by stewart B. Segal, MD
Many years ago, I was blessed to receive an invitation to serve on a national advisory board for a pharmaceutical company. I was privileged to sit in a room with 15 experts in their fields of medicine and share in their knowledge. Since then, I have been to many such meetings and, each time, I have harvested clinical pearls to be used in my practice of medicine. At the most recent meeting, a well known family doctor talked about the “look backwards” approach to medicine and contrasted it to the “look forward” approach. The difference between the two styles is remarkable and I look forward to sharing my newfound pearl with my patients.
The “look backwards” approach is what I have done for 27 years. Mr. A comes in for his blood pressure, blood sugar and cholesterol check. I look back over the chart and determine that Mr. A has not done anything we discussed at our last visit. His numbers are not good and I point out to Mr. A that his behavior is fueling the fire that is going to burn him. I inform Mr. A that I am going to increase his current medications and add one new one. Mr. A feels guilty and does not want more medication and says he will do better. “Doc, give me three months. I can do better!” Five months later, Mr. A returns, nothing has changed and we start the cycle over.
The “look forward” approach identifies the current problem and puts an action plan in place. Medications are adjusted appropriately. Plans are made for behavioral and dietary changes when appropriate. A care team is constructed. Nursing support is set up with a predefined call back schedule being arranged and the patient knows that, if he experiences any problems, he can call his team nurse for help. Referrals for nutritional and exercise counseling are arranged. Deadlines are set. The patient commits to the team approach and returns in one month for a follow up visit and assessment of the success or short comings of the treatment approach. At each visit, future treatment objectives and changes in current treatment options are reviewed.
Most patients mean well. They are going to work on their diet, but the boss calls them in, gives them a new assignment and their personal plans get pushed back. They are going to exercise; but they are working 16 hour days and they are exhausted when they get home. They are going to eat fruits and vegetables and whole foods but they are in a hurry and the drive in window at McWhatever restaurant is more expeditious than parking and running into the grocery store.
A care team and “look forward” approach is going to solve the harried life of today’s worker. What it will do is help develop realistic work-arounds to the above problems.
- You need to diet to lose weight. You stress eat. Your boss stresses you. Currently, you pledge to work on your weight loss as soon as the stress lets up. Realistically, the stress never lets up. The answer is better stress management. One goal of your care team is to find stress relievers other than food.
- You need exercise but your 16 hour day is exhausting. You promise to exercise as soon as work gets better. Work doesn’t get better. Another goal of your care team is to find novel ways to build exercise into your work day.
- You need to eat a healthy diet but your car won’t stop pulling into the drive-in window at McWhatever. You know you shouldn’t; you feel guilty, but your hunger gets the best of you. Your care team’s goal is to counsel you on food choices and meal planning. They advise you to eat healthy snacks more often so your hunger doesn’t get the best of you.
Looking forward to something is much better than looking back and lamenting. After the heart attack or stroke, looking back at what was not accomplished is truly miserable. I look forward to shedding the “look back” approach. I look forward to working with you. I look forward to helping you improve and maintain your health. I hope you will look forward to the same.