A Country Doctor Writes:

So many primary care patients have several multifaceted problems these days, and the more or less unspoken expectation is that we must touch on everything in every visit. I often do the opposite.

It’s not that I don’t pack a lot into each visit. I do, but I tend to go deep on one topic, instead of just a few minutes or maybe even moments each on weight, blood sugar, blood pressure, lipids, symptoms and health maintenance.

When patients are doing well, that broad overview is perhaps all that needs to be done, but when the overview reveals several problem areas, I don’t try to cover them all. I “chunk it down”, and I work with my patient to set priorities.

What non-clinicians don’t seem to think of is that primary health care is a relationship based care delivery that takes place over a continuum that may span many years, or if we are fortunate enough, decades.

Whether you are treating patients, coaching athletes, raising children or housebreaking puppies, the most effective way to bring about change is just about always incremental. We need to keep that in mind in our daily clinic work. Small steps, small successes create positive feedback loops, cement relationships and pave the way for bigger subsequent accomplishments.

Sometimes I avoid the biggest “problem” and work with patients to identify and improve a smaller, more manageable one just to create some positive momentum. That may seem like an inefficient use of time, but it can be a way of creating leverage for greater change in the next visit.

I actually think the healthcare culture has become counterintuitive and counterproductive in many ways; it helps me when I focus intensely on the patient in front of me, forgetting my list of “shoulds” (target values, health maintenance reminders and all of that) and first laying the foundation for greater accomplishments with less effort in the long run.

Six months ago I wrote this about how I try to start each patient visit. And in my Christmas reflection seven years ago I wrote about the moment when a physician prepares to enter an exam room:

I have three fellow human beings to interact with and offer some sort of healing to in three very brief visits. Three times I pause at the doorway before entering my exam room, the space temporarily occupied by someone who has come for my assessment or advice. Three times I summarize to myself what I know before clearing my mind and opening myself up to what I may not know or understand with my intellect alone. Three times I quietly invoke the source of my calling.

It’s all about the patient, the flesh and blood one in front if you in that very moment and what he or she needs most from us today. In physics I learned that you get better leverage when your force is applied a greater distance from the fulcrum. In human relationships and in medicine it is the opposite; the closer you are, the greater leverage you achieve.

I scribbled my signature on a pharmaceutical rep’s iPad today for some samples of Jardiance, a diabetes drug that now has expanded indications according to the Food and Drug Administration. This drug lowers blood sugar (reduces HbA1c by less than 1 point) but also reduces diabetes related kidney damage, heart attacks, strokes and now also admission rates for heart failure (from 4.1% to 2.7% if I remember correctly – a significant relative risk reduction but not a big absolute one; the Number Needed to Treat is about 70, so 69 out of 70 patients would take it in vain for the heart failure indication. The NNT for cardiovascular death is around 38 over a three year period – over a hundred patient years for one patient saved). There are already other diabetes drugs that can reduce cardiovascular risk and I see cardiologists prescribing them for non-diabetics.

It’s a bit of a head scratcher and it makes me think of the recently re-emerged interest in the notion of a “Polypill” with several ingredients that together reduce heat attack risk. The tested Polypill formulations are all very inexpensive, which is a big part of their attraction. Jardiance, on the other hand, costs about $400 per month.

The “rep” asked whether this medication would be something I’d be likely to discuss with my diabetic patients.

“Well, you know I’ve only got fifteen minutes…” dampened his expectations. But I told him about the Polypill studies. I think patients are still not ready to make the distinction between on the one hand medications that treat a more or less quantifiable problem like blood sugar levels, blood pressure or the much less straightforward lipid levels and on the other hand ones that only change statistical outcomes. Most of my patients have trouble wrapping their head around taking a $400 a month pill that doesn’t make them feel better or score a whole lot better on their lab test but only changes the odds of something most people think will never happen to them anyway.

I’m a simple minded person in some ways, I guess, but it helps me in my patient interactions to distinguish between what we know with decent certainty and what we think is a good probability and also between what tangible benefit a treatment can be expected to offer as opposed to just some statistical advantage that means nothing if you draw the shorter straw.

It almost makes sense to think of a two tiered approach to healthcare: some people truly want every statistical advantage and pharmaceutical intervention possible while others just want to treat what they can see or measure, and I think we have to figure out where each patient falls on the spectrum between those opposites, or we will overwhelm and lose patients and see them give up on everything we might have to offer.

Whichever approach patients take requires their commitment and determination and we need to listen carefully for clues about their beliefs and willingness to treat. There’s no point in prescribing anything in a half hearted way, because treatment adherence isn’t likely to be very good then. And doing a hard sell to a disinclined patient in fifteen minutes along with many other things we need to cover is a pipe dream and a guaranteed turnoff.

So, and this is a thought I’ve developed working with horses: Doctors shouldn’t be horse whisperers, nor should horse people. People have looked at this from the wrong vantage point. You don’t whisper to the horse so it will do what you want – you must first listen to the horse, and then, once you know how the horse feels about things, you can whisper your suggestion. And because the horse trusts you and knows you’d never suggest anything that is completely against its nature, the horse is likely to follow your low key, “whispered” suggestion better than a harsh command.

But listening comes before whispering, in horsemanship and in healthcare.

We knew that the most powerful way to provide substance abuse treatment is in a group setting. Group members can offer support to each other and call out each other’s self deceptions and public excuses, oftentimes more effectively than the clinicians. They share stories and insights, car rides and job leads, and they form a community that stays connected between sessions.

Participants with more experience and life skills may say things in group that we clinicians might hesitate saying, like “Now you’re whining” and “Time to put on your big boy pants”. They can become role models by being further along in their recovery and by at the same time revealing their own fear or respect for the threat of relapse.

What has also happened in our clinic, entirely unplanned, was that after an informational meeting where we explained the group model and had a national expert physician speak about opioid recovery, several parents raised their hand and said there should be a group for families, too.

We listened and within a few months we started such a group and now, a year and a half into it, the group is co-led by a few of our patients, who naturally had become leaders of the patient group earlier.

There is magic in having these more experienced patients explain to our sometimes bewildered parents and family members how the addicted and recovering mind works, not from having seen it a hundred times, like the clinicians, but by actually having lived it.

The positive feedback and appreciation of this, our “Friends and Family” group has elevated these experienced patients to a mentor role now also for the families trying to be the most help for their loved ones in recovery.

Our biweekly conversations are turning the spotlight on the small and large victories that come with recovery and have put the challenges in perspective through stories of the ultimate successes these mentors have had themselves.

This week, my Tuesday patient group and the Friday Friends and Family group will be held without the two clinicians who usually run the groups and also without our medical assistant, who herself plays a crucial role as both confidant and voice of the program. A stand-in clinician and a covering medical assistant will be there and I will be there virtually as usual through video conferencing.

The glue that will hold everything together will be our informal peer counselors, and I have no doubt the groups will continue as if nothing had changed because of the momentum these folks have brought to our endeavors.

They know how much they mean to all of us. By sharing the experience of their own recovery, they have breathed irreplaceable life into these groups to sustain them even if some of the facilitators are on vacation.

The Swedish word for physician is läkare, which literally means healer. That seems a lot more glamorous than the American word physician, which is derived from physic, the old fashioned laxatives that were thought to rid the body of poisons and impurities. But we are actually the healers a lot less often than we think.

The more we learn about how the body works, the more we have to admit that rather than us doctors, it is each patient that heals themself with at most some guidance from us.

We may recommend a change in diet, but we aren’t there to watch what our patients make of the advice we give them. We may prescribe a medication, but we know that many of the standard treatments in our armamentarium are only marginally better than placebo, and we now understand a little bit about psychoneuroimmunology, so we have to admit that patient expectations greatly influence the efficacy of treatments, even surgical procedures. We have learned this from sham knee operations for meniscal problems, for example. Imagine that, placebo surgery, not just pills.

This goes all the way back to the words of Hippocrates: “Let food be thy medicine and medicine be thy food”, “Walking is man’s best medicine” and “The natural healing force within each of us is the greatest force in getting well”. These quotes seem especially relevant in our struggle with the chronic diseases of the times we now live and practice in – heart disease, diabetes, arthritis; all of them at least in part autoimmune in their pathophysiology. If he body can attack and destroy itself, it also has the potential to do the opposite, to heal.

Our job, then, is to provide basic medical care AND to inspire, empower or whatever one calls awakening the self healing potential that a good diet, physical activity, good sleep, healthy relationships, care of one’s emotional needs and a good measure of faith, trust and optimism can ultimately bring about.