Patient self-management

I recently attended a patient self-management seminar. The idea is to involve patients in their own care, thereby increasing the chance that they will actually make appropriate lifestyle changes. After completing the course, filled with religious self-management fervor, I was un­leash­ed upon my unsuspecting patients. 

I found the most applicable issue in my practice to be weight control, so when faced with an obese middle-aged man I launched into action. First I established rapport. “Bob, you are really fat and are going to die.” (I actually started with, “Bob, there is lots of evidence that being overweight is bad for your health and I am concerned about you.”) 

Next, I got Bob thinking about the issue while encouraging him to be an active part of the solution. “Bob, there are two basic factors involved in weight control. Do you know what they are?”

“No.”

I was taken aback, but sometimes more groundwork is required. 

“Well, Bob, the two factors are how many calories you consume—diet—and how many you burn off—exercise.” Now it was time to give control back to the patient. “Which of these would you like to talk about?”

“We can talk about diet but I don’t eat anything.”

“Bob, you’re 5'9" and 300 pounds but you don’t eat anything?”

“That’s right Doc. You would be surprised by how little I eat and what I do eat is all healthy.”

I think Bob and I would both be surprised by what he eats. If the patient isn’t ready to talk reasonably about one item then it’s probably better to try a different approach, “Well, Bob, since your diet is so good how about we talk about your activity level?”

“I walk everywhere.”

“Everywhere?”

“Yes, everywhere.”

“So let’s get this straight. You don’t eat anything and walk everywhere but continue to gain weight?” 

I wanted to tell Bob that he was the only living creature on the planet capable of creating mass and that I wanted to study him in the lab, but I remember the kind people at the seminar stating that ridicule isn’t an effective self-management technique. 

“Well, Bob, if you can’t improve your diet and you’re already walking everywhere, the only solution is to increase your activity a little more. Other than walking, is there any other type of exercise you like?”

“I love to exercise.”

“I notice you live by the pool. How about swimming?”

“I don’t like to get wet.”

“There’s a gym at the pool, how about using the stationary bike?”

“My thighs rub.”

“Elliptical trainer?”

“I get dizzy.”

“Rowing machine?”

“I don’t like the sound they make, it creeps me out.”

In the seminar they did say that sometimes you have to accept that some patients just aren’t ready to change. However, I have a problem with this whole self-management thing. It feels a little like babysitting. Who doesn’t know that being overweight isn’t good for you? Have any of you ever had a conversation with a patient like this? 

“Hey Bob, probably no one ever told you this before but being overweight is bad for you.”

“Really, you’re kidding. Shut the front door! Bad for you? I’ve been seeing doctors for years and you’re the first one to tell me. Well, if it’s bad for me then I’ll lose weight and take better care of myself. Thanks Doc.”

Another life saved. 
—DRR