Monday, October 14, 2013

Bad Habits or Critical Thinking?

Danielle Ofri, a physician at NYU Medical Center (in New York City) and a New York Times contributor, is one of my favorite medical commentators. Her insights and judgment into issues such as the use of the medical narrative are impeccable. However, I wonder if in this recent opinion piece she might have missed the mark a bit.

In this article, she takes herself to task for a “bad habit” of not following the ‘Choosing Wisely’ guideline from the Society of General Internal Medicine (SGIM) concerning routine visits. She still sees her patients routinely for health checks, even though this particular SGIM guideline states “Don’t perform routine general health checks for asymptomatic adults.” The guideline then goes on to explain:

 “Routine general health checks are office visits between a health professional and a patient exclusively for preventive counseling and screening tests. In contrast to office visits for acute illness, specific evidence-based preventive strategies, or chronic care management, such as treatment of high blood pressure, regularly scheduled general health checks without a specific cause including the ‘health maintenance’ annual visit, have not shown to be effective in reducing morbidity, mortality or hospitalization, while creating a potential for harm from unnecessary testing.”

And yet, while Ofri considers her own actions to be bad habits, I consider them good critical thinking—and good instincts. I believe this “bad habit” is really related to a deep understanding she has of the doctor-patient relationship—an understanding not reflected in the guideline.

While this guideline (and the many others that accompany it) is well-intentioned and an important step toward making us all wiser doctors and patients, it’s also important to think critically about it.

The guideline is based on scientific studies of populations and the population effect on reducing morbidity, mortality and hospitalization, but it doesn’t take into consideration other studies that have documented the eroding trust in physicians, as well as the studies that document the morbidity increases resulting from lifestyle diseases.

I find it difficult to separate these two issues. Patients must trust their doctors if they are to follow doctors’ advice concerning lifestyle, as well as the more immediate advice doctors give suggesting diagnostics and therapeutics. If patients are going to take medications as they were meant to be taken or undergo a diagnostic test that will ultimately help them better, they must have a relationship with the physician built on trust. That kind of relationship only happens when the doctor gets to know the patient as a person—not just his or her physiology and health risks—and that requires regular contact between a doctor and an individual.    

In today’s world, it is more important than ever to think about what happens outside of the doctor’s office as well as what happens inside it. Before the person ever sees the doctor, how does he or she decide whether to go in the first place? It often depends on how much trust a person has in that doctor—and how much value he or she thinks the visit will offer. In an absence of trust, a person may not even go to the visit—and miss an opportunity for early treatment.  Or, when that person leaves the office, will he or she act on the physician’s advice?  What if the physician wants to try “watchful waiting,” which requires a great deal of patience and confidence in that guidance?

We should ask ourselves if the guideline’s goal should also be related to trust. Shouldn’t trust be at least as important as the epidemiology of a borderline cholesterol level? Perhaps the real benefit is not just in treating that borderline cholesterol, but comes home to roost 1 or 2 years later, when—in an urgent situation—the person actually calls the doctor he or she trusts.

Many years ago, I ran a nutritional support service and made regular home visits to the patients we treated. I found I learned the truth about what patients were really doing when I went to their homes. I learned about the real-life barriers that prevented them from following the advice I gave. I formed a bond with them that was related to my willingness to meet them where they were, not just emotionally, but physically.

In healthcare, we are beginning to recognize the importance of shared decision- making—in which the doctor and the patient jointly decide the best course of action. This can only occur with trust. It only occurs when the doctor knows the person, and not only the patient. It only occurs when the patient believes the doctor has his or her best interest at heart--and not the best interest of the health system they work for, the government, or even society as a whole--no matter how “noble” that may seem from a population perspective.  

Perhaps we could modify the Choosing Wisely guideline so that we avoid lab tests at those yearly visits, but maintain the yearly visit itself to help maintain the bond? Perhaps it should even be a yearly home visit (although I suspect that would not be warmly received by most doctors or health policy people) to really see all that the patient and the family unit has to deal with in order to try and stay healthy?  A modification in the guideline that fostered trust and relationship building could result in better care and even more cost savings.

I applaud Dr. Ofri’s instinct to follow her own path, rather than following the guideline in this case. Her voice will help SGIM and all those involved in setting guidelines better understand that healthcare needs trusting relationships as much as it needs science and epidemiology. I hope that she continues to use the critical thinking skills that are reflected in so much of her writing to build trust and motivate patients so they call when they are in need--and follow the sage advice I am sure Dr. Ofri gives.