Built more like a former professional basketball player than an elementary schoolteacher nearing retirement, the patient dropped a bagful of prescription medications on the table in the examining room and fell back into a chair. He couldn’t remember what most of them were for.
Several weeks earlier, he had seen a new doctor who’d prescribed several new drugs and spent much of the visit reciting a list of advice — lose weight, exercise more, stop smoking, eat more fruits and vegetables. Before he even arrived home, he realized he couldn’t recall any of the details of what the doctor had said.
“I felt like I was in a Charlie Brown cartoon,” he said, recounting the visit with a laugh. “All I can remember the doctor saying was, ‘Waw, waw-waw, waw-waw.’ ”
This patient is far from alone in his difficulty absorbing a fire hose of advice. Thanks to some dazzling advances in preventive medicine and public health, doctors in almost every specialty of medicine now have a panoply of proven preventive recommendations to keep their patients from getting sick. And as the number of validated interventions has grown, so has the pressure on doctors to remind their patients of all the now-standard advice in the course of a 15-minute office visit.
Faced with an impossible task, some physicians have thrown up their hands and chosen to focus on only a couple of topics at each visit. Others have resorted to handing out typed lists of the recommendations for patients to read at home. But an increasing number of doctors, under mounting pressures from insurance companies and others to prove that they are delivering quality care, are simply scrambling to cover as many of the wellness recommendations as they can, piling on the dos and don’ts in what a colleague of mine once referred to as “the grand information dump.”
In no other specialty is the problem as acute as in pediatrics, as two papers published this week in the journal Pediatrics underline. For children’s doctors, the preventive pearls, which have been amassed in a hefty 648-page official guide titled “Bright Futures,” include recommendations on using of car seats, wearing bicycle helmets, limiting television, eating more fruits and vegetables, cutting back on consumption of fruit juice and setting hot-water heaters at no more than 120 degrees Fahrenheit.
If acted upon, all of these recommendations can prevent myriad injuries, even deaths, in children. But it’s a humongous “if.” Currently there is very little proof that simply telling patients and their families to do something, much less cramming all the recommendations into a 15-minute visit, will result in any behavioral changes at all.
“If it were that easy, we wouldn’t have the obesity epidemic we have now,” said Dr. Robert Needlman, author of one of the articles and a professor of pediatrics at the Case Western Reserve University School of Medicine. “But we keep serving up these recommendations one after another to our patient families, like waiters at a 10-course banquet.
“It’s great when you’re flying a plane or doing heart surgery,” Dr. Needlman added. “But there’s not a lot of great evidence that checklists are the way to go if you are trying to develop a relationship with parents around shared concern for a child.”
It may be that for certain recommendations, the message gets across best when it’s presented less directly — a possibility suggested by the second Pediatrics paper, a study that looked at how much mothers altered their babies’ diets after being counseled by pediatricians on healthy eating habits.
For the study, one set of mothers received the usual advice culled from the “Bright Futures” manual, including giving single-grain, iron-fortified cereal when beginning solids, introducing new foods one at a time and limiting juice consumption. The second group of mothers received more detailed advice and were asked to serve two to four tablespoons of fruits and vegetables each day, never to feed from the jar but to use a spoon and dish, and to start each meal with vegetables. The last group was simply reminded, among other things, not to skip meals, to turn off the television while eating, to eat as a family and to make sure that they themselves ate five servings of fruits and vegetables daily.
After a year, the researchers found that it was the mothers who received guidance about their own eating habits who had made the most changes toward feeding their children a healthier diet.
“Doctors may have good intentions when they’re doling out advice,” said Dr. Gina M. French, lead author and an associate professor of pediatrics at the John A. Burns School of Medicine at the University of Hawaii. “But we have to come up with ways of giving that advice that actually make a difference for patients.”
Both Dr. French and Dr. Needlman believe that more work needs to be done on finding the best ways to relay advice to patients, even if such research results in eliminating certain topics altogether. “It may be that we just can’t change certain things in our offices and that there are other places better suited to do so,” Dr. French said.
The goal, both doctors believe, would be to find the best combination and most efficient way of relaying recommendations. “Ideally a visit with the doctor is 15 minutes that can be used to build a very powerful relationship and transfer crucial information that will make our patients healthier,” Dr. Needlman said.
He added: “Because we have so little time, we have to be able to devote our time to the things that will make a difference.”