Breaking Down Patients’ Barriers

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This story is from the Anamnesis episode called Winning in Medicine and starts at 16:04 in the podcast. It’s from Fred Pelzman, MD, medical director of Weill Cornell Internal Medicine Associates in New York City.

Following is a transcript of his remarks:

Defining success for a general internist in primary care practice is really interesting. We are different from, say, an oncologist or a surgeon. We don’t fix broken bones. We don’t remove body parts. We manage a lot of acute and chronic symptoms, chronic diseases. We have small successes. Certainly, we have big ones. We make diagnoses when no one else has been able to. We find a way to treat something that no one else has done. We help get medical problems under control.

But so much of what we do is longitudinal, and taking care of patients over years and years and years. It is what I think of as chipping away at things to help patients get to the place they need to be for their health moving forward.

We tend to not cure a lot of diseases, but manage and control them — getting patients to get to things like healthier diets and lifestyle, and smoking cessation, and completing healthcare maintenance topics, things that they need to do for their long-term health.

This is less sexy than some other fields of medicine, I think, in that no one donates $10 million to the hospital, because I ended up getting them a colonoscopy or their mammogram, even if it finds something. Those things are reserved for the neurosurgeons who take out the brain tumors or cure someone’s child’s cancer. But we make an enormous difference over the long-term of people’s lives by getting to a healthier place.

Getting patients to these small successes or large successes, a little bit at a time, is what most of our relationship is like with patients. We see them in the office. We communicate with them over email and the portal about their medical conditions and their concerns. We have an agenda, and they have an agenda. Sometimes the two don’t always agree, but we will continue to push people towards the healthiest behaviors that we think are the right things for them to do.

The Same Old Story

I was thinking, for instance, of a patient of mine who I have taken care of for probably more than 20 years now. Over the past decade, he has gotten a little less healthy in his diet and lifestyle, and has a strong family history of heart disease. His cholesterol has crept up over the decade.

At every annual physical, we’ve addressed this and talked about it. We would finish a visit, and we would check his blood test. We’d communicate about the results. He would always tell me, “This has been a challenging year. I have had a lot of stressors. I haven’t been exercising or taking care of myself as much. I have been using a lot more comfort food and so I wanted to work on making some healthy changes now, and then let’s recheck in 6 months or so and see where I am, and then I’ll consider taking medicine.”

Now, this all occurred in the context of his several family members, including an older brother, having had a heart attack. I sort of was more concerned as the years crept on. I got his blood test back at his most recent physical. His cholesterol was sky high and at a range that really warranted treatment.

I sent him a patient portal message and got the same reply back from him. “Let me make some changes. It’s been a difficult year. I have been turning to the foods that make me happy late at night. I’m going to really knuckle down and really make some big changes, and let’s recheck in 6 months.” I replied, “Okay, I’ll set up a future lab test and you can come in.”

Then I sat there and I thought to myself, “This sounds familiar.” I looked back at my visits with him in previous years and I called him on the phone. I said, “You know what, we just had this conversation, but I look back, and we’ve had this conversation 10 times, and 10 times you’ve said you’re going to make big changes, and 10 times you came back the next year and said, ‘This year, I’m going to be better.'”

We talked about that back and forth for a while, and he said, “You know what, Dr. Pelzman, I think I need to take the medicine.” He started on the medicine and tolerated it without any side effects, and now has a fantastic cholesterol profile that I think will serve him better over the next decade of his life and keep him out of trouble.

Magic in Medicine

At that moment when he agreed to take it, I felt like I wanted to bottle that moment and give it to all the rest of my patients. This is what we dream of. Look, I don’t dream of giving patients medicine. I’d rather do this without. But when we get to a point where I think things are needed, that this makes the most sense for someone’s long-term health, I want to do everything I can to get them to that place.

That magic that was him getting to the place of recognizing a pattern in himself — that while I may not have worn him down, I was finally able to break through by showing him that his best-laid plans had led to no significant improvement — was really powerful for me. I have actually told this to other patients and gotten them to agree that, no, they’re probably not going to make those changes that they have been talking about for a couple of years now. It’s really an interesting little way of getting people to move towards change.

I think the lesson of having a relationship with people and helping them see those patterns, and understand what that means for them, is the big picture here. That knowing that they can make these big promises for themselves, I think of it like New Year’s resolutions that we all make, having the ability to reflect on that over time, longitudinally, was able to let me help him get to a place where he was ready to make that change.

Breaking Down Patients’ Barriers

Getting patients to do some of the things that they have been resistant or reluctant to do is one of the biggest challenges we face. In a similar way, I’ll have patients who I have looked back and every year I have referred them to one or another form of colon cancer screening. Or I have ordered their mammogram over and over, and we’ve had a discussion of the reasons why these are a good idea to proceed.

There is certainly power in asking them at a particular visit when you notice they haven’t done something, “So, what are your barriers? What is the reason you think that you might not be going ahead with getting this done?”

Sometimes that has indeed helped uncover their own internal issues with going ahead with this. That’s sometimes fear of discovering a disease. It’s better to have that conversation now and go ahead with the test, and help us explain to you why we think the test is right to do when you don’t have symptoms than waiting until you have the disease. It’s much better to screen for something than chase down a symptom. I would much rather do a colonoscopy when you are totally asymptomatic and have it come back negative and we’re all really happy, than wait until you have constipation and abdominal pain, and a change in your bowel movements, and then we’re looking with more trepidation.

Having them miss a few colonoscopies is usually not so terrible if they are continuing to come and follow up, and we can make inroads to overcoming that resistance. There are certainly patients who have gone their whole lives and have never done some of these things. Many of them have no consequences, no bad outcomes. But some do and that’s the reason to screen.

There are patients that I have pushed for a recommended test like colonoscopy for many years. Some people agree right off the bat and some people need a couple of years to get to that place. Again, sometimes they are worried about the preparation. Or they had a friend who had one done and they had a complication and the like. Those are n’s of 1. That’s someone else’s experience and yours will be very different.

I have had patients who on their first colonoscopy have found colon cancer, large masses that needed to be resected. Those patients are really grateful. More patients have multiple polyps, premalignant lesions, that we were really glad that we got in there and found those out. They weren’t going to cause a problem now, but they were going to cause a problem in 5 or 10 years. Because this is a screening test, the vast majority of them have absolutely nothing and that’s what we want to have happen.

Other stories from the Winning in Medicine episode include “Early in COVID: A Win and a White House Call” and “A Victory for Cancer Prevention.”

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