A Country Doctor Writes:

A year ago this week, I made a stir with my post about five common weight loss myths. Today I had a patient conversation I have had so many times before: Someone was trying to eat healthier and lose weight at the same time. They are not necessarily the same thing.

This person was using flavored coffee creamers. I pointed out that they often have harmful fats, like palm and coconut oil, and chemicals that may not be good for humans to consume (corn syrup, trans-fats, milk protein [yet it’s called non-dairy], phosphoric acid [found in Coca-Cola, pesticides and fertilizer], mono- and diglycerides, sodium aluminosilicate [also known as feldspar, a ceramic glaze; it is explosive in powdered form] and proprietary artificial flavors). I even told her about Björn Gillberg, the Swedish chemist who in 1971 washed his shirt on TV with the powdered non-dairy creamer Coffee Mate.

“So what kind of creamer should I use?” She seemed flustered.

“Cream or half and half”, I answered. “They’re not all that good for you, but better than the alternatives.”

I pointed out that most of us want to do both things, eat healthy and achieve or maintain a healthy weight. But salmon, avocado, almonds and olive oil have calories, just like pizza, ice cream and Coca-Cola.

So it helps to prioritize a little. My recent patient, after some thought, wanted to attack the weight first. So my advice was about what to eliminate, rather than what to substitute it with. My point is that it makes little sense to skip the nightly ice cream and start eating yogurt instead if your number one objective is to lose weight. “Eat the real thing that you love, but only do it on the weekend”, I might say.

I scribbled down the math behind the lazy man’s guide to calorie counting, the theoretical 1 lb weekly loss if you eliminate 500 calories (kcal, to be correct) from your daily routine. I do it often enough I might save some time if I created a handout, but I believe in showing the math evolve on the paper as I talk – it’s more like telling a story.

Only after someone who wants to lose weight has eliminated some things do I discuss substitutions in earnest. People want to see results, and giving up ice cream, soda, donuts or beer brings results and makes people believe they can do it. Then, it makes more sense to talk about adding back something with fewer calories.

Like in so many other clinical scenarios, I like to “chunk it down” (see Leveraging Time by Doing Less in Each Chronic Care Visit) and to focus (see The Power of Focus): Reversing a disease process that has been going on for a long time is not usually something that happens quickly.

Five Weight Loss Myths I am Constantly Fighting

The other day I happened to talk with a colleague about our respective electronic inboxes. Office workers in other trades often spend their entire workday at their computers and sometimes the bulk of that time reading and answering emails that arrive in their inboxes. They do that because that is what they are getting paid to do.

Doctors and their employers basically get paid only when there is an encounter – face to face or via telemedicine, hardly ever when the exchange happens over the phone. Consequently, doctors, PAs and NPs are scheduled to see patients (generate revenue) all day long. Unlike office workers, we have no time set aside for managing our inboxes. Except for past payment models like HMOs and future reiterations of capitated care not yet in place, inbox management occurs at the expense of the employer or the medical provider. The general tendency is the latter – “between patients” (a post where I suggest the opposite – protected time for the inbox and then two MAs, more exam rooms and more efficient visits to make up for that computer time) or after hours without overtime or even regular pay because we are salaried.

Electronic inboxes are definitely burnout factors. I have found that medical organizations don’t have systems in place to manage this aspect of healthcare delivery. So it is typically up to each of us to figure out how we would want the flow to go. And we must then work with our support staff, whom we don’t supervise, to meet our patients needs without causing undue stress, interruptions, delays and confusion in our respective workdays.

A natural support staff response is to simply pass on questions and messages to the provider, like the title message. As a physician who generates the revenue that pays both me and my support staff, plus my bosses, I try to create a sense that my time on the phone or in the inbox needs to be as efficient as it possibly can, not because I am lazy but because I want to be efficient.

A lot of people in management are nervous about having unlicensed staff give medical advice. These are my thoughts on this: We need our staff to ask common sense questions and we need them to know when it is an obvious emergency. We can’t bottleneck everything by passing every request unfiltered to the provider – or we would have them answer every incoming call themselves already. (Or imagine a president with no admin support opening his own mail.)

We must allow and encourage all staff to use common sense. A person who has made it to adulthood, raised children or cared for a sick family member should and does know pretty well what basic self care is and what the doctor might need to know when you need advice. In the example above, why should the doctor be the first one to ask how long, what symptoms, getting worse or dragging on, what self care measures have you tried etc. See my post THE ART OF THE MESSAGE and the PowerPoint staff talk about common sense telephone triage I created a decade ago (where these slides are from).

When it comes to the most common requests, we have options: Websites, recorded messages on common topics, hyperlinks and things like that with generic advice on colds, sprains, allergies, child rearing and so on. The days are over when the family doctor was the ONLY source of medical information. 

My philosophy is that I need to mentor and support the people I work with to make them more than robot message takers. I explain what I need in order to make good decisions. If I get a good message I can give a simple answer that makes their job easier. If I get a sloppy or vague message, it will just be returned with my request for common sense information.

But I also encourage bypassing the back and forth messaging by having a running conversation: In my Van Buren clinic, my medical assistant/LPN and I share an office. This is a mixed blessing, but it allows exchanges like “Mrs. X left a message asking…” and I can say “If she says this, we’ll tell her to do A but if she says that, she needs to go to the ER”. I may still get a message about the outcome of that callback, but that is just to sign off, not to tie me up on the phone.

My support staff knows I don’t want to end up conducting visits on the phone that belong in the exam room or at least in a telemedicine session. If someone has an upcoming appointment and calls with requests for a new referral or a random blood test they’ve read about, I don’t even get a message – the patient is advised to bring it up in the next visit, or they can come in sooner.

Phone medicine isn’t just bad for the practice’s bottom line. It can also be bad medicine. A patient’s medical history is definitely the most important factor in making a diagnosis. But, very often, even the briefest of clinical exams can alert the physician to a patient’s over- or underestimation of the cause or significance of their symptoms.

It can be false economy for both the clinic and the patient.