American College of Physicians: Internal Medicine — Doctors for Adults ®

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.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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