Abstract
Summary:
Keywords: Patient engagement, office notes, chronic conditions, obesity, communication.
Citation: Sands DZ. How a patient was motivated by reading his office notes. J Participat Med. 2016 Feb 29; 8:e2.
Published: February 29, 2016.
Competing Interests: The author has declared that no competing interests exist.
Author’s Note: This is an entirely true story (I actually referred to my office notes as I wrote it), with only the patient’s name changed.
I saw Joe (not his real name), a 63 year-old retired corporate manager, for his annual wellness visit. Joe has been my patient for 20 years. He has always been overweight, and only once did we make headway in changing his lifestyle and helping him to lose a bit of weight, but this was short-lived. And it was not for want of trying. I tried many different approaches and prescribed specific dietary and exercise interventions. But he never seemed fully committed to changing his diet or to exercising. It didn’t help that many people he knew, including his wife, were overweight—we know that obesity is contagious in social circles.[1] He also had a mostly sedentary job, another risk factor. [2]
Photo credit: Magnus D on Flickr
He inexorably gained weight over the years, about 30 pounds in all. Along with the extra weight, he also accrued other medical problems. At his first visit he complained of longstanding heartburn. I made a diagnosis of gastroesophageal reflux, which we managed with lifestyle changes and antacids. Later, he developed hyperlipidemia (high level of “bad cholesterol”) which eventually required treatment with a statin. His blood pressure rose. He developed sciatica, which worsened with time (and weight gain). He developed osteoarthritis. Throughout all this time, he remained unwilling to undertake important lifestyle changes (or even to take small steps), despite my exhortations that it would really help him feel better and require less medication.
When I saw Joe at his wellness visit (and to assess his now chronic conditions, including obesity), he was miserable. He told me that his brother had recently died of a heart attack. He complained that he had chest pain when he swallowed, and was taking a large amount of antacids. He had general achiness (wondering if it was from the statin he had been taking for years) and mild diffuse joint pain. His arthritis and sciatica were worse. And he was even having problems with his libido.
On examination we found his weight was higher as was his blood pressure. The rest of his examination was unremarkable.
I offered him medications to treat his various ailments and a course of physical therapy for his arthritis. For some of his conditions I simply prescribed a trial of lifestyle modification. I also ordered blood tests to further evaluate his various symptoms. In all, I prescribed three new medications that day and ordered about a half-dozen more blood tests to evaluate some of his problems (and I tend to be very conservative about ordering tests). I asked to see him back in three months to assess his symptoms and re-check his blood pressure. I was considering some additional testing if he did not improve. Of note, his blood tests showed that he had developed pre-diabetes, which I explained in a letter (although he could see his results online, I routinely notify patients anyway, to provide them my interpretation and context).
Three months later I walked into my examination room to see Joe. I did a double-take, thinking I had entered the wrong room. There was a man wearing a muscle shirt, exercise shorts, running shoes, and a fitness band on his wrist. Although he looked like Joe, he was thinner and visibly healthier. I had never seen him looking so good. His weight was down twenty pounds (but still in obese range) and his blood pressure was in the normal range.
Photo credit: Fitbit
I said “Joe, what happened? You look great!” He said that following his last visit he was reading his problem list and office note (Beth Israel Deaconess was one of the principal sites in the OpenNotes study, through which patients can view their visit notes through our patient portal). He saw the word “obesity” on his problem list and in his note as a potential contributor to many of his problems. Even though I used the term in the office and type my notes while he is in the room with me (which I do for most of my visits), he says there was something about seeing it on the screen that suddenly struck him. He said, “I decided I don’t want to be that guy–I want to be healthy.”
Soon after that he bought a FitBit and challenged 16 friends and family across the country to compete with him. He started going to the gym every day, power walking on a treadmill, weight training, and then doing another aerobic session. In two months he racked up 1 million steps (an average of 16,000 per day). He also greatly improved his diet. He monitored his weight and blood pressure at the gym, and as his weight and blood pressure dropped it further reinforced his behavior changes.
Joe was happy with his improvements, but now finds he notices his excessive weight when he looks in the mirror and it bothers him — motivating him to want to lose more. His wife and overweight friends are concerned that he’s overdoing it, but he’s undeterred.
More importantly, almost all of the symptoms that were bothering him at his prior visit had vanished. He no longer required any of the medications I had newly prescribed.
What can we learn from Joe’s story?
1. Allowing patients to view their medical records online lowers barriers to patient engagement;
2. We don’t need to sugar-coat our office notes, thinking like Colonel Jessup that “You can’t handle the truth”; while pejorative language has no place in the medical record, the medical terms we use to describe conditions, including obesity, can be motivating to some patients (even though it may be off-putting or even painful at first);
3. Fitness tracking devices, particularly when coupled with friendly competition, can serve as a powerful motivator;
4. Self-measurement, of weight for example, can show patients the impact of maintaining a care plan (and sometimes qualitative self-observation can be motivating);
5. It can take years for motivational interviewing and exhortations to have an impact (contrast this with some patients learning about a dangerous condition and making dramatic changes to their lifestyle), and finally,
6. Lifestyle changes, while difficult for many patients, can positively impact many symptoms as well as, or better, than medications (and at a fraction of the cost—something we have known for a long time but often gets lost in the frantic time crunch in the office with the allure of easily prescribing drugs and other expensive treatments.
While I realize that not every patient is like Joe, we should try as many ways as we can to engage individuals in their health and health care. The lessons here are instructive.
Let me know what you think in the comments below.
References
- Christakis NA, Fowler, JH. The spread of obesity in a large social network over 32 years. N Engl J Med 2007; 357:370-379. Available at: http://www.nejm.org/doi/full/10.1056/NEJMsa066082. Accessed February 22, 2016. ↩
- Hamilton MG, Hamilton DG, Zderic TW. Role of low energy expenditure and sitting in obesity, metabolic syndrome, type 2 diabetes, and dardiovascular disease. diabetes care. Diabetes. 2007 Nov;56(11):2655-67. Available at: http://diabetes.diabetesjournals.org/content/56/11/2655.full Accessed February 22, 2016.↩
Copyright: © 2016 Danny Z. Sands. Published here under license by The Journal of Participatory Medicine. Copyright for this article is retained by the author, with first publication rights granted to the Journal of Participatory Medicine. All journal content, except where otherwise noted, is licensed under a Creative Commons Attribution 3.0 License. By virtue of their appearance in this open-access journal, articles are free to use, with proper attribution, in educational and other non-commercial settings.
Terrific case report, Dr S (for full disclosure, we’re colleagues at BIDMC and have been for a long time).
What’s interesting for us who are steering the OpenNotes efforts is that “obesity” was one of the 4 principal areas that worried docs contemplating the use of fully transparent records (the others were cancer, mental illness, and substance abuse). They were afraid that their noting “obesity” would offend their patients.
We’ve now had quite a few reports similar to the one Danny recounts: Patients who’ve had trouble addressing their obesity who finally take action once they see it written down and clearly a cause of concern to their clinician. The anecdote I’ve always liked was the patient who told us something to the effect: “Now that I’ve seen that word written down, I want to make %$##$@#!@!# sure I don’t see it again!” And the accompanying subtext is, “I didn’t realize how worried my doctor was until I saw it in his/her words in my record…
The real power of FitBit is not yet known to most of the FitBit users. It’s the FitBit Dashboard with Facebook like functionality of letting you know how you fair in comparison to your friends who are also on FitBit
Joining a FitBit Challenge is akin to putting ones Medical Record for public Scrutiny and then striving hard
I personally think all digital health evangelist and proponents of Digital Records must set an example by experimenting their own health Data ( let’s say just the activity data) and clean information out of it. Until and unless we themselves put our thoughts into actionable mode we cannot motivate others to go digital
I did a Joe in Oct Nov 2014 and needless to say, I had to buy all new pants.
Then I washed my FitBit in a washing machine and it was Business As Usual.
Fantastic story! Confirms my intuitive sense and personal experience that patients will, at least much of the time, pay close attention and be willing to make changes when they see important information about their health in writing. Kudos to you, Danny, both in your treatment and in presenting this case for policymakers and patients to benefit.
I can totally see how this patient took his information and made such drastic changes in his lifestyle and ultimately his health. My organization just last fall became a PCMH and we are just implementing ways to engage patient’s in their healthcare. Initially, they may be off put by what they read in their health record but once they fully understand they can take the information and really move forward with positive changes like your patient did. Congratulations on such a positive outcome. Would you please let us know if he continues on this positive road and how he meets his challenges? Thank You.
Sharing office notes is an easy way to engage patients. Years ago when I studied an innovative medical practice that incorporated decision support tools to encourage patient engagement, and found almost universally patients loved the fact that office notes were shared at the end of the visit. Patients referred to them for myriad reasons: e.g., when they travel, to obtain correct spelling of medical words that they want to find more info about, to review when anxiety prevents them from absorbing what the MD explains during the visit, to keep a record of their history for their children. Worst case scenario — they throw the notes away if they don’t want them. It fosters transparency and trust. I don’t understand why sharing notes is not common practice.