A joint post by e-Patient Dave and Dr. Danny Sands, written from alternating points of view.

Danny: An important moment happened a few months ago during office hours – important because it brought a profound shift in Dave’s view of the doctor-patient relationship. And that’s a vital part of participatory medicine.

Dave: As many of you know, my primary physician is Dr. Danny Sands. I was there for my annual check-up.*

He was late as usual – regardless of the economic pressures on doctors today, he declines to rush: he spends as much time with each patient as he finds necessary. I’m accustomed to this, so I bring work to do while I wait. (There are many aspects to being an empowered partner engaged in the healthcare system!)

Our visit went fine: nothing dramatic, a few minor complaints, updates on issues we’d covered before. My cancer’s in the past – I’m now just an ordinary middle-aged schlumpf. As our visit came to a close, the doctor’s main advice was “You should lose weight.”

And that’s where it got interesting.  Because earlier in the visit he’d mentioned a patient he’d seen earlier in the day, whom he’d lectured pretty strongly about not sticking to the plan. But after he discussed that my weight had gone up, in a really not-so-good way, he just finished the visit – with no lecture.

I thought, that’s odd: he lectured the other guy, not me. Feeling bold, I spoke up: “So, why aren’t you harder on me about my weight?”

Danny: I stopped, reflected, and realized: I’m hard on someone if they complain about things resulting from a lifestyle issue, and aren’t doing anything about it. Dave wasn’t making the best choices he could, but he doesn’t complain.

But I thought, why not document this? So I sat back down at the screen, turned it so the patient could see it, and following the five items we’d already discussed, I typed: “6: Obesity.”

I added comments about his need to address it, and told him verbally: “It’s my job to give you the information, but you know what you need to do.”

Dave: That was a perfect expression of our 2008 post about Stanley Feld’s “Physicians are coaches. Patients are players,” echoed here in July by ICSI president Kent Bottles. (Great comments on that post.)

So the interesting question to me is, why was the coach hard on the other guy, and not me?

Danny: People respond to information. I use different approaches for different patients: (some need a nag, some just need the information; in industrial settings all we need to do is let people know their productivity and they’ll know what to do. Same thing in medicine: If you tell a doctor they have a low proportion of patients who’ve had a necessary test, they will improve their performance, but without the data they won’t do it. There are patients like that too.

I’d probably misjudged Dave’s need on that scale. He had the information but still wasn’t acting on it.  I could have been harder on him.  While some patients respond well to my tough remarks, there are patients who don’t take to that at all well.

Dave: And it dawned on me: in my relationship with him, I’d been making it all about me – it hadn’t dawned on me that he needs the people skills to deal with the whole spectrum of patient personalities.

This is fascinating to me. The more I learn about being a full colleague in my care, responsible not just for my own health but for our relationship, the more I appreciate the range of skills clinicians need.

When I got really really bad news about terminal cancer, Dr. Sands was supremely calm, gentle and clear; but day by day, he also needs agility and grace in adapting his style. Oh yeah, then there’s the medical knowledge. That too.
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Participatory Medicine takeaways:

• Patients: You might want to think about being responsible for yourself, even if your health professionals aren’t leaning on you. Maybe you’re not the center of their universe! The physician is responsible for a thousand bodies; you’re the master of one.
• Physicians: Encouraging behavior change is difficult, and there’s not a single model for every patient.  While we try to tailor our approach to what we think each patient needs, we sometimes miss the mark.  It’s never too late to make mid-course corrections so we can best help our patients.

Remember the definition: “Participatory medicine is a cooperative model of healthcare that encourages and expects active involvement by all connected parties (patients, caregivers, healthcare professionals, etc.) as integral to the full continuum of care.”

In a sense we knew that, but our exchange this appointment brought it home in a new way. And we both left feeling more empowered.
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Update eight years later

Dave, April 2, 2018 – Four years later, in November 2014 Dr. Sands reported that my hemoglobin A1c was a bit elevated, and he added PRE-DIABETES to the Problem List in my record. I’d long forgotten about this post between us. I bought a fitness tracker wristband, which by itself didn’t accomplish anything. Then I got into the “DPP” Diabetes Prevention Program, which is not tightly prescriptive – it teaches food awareness and gently encourages becoming more active. I started going for walks, then long walks, then a year later became a runner.

Ultimately I’ve lost forty pounds and kept it off (ranging from 34-45 pounds, actually) and on March 15, 2018 posted on Facebook that Dr. Sands had written to me: “You no longer have prediabetes. I have removed it from your active problem list. Good work!”

Reflecting on this post eight years ago, I have to say that although his words didn’t work magic, throughout the whole experience it was always clear that it was up to me.

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* ^{“preventive health evaluation,” in doctor-speak … the least important part is the physical exam – 80% of the info we get is from the talking and listening, 10% from tests, 10% from the physical. Talking & listening tells us what we should be looking for in the exam.}