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    Why Doctors Fail To Provide Lifestyle Coaching
    Michael Dansinger, MD posted:
    Not all doctors fail to provide lifestyle coaching, but most of those who SHOULD be providing this are not doing a very good job.

    For example, several studies show that patients with obesity who have seen their primary care proviider within the past year report no lifestyle counseling or mention of their obesity within the past year in 60% of cases. So 40% have PCP's that at least mentioned the obesity within the past year, but that is not good enough. This 60% failure rate has not changed over the past 10 years.

    I'd like to hear people's thoughts about why you think doctors fail to provide lifestyle coaching, and then I'll share my views on why I too failed to do this during my first few years in primary care.

    Michael Dansinger, MD
    DavidHueben responded:

    I am not exactly sure what constitutes "lifestyle coaching".

    I am fairly sure that patient load, insurance reimbursement, and inadequate medical school training contribute to the problem.

    Watch what people are cynical about, and one can often discover what they lack. - General George Patton Jr
    mhall6252 responded:
    Ooohh, great question. I can think of a number of reasons:

    1. the doctor himself (herself) is overweight and finds it hard to preach "do as I say, not as I do."
    2. the doctor is overbooked and doesn't have time to spend an extra ten minutes discussing lifestyle changes in depth. My doctor's office schedules "checkup" visits ten minutes apart!
    3. the doctor has become cynical and thinks that people won't make lifestyle changes, so it's easier to give the patient medication. At least then he has a chance of helping the patient avoid complications.
    4. the doctor has pharmaceutical reps introducing him to the latest "pill" for everything. Too bad fitness centers don't market to doctors with the same tenacity. Can you imagine, instead of a prescription for a pill and a few samples, the doctor gave you a prescription for an exercise program and a discount certificate to a fitness center. Even better, what if the insurance companies covered a percentage of the cost?
    5. health insurance is focused on paying for medical problems and procedures, not preventing medical problems and procedures. If they would focus on rewarding doctors for prevention measures and come up with a method to measure the results, doctors would be financially motivated to focus on lifestyle changes.

    phototaker responded:
    Michael, I greatly agree with most of the comments from the previous posters on this.

    My views:

    1) The doctors are stretched so thin, with so many responsibilities and time limits for each patient, that they don't have the time to do these long discussions with questions. We did not have diabetes classes for pre-diabetes at the time I was diagnosed. I could have been "saved" from getting diabetes earlier, if I had attended those classes. I DID have to pay for the classes, though, which probably should have been paid by Kaiser, for in the long run, they would have saved money. I also heard from the Ed. Dept. there(after I was diagnosed with diabetes, and told them my thoughts about classes) that many patients never even attended the classes
    or night groups they set up.

    2) In my personal case, my doctor knew how diligent I was about my health, because of my high cholesterol then, and how I attacked getting my numbers down by eating healthy. He also knew my mom was diabetic and "probably" assumed I knew what to do. I didn't. My mom was very different than me in how she handled her diabetes. She even used insulin, ate frozen pies(from an emotional food addiction), and walked every day. She was very stressed out with 3 children and a husband that worked long hours.

    3) I agree with others when they said the doctor might feel inadequate when telling others to lose weight when he/she is overweight themselves. I've had this happen, and I just looked at them, thinking how could they tell me when they need to lose weight, too(that was a long time ago).

    4) I also was very surprised to see how some doctors know very little about diabetes. Now that I know more, I understand it's impossible to be everything to everybody. Also, so many diabetics have different needs, so it can become overwhelming. They should send diabetics to specialty doctors, but most don't.

    My answer would be to send diabetics to PAID FOR BY INSURANCE diabetes classes. I would also have the original doctor suggest strongly that the diabetic go to these classes to learn the basics behind diabetes, and how important this is.
    I would have some past patients who would volunteer to be a sponsor for this new diabetic or support groups for them. I would have a special nurse who could sit down for one session with new diabetics to show them how to test their blood, talk about what to eat, and just simple things before the diabetes classes.

    You can't do anything about the diabetic that is in denial.
    If someone doesn't want to take care of themselves, you can't make them, but our diabetes class talked about what could happen to you, if you didn't take care of yourself. I had no idea what neuropathy could do to your body, about blindness, and the harm to your organs, even having a diabetic mom. She was always talking about her illnesses, so I shut down as a child and stop listening in my teens.

    Michael, there are people with emotional problems who overeat, too. There's not much you can do about that except suggest therapy, if you see them killing themselves with their emotional eating, and even then, I'm sure that would be difficult to do. I went through many, many years of therapy to take care of the issues behind my emotional eating, and even "still" there are rare times when it's so hard for me to stay on track. It's constant "thinking" and work to do what's good for me.

    Thank you for taking the time to want to become an even better, more understanding doctor towards your patients, and for trying to help other doctors to see the light, too. So many more patients can be helped, if more compassion paired with strong warnings for a new diabetic, not to scare them, but enough for them to know how important it is for them to succeed with diabetes. I wished now that my doctor(whom I loved, by the way)had strongly let me know I needed to buckle down when I was diagnosed pre-diabetic. I honestly think I would have listened to his words.
    DianeR01 responded:
    I agree with the other posters about time being a huge constraint on doctors. I also think part of the blame lies with the patient. At diagnosis I was given meds and a card with the outline of a 1200 calorie diabetic diet. I had no clue what I was doing or what really needed to be done so I started asking questions and Dr. K stepped up and helped me get the education I needed. Almost four years later he has gotten used to my questions and does not hesitate to explain and discuss issues.

    My thought is if the patient is going to ask the questions and take action, most doctors will be willing to take some time and do some coaching.
    xring responded:
    What everyone else said pretty much sums it up.

    The financial ties between doctors & the pharmaceutical industry is likely the biggest factor. When drug companies pay doctors fortunes to speak at drug company-sponsored seminars & also pay for doctors' "Continuing Education," they certainly aren't going to talk about diet & exercise.

    Lifestyle coaching takes time & also takes away drug company profits as well.

    I couldn't help but notice that many doctors have very little nutritional knowledge themselves. My first doctor was 100 lbs overweight. First, he tried to push hospitalization, (then changed his mind after he found out I had no medical insurance), then insulin, then drugs. Then he handed me a suggested diet (with drug ads on each page) & the diet included processed, high-fat, low fiber foods at each meal along with suggestions for "smart eating" at McDonalds, Burger King & Taco Bell.

    I have heard the excuse: "Why should doctors bother with lifestyle coaching when patients won't follow it anyway?" I find that to be a pathetic excuse for incompetence - one that fails patients who would follow it.
    If a man yells: --YOU LIE-- in a room full of politicians, how do they know who he is talking about
    betaquartz responded:
    I have talked about this issue with my own Dr. concerning his approach to me with the metformin, and his advice to stay away from white. Really not lifestyle change counseling, but if followed would have done the job. His thought was that most of his patience would not have made as major a change as I was willing to and stick to it. He also stated that SOP was to follow the guidleines from the ADA in prescribing the metformin to bring numbers in line. I don't know if this was his or his firms/companies policy. He is part of a county wide health care facility. In the end, he is pleased that I stood up to him, and undertook the changes I did. At least that is the way I read him.
    xring replied to betaquartz's response:
    I agree that most patients would not have the self discipline to follow major lifestyle changes.

    However, a truly dedicated doctor would say something like:

    "Mr. or Mrs. ________, you can manage your health with drugs, and accept their risks, or I can recommend some lifestyle changes that may keep your blood sugar, cholesterol & blood pressure normal without the risk of drugs - more difficult, but better for your health." This allows PATIENTS to decide what they can or can't do.
    If a man yells: --YOU LIE-- in a room full of politicians, how do they know who he is talking about
    MSUphysicsFRIB responded:
    I know someone who changed doctors after her doctor suggested that she lose weight.
    arealgijoe replied to DavidHueben's response:
    I have had no shortage of garbage docs...

    That said, I have also had some good, even a couple great docs. Many of my docs have had both good and not so good aspects. Probably the only speciality where I had no bad docs was oncologists.

    REMEMBER doctors are HUMAN..with all the good and bad that goes with being human, (OK so a few pedistal themselves as psudo GODs)

    There is NO EASY answer to this question/issue.

    As far as diabetes is concerned, my best session was an hour with a nurse that was a type-1 diabetic; she understood like no other person could, doctor, endo or otherwise. Reading and studing a topic is far removed from LIVIING it!

    Doctors and patients do not allways speak the same language. The same word can mean one thing to the doc and yet another to the patient. Doctors should know what QUESTIONS to ask, but often do not, and many times patients do not know what to tell, and may miss an important detail.

    There has been some good dialog here already.

    BOTTOM LINE... doctors NEED to at least make more of an EFFORT, and at least earn the 'E'

    Gomer :-( :-)
    cookiedog replied to arealgijoe's response:
    I feel uniquely qualified to respond to this since I just got out of the hospital again. I have been hospitalized three times since 12/15.

    I am always urged to make certain lifestyle changes and my doctors check to make sure I understand what I am supposed to do.

    I agree that many doctors do not discuss lifestyle changes with their patient. I also agree many patients ignore the advice they are given. My transplant manual gives me a very detailed list of lifestyle issues I must follow. The manual also says about 80% of patients who come for transplant evaluation do not make the necessary lifestyle changes to be listed.

    If folks won't make fairly simple changes concerning diet, sodium consumption, OTC drug avoidance, etc in order to have a life saving surgery, then they are sure not going to follow lifestyle changes advice concerning every day issues such as weight control.
    betaquartz replied to cookiedog's response:
    Amen! Too bad there are some of us willing to make the changes that come across Dr.s that have been jaded by the other side of the population. It does make them at fault for not putting forward the effort, but it is understandable as to where they are coming from-"Why bother".
    cookiedog replied to betaquartz's response:
    My lead transplant doctor is a prominent researcher. He will spend as much time as I need making sure I know what I need to do and why.

    He always says he will tell any patient once in detail what they need to do. He will even tell them in detail a second time. But he will not take time away from motivated patients to keep telling some folks the same thing over and over again.

    I am in a support group. Most of us whine and moan about our "rules" we have to follow but we follow them to the letter. But we have quite a few folks come into the pre-transplant support group, mess around and break rule after rule and are never listed for their transplant.

    I am not talking recovering alcoholics who are a special population who may need more coaching than most in the beginning. I am talking about folks with other kinds of liver disease which will kill them for sure and soon but they just keep eating and salting and not exercising and not doing food journaling and other things we are required to do.

    I have always said I was slow to make lifestyle changes for diabetes since I felt basically normal. I also agree many doctors do not spend the time educating us about what we need to do.
    flutetooter responded:
    My "lifestyle coaching" came not from my doctor, but from a friend who was a "life style coach", teaching success oriented classes at a university, and also in private practice. I had already begun losing weight, exercising, choosing clothes more carefully, and working hard to increase my artistic, musical, and management skills. The "coaching" skills were just icing on the cake.

    AFTER the weight started falling off, my doctor noticed, and ordered tests to confirm the information I had brought TO her, on my fasting sugars (I had bought my own meter and testing strips). She then commented that I would probably never need medications because I was obsessively counting carbs and tracking my numbers.

    I do agree 100% with Phototaker about the emotional component of diabetes. When we feel better about ourselves, we take better care of ourselves. It can work in reverse -- if we just start taking care of ourselves better, we will probably feel better when others start reacting positively to our new image and smile.
    If at first you don't succeed, try, try again!
    krhudson responded:
    It is possible that the Dr.s are treating the problem at hand that caused the office visit in the first place such as dealing with blood pressure problems, thyroid, heart, skin irritations, allergies, the list goes on and on and that they cannot provide the time involved to give instructions about lifestyle changes if they know the patient has not shown signs that they are interested in making lifestyle changes. Maybe they wait for the patient to initiate the conversation. The Dr.s only have 15 minutes with a patient depending on the severity of the medical condition. I am thinking their are a lot of reasons that obesity happens whether emotional or physical or both.

    I think a caring Dr. with an extra couple of minutes may have the time to write out strict instructions on certain exercise that a patient can start with and a diet plan and set another appointment for 90 day follow up to see how the plan is going and if the instructions are being followed and if not, you can lead a horse to the water but if they will not drink, what can the Dr. do accept warn the patient of the dangers they face if the measures laid out for them is not followed.

    I would say most of it is time. The Dr.s just plain do not have the time. Wouldn't it be nice if they could just refer the patient to the dietitian and prescribe the level of exercise allowed based on the EKG etc...?


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