
ReplyDeleteA lot of it is asking questions to which the answer is obvious is asking them to tell you something other than what is known. Dorothy used to tell me to not give Ramses the opportunity to lie by asking him questions to which I already knew the answer.
ReplyDeleteJose, you are spot-on in this comment. I try not to ask the morbidly obese patient IF they overeat, but I ask what is there biggest temptation or weakness. I don't ask smokers IF they smoke but how much. Sometimes- I am more direct, depending on the patient. I sometimes use humor. Sometimes that motherly tone. Sometimes, I let it go. Many times I give them a visit or two to feel comfortable.
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