Sunday, October 6, 2013

Doctor realizes she is no different from her patients when it comes to changing habits

From the New York Times, Dr. Danielle Ofri on the difficulty of breaking the habit of the annual checkup.

We doctors constantly lament how difficult it is get our patients to change their behavior. We rant about those who won’t take their meds, who won’t quit smoking, who never exercise. But the truth is, we are equally intransigent when it comes to changing our own behaviors as caregivers....

The problem is, most of us are just like our patients — we often ignore good advice when it conflicts with what we’ve always done.

I thought about this as I read the latest recommendations from the Choosing Wisely campaign — a project led by the American Board of Internal Medicine to inform doctors and patients about overused and ineffective tests and treatments. Medical groups were asked to list five things in their field that are often overutilized but don’t offer much benefit.

Last month, my specialty group — the Society of General Internal Medicine — released its Choosing Wisely recommendations. No. 2 was: “Don’t perform routine general health checks for asymptomatic adults.”

This runs counter to a basic pillar in medicine that doctors and patients remain strongly attached to: the annual checkup. This is our chance to do screening tests and vaccinations and to discuss a healthy lifestyle. Anecdotally, we all can cite examples of checkups that uncovered serious illness. But the scientific evidence shows that on balance, the harm of annual visits — overdiagnosis, overtreatment, excess costs — can outweigh the benefits.

Yet, I still do them. Each time I see a healthy patient, I close the visit by saying, “See you in a year.” It’s a reflex.

After the research was initially published last year, I grappled with the evidence, or lack thereof, reaching a conclusion that I mainly still supported the annual visit, if only because it establishes a solid doctor-patient relationship. But seeing these new, strongly worded recommendations, I may have to re-evaluate. At the very least, I should take a moment to think before I reflexively recommend the annual visit. But I know that I might still end up doing the same thing, despite the evidence.

Humans are creatures of habit. Our default is to continue on the path we’ve always trod. If we doctors can recognize that impulse in ourselves, it will give us a dose of empathy for our patients, who are struggling with the same challenges when it comes to changing behavior.

Dr. Ofri is very unlikely to stop recommending the annual checkup. As she writes, changing habits is difficult. Without a determined objective ("I will urge my patients to follow the guideline and not schedule a routine physical if they don't show any symptoms"), she will certainly revert to what she's always done. Her article is a fascinating demonstration that ignoring recommendations is not limited to mere patients. Professional doctors are just as prone to wave stuff off, even stuff they believe to be best for them and the patients.

But if she is serious about the Choosing Wisely recommendation, she should first set a clear objective to do it, and not simply "take a moment to think before I reflexively recommend." What would she say to her patients who treated one of her recommendations that way?

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