I’ve been talking and thinking a lot about change recently. I’m seeing people struggle with alcohol, cigarettes, obesity, general compliance with medical treatments – fairly typical primary care and family medicine stuff. I usually try to emphasize making a long-term commitment to the change process – not just looking for short term fixes, setting achievable goals, and celebrating small steps toward those goals. Frequently, though, as I proceed down this line of discussion, I see eyes start rolling, legs get fidgety, and the whole atmosphere changes subtly. These patients feel as though they’ve been through all this before…and it hasn’t worked. So they come to me for the next, usually more intensive or expensive, step.
In the routine care of acute complaints (colds, aches/pains, headaches, etc.), I believe (and ecology of care models support) that there is somewhat of a self-triage process that goes on – once the patient takes the trouble to make the appointment, they have often tried the "simpler" things to get better, and those have not worked.
However, in our increasingly medicalized world, where the more technological and expensive treatments are more heavily advertised, patients are presenting earlier and earlier in the course of their illnesses – hoping for the "best chance" of recovery, rather than waiting for the "triage of time" or trying the more difficult route of behavior change. I think this is a general trend, but, of course, this does not apply to everyone.
Many of these conversations (over antibiotics for URI, sleep aids, weight loss interventions) start to feel like the patient and I are at opposite ends of a playing field. I imagine the patient is trying to get what they think (or have been told by advertisements) will work, and here I am standing in the way with my talk of healthy lifestyle changes, and non-pharmacologic interventions. How did this happen? No wonder patients feel as though they need "patient advocates" nowadays – how did we come to be perceived as NOT being the patient’s advocate? How did it happen that our profession has turned from "professional consultation" to simply "service"?
The profession of medicine is changing, and I’m not always certain it is in a good direction. Our practice is influenced way too much by politics (legislation of care), business (insurance, pharmaceuticals and devices), advocacy (special interest groups) and fear (litigation). These influences have suceeded in changing our practice without our consent and frequently without our involvement. To the extent that these changes have been driven by perceived or real problems with our professional performance, we deserve them if we haven’t changed ourselves to improve our performance. In a very real sense, we’ve made the bed that we’re currently lying in – so I should probably have more patience with my folks struggling to change – they are a very real reflection of OUR inability to effect the needed change.