Blog | Tuesday, May 31, 2016

Overcoming shame


Doing taxes feels like a financial rectal exam. I hate doing taxes. Yeah, I don't like getting rectal exams either.

It's not that I resent paying the government for the fine services they render and the high quality of elected officials we have. It's not the existence of taxes I hate; it's just doing taxes make me feel extremely insecure. Sharing my personal and business finances with my accountant and the government makes me feel like a dope. I feel like I'm stripped naked with all of my flaws exposed.

This is actually ironic because my accountant is a patient of mine. He also, despite my urging, has been slacking on coming to see me. “I just haven't been taking care of myself and feel ashamed,” he told me in an e-mail. “It feels like I'm going to the principal's office.”

I know how that feels. I did go to the principal's office plenty as a kid. So I told him (my accountant, not the principal) that this was exactly how I felt each year during tax season. So we made a pact: I wouldn't make him feel like an idiot, and he'd not make me feel like one. That's easy for both of us, as we are used to seeing other people's financial/physical nakedness.

His feelings about going to the doctor are very common. People often feel insecure and ashamed. Just today, a woman with COPD bowed her head in shame when she confessed she was still smoking. “How stupid is that?” she said, “I have COPD and recently had pneumonia, yet I still can't stop using these things! My kids are always on my case; I just don't know why I can't quit.”

This is true with diabetes, obesity, alcohol consumption, and anything else that seems like it should be easily handled (or at least improved) by lifestyle change. People don't know why they compulsively do bad things or compulsively avoid doing the right thing. This is why I often tell patients is that one of the best things about being a doctor is that I see that everyone else is as screwed up as I am.

This insecurity is the biggest challenge in my practice: getting people to change their behavior. Somehow I have to somehow get people to pay attention to their health when they'd rather ignore it, to be taking medications when they'd rather not, to be exercising when they don't want to, to lose weight when they love cheeseburgers, and to be checking their blood sugars when they'd rather not know how high they are. After trying lots of things over the past 20+ years, the one thing I find almost never works is what is usually done: lecturing the patient.

ACOs and “Meaningful Use” have made lecturing the norm. Here's a clip from the end of a note from a patient's recent visit to the ER: Estimated body mass index is 30.94 kg/(m^2) as calculated from the following: Height as of this encounter: 1.638 m (5’ 4.5”). Weight as of this encounter: 83.008 kg (183 lb). Discussed the acceptable BMI with this 47-year-old female. Her BMI is >25 which is above average for a patent 18-64 years old. BMI management plan: regular exercise and dietary management, education, guidance, and counseling. We discussed the divided plate method.

Great. I am sure this will change her life. She probably loved being lectured by someone she didn't know when she was in the ER for something unrelated to her weight. I'm sure she never realized she was overweight. Her life will be better because of the divided plate method. I sure as heck am delighted to see my patients are lectured about their weight by strangers.

Everyone is lecturing my patients on their weight, smoking, exercise, checking their sugars, taking their medications, and “reducing stress” in their lives. How can you reduce stress when you are surrounded by a bunch of medical busy-bodies? The consequence I see is a bunch of folks who are like my accountant: afraid to get care because they are waiting for a lecture. Many lie to cover up their shame, while others just don't come.

So what to do about this? How can we create a system that promotes honesty and encourages engagement? We can't just ignore these problems. I've had people who used my lack of mentioning their smoking or morbid obesity as me saying they are OK. People need us to be engaged in their struggles in ways that are truly helpful, either helping them overcome these struggles or at least giving them a sympathetic ally in their battles. I want people to come to me for help, not to avoid me or hide the truth because they fear me.

This, of course, brings me back to the idea of patient-centered care. How do we address issues, such as weight, smoking, and non-compliance in a way that is patient-centered? It's harder to answer that question than to answer the opposite: what's the least patient-centered way to address these issues? Checklists that tie reimbursement to lectures.

Checklists force caretakers to ask questions and address topics when they aren't relevant. They are centered on doing the “right” thing for the wrong reason. ACO's and “meaningful use” tie documentation of addressing these issues with reimbursement. So, we either lecture our patients halfheartedly or we simply lie by checking the box. I suspect the majority of times it is the latter. Why, after all, should a urologist lecture a patient about weight loss (other than to get a bigger check from the government, which is the obvious answer)? So patients get buried in an avalanche of lectures and handouts telling them what they are doing wrong.

The solution? I'd be on Dr. Oz right now if I knew an easy way to help people lose weight, quit smoking, or fight their other personal demons. There is no easy way. But it helps a lot to have someone who is fighting with you, not making you feel foolish. I've recently lost 20 pounds by the magic formula of eating less and exercising. It's simple, but it sure as hell hasn't been easy. So the best approach I've found is to sympathize and encourage. I want people to tell me about their struggles and failures, not hide them.

I'm realizing as I get toward the end of this post that I'm not coming to some grand conclusion. This is not magic. It's not a secret trick that can make things easy. Life is a struggle we all face, and it is best faced with good allies. I want people to come to me when they need help, not run from me fearing judgment and lectures. Somehow, despite the checklist culture of our system, we need to keep care away from shame. Yeah, people make bad choices, but that doesn't mean they are bad (or stupid) people. In truth, they're just like their doctors and nurses.

And, it turns out, their accountants.