Tag Archives: behavior change

The changing face of rural America

–Therese Zink

Rural counties, especially those located adjacent to metropolitan areas have seen population growth. Challenges arrive along with these new Americans: How do two or three different cultures live together? How does a small clinic with limited resources accommodate different languages and different understandings about health and healing? The diabetic diet looks different from a Mexican diet where beans and rice are staples and different from the farmer who wants his meat and potatoes. Some workers arrive without family, leaving their wives and children back home for the season or several years. Problems such as alcohol abuse, sex trafficking, and violence often accompany this disconnected lifestyle.

(Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

How do we meet the needs of patients that extend beyond the clinic.  These are often called the social determinants of health. These play an important role in keeping people healthy and helping them achieve health.  Health care professionals need a team to address these issues and that team includes public health, social workers, as wells a policy makers and community advocates.  Pay attention in you community.  Is your preceptor aware of the other factors affecting a patient’s situation?  An alcohol problem? Housing problems? No money for food? Family problems?

Sometimes new Americans or immigrants have a more difficult situation because supports do not yet exist to help them and language barriers make it hard to communicate. If you community has immigrants, how are they welcomed into the health care setting?  Interpreters? Signage? Specific patient education? Multi-lingual providers? Art on the clinic walls?

If you were in charge what would you do differently?

A Modern Country Doc–playing the game

Tom Bibey

The insurance companies love to play doctor. Take my noncompliant diabetic patient with a hemoglobin A1C that does not meet goal. (We explained this in an earlier blog post.) The first order of business, since I wish to stay in practice, is to send him to an endocrinologist. If possible, one should bolster the case by the choice of one from a medical center. A year later, the patient will still have the same numbers, unless he comes to Jesus and decides to change his life. The cost of the endocrinologist changed nothing but increased the bill to insurance, and my risk as a target for the blame is dramatically lowered due to the referral.

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

Here Dr. B is referring to our effort to meet certain treatment goals with patients. Some insurance companies reimburse physicians with extra money if a certain percentage of their patients reach the recommended goals. This is called Pay for Performance and sometimes referred to as P4P.

A large randomized controlled trial on diabetes–ACCORD— helped to outline the goals management of  patients with Type 2 diabetics. Here is an easy explanation.

The challenge is to motivate patients to change their behavior, often easier said than done. In earlier posts we’ve talked about Motivational Interviewing techniques to help patient weigh the pros and cons of continuing to do what they do. As you spend time in clinic, you’ll see different attempts to help patients quit smoking, lose weight, start exercising, be compliant with their medications. It is no easy task. However, I don’t want to leave you with a downer. When you do assist someone in making a behavior change, there is nothing like it—it can make your whole day or week for that matter.

We are rural.

–Dr. Tom Bibey

 The landscape may be in evolution, but some things never change. Spring planting will come around every year, and some of our patients will sit on the front porch and smoke cigarettes because that is what they do. Yeah, our patients eat too much at times and don’t exercise enough, and maybe they aren’t all that sophisticated, but don’t diss ’em. They are our patients. We are them, and they are us. We don’t talk bad about our own.

 (Excerpted and used with the permission of the author, published in The Country Doctor Revisited, KSU, 2010)

 In rural health care we often live in community with our patients. As we’ve discussed in other posts, this poses challenges for confidentiality and privacy. [See October 3rd post] Familiarity can breed tolerating the status quo as well as understanding the underlying dynamics and issues that need to be addressed to help patients problem solve and make better choices in their lives. Sometimes a fresh perspective brings new energy and ideas. Often clinics like having students for those reasons. A new set of eyes can ask the same old question from a different angle, a mind fresh from training shares new information and new thinking. 

 There is value to understanding what cannot and will not change. It can save us lots of energy and head banging when working with patients. It is our job to present options to patients, but ultimately their choices are their own. There may be ramifications to those choices,  but it is the patient who has the power to change his/her behavior or his/her situation.  Understanding Prochaska and DiClemente’s http://www.motivationalinterview.org/ stages of change can help during patient care. The Transtheoretical model was developed in the 1970’s based on different psychological theories about how people make and adapt to changes in their lives. An individual cycles through various stages when deciding to change a problem behavior.  Precontemplation—you don’t think you have a problem; Contemplation—realize you do have a problem and examine the pros and cons to making a change; Preparation—gathering the tools and support to make a change; Action—actively taking steps to change a behavior; Maintenance—continue the change for more than six months.  Of course, patients cycle through contemplation and action and even maintenance repeatedly. Think of a person who quits smoking, loses weight or starts an exercise program.

 As a provider, when a patient is in precontemplation, it is my job to remind him/her that his/her behavior is a problem. “Losing even five pounds could make a big difference for your blood pressure control…” I won’t waste my words or time about how to do it if he/she isn’t really interested in making a change. If I receive the response, I like my cigs, doc, the I remind them with humor –“I wouldn’t be doing my job if I didn’t bother you about our cigs.” Humor almost always. When a patient is actively weighing the pros and cons, then it is worth my time to talk about the supports available for the behavior change–quitting smoking, exercise, etc. However, instead of lecturing, motivation interviewing helps the patient explore their assets and blocks for altering the behavior.

 Think about patients you’ve seen. Who was or was not ready to change his/her behavior? It is the new year, a time that many people take stock and make resolutions to change. Some will be successful, some will not.

Share the story without using identifying information.  Did the provider or nurse you worked with do a particularly good job of addressing behavior change with the patient? If so, tell us about it. If not, what could they have done differently that would have taken a motivational interviewing approach.

If you don’t have what you want…

–Joseph Gibes

Dr. Gibes periodically does home visits to Amish patients in Wisconsin.  He tells a story about performing a circumcision on an infant.  You can see him read this on <YOU TUBE>

I gently lifted the little patient from the bassinet and laid him on the board, molded to cradle a newborn baby, and secured his legs with the Velcro straps. He struggled and fussed for a few seconds, but then settled back down, oblivious to his fate. I put on the gloves and started the procedure. Elim [his father] gently held a pacifier with a little sugar water on its tip in his son’s mouth, which was enough to keep him quiet. I tried to keep up a little conversation with the farmer as I worked.

“Cold, isn’t it?”

“Yes,” he replied. “I think it gets even colder here than it did in Pennsylvania.”

“What kind of stove is that you have?”

“Kerosene.”

While we spoke I worked quickly. Two clamps on. Probe to reduce adhesions. Third clamp on, to mark the extent of the foreskin to be removed. Then apply the Mogen clamp and close it. The patient remained stoically quiet through the whole thing. The procedure was all over except for the actual cutting. I reached to the sterile field for the scalpel. I couldn’t see it in the dim light. I pushed the instruments around, looked under the gauze: no scalpel. Trying to sound calm, I asked Elim, “Is there anything else in the kit?”

The farmer obliged by reaching in and feeling around. “Nope,” he said.

It suddenly seemed to be getting warmer in the little room, and I started to sweat. The nurse and I had checked and double-checked, and I had checked again, to be sure that everything was there, and we had missed the most important instrument.

The scalpel.

It was a twenty-five minute drive from the clinic and hospital. A little apologetically, I asked the farmer, “Do you have any kind of knife I could borrow?”

If he thought this a strange request, his face did not betray it. He stepped out of the room and said something in their own language to Rebekah [his wife]. A moment later he returned, bearing in his hand the instrument his wife had found, an eight-inch steak knife. “Will this do?”

Given the situation, I wasn’t sure I was going to get anything better. Fortunately, this part of the procedure required neither a sterile instrument nor finesse. “Sure,” I said, trying to sound nonchalant, trying to sound as if doing a circumcision with an eight-inch steak knife was a routine occurrence.

The knife was quite dull, and I had to saw at it a bit to get the job done. The patient lay there placidly, Elim looked on placidly, and I tried to look placid. I left the clamp on for another minute and a half to minimize any bleeding. When I removed the clamp, there he was, as good as if I had used the finest sterile precision surgical instrument in the world…

Once outside, I started to berate myself in earnest. I can’t BELIEVE I was so stupid to forget a scalpel! They must think I’m an idiot! Nevertheless, I attempted to keep up an air of nonchalance as I walked to my car. I opened the door and collapsed into the seat. The mental strain of maintaining a matter-of-fact exterior and trying not to appear completely inept had exhausted me.

I sat and stared out the window for a moment, and as I did, in the midst of my self-reproach, a phrase suddenly popped into my head, a phrase I had heard from a missionary doctor while I was a resident working in a bush hospital in Kenya: “If you don’t have what you want, you gotta want what you have.”

Well, that certainly was true in this situation. And as I stopped berating myself long enough to realize what had just happened, I started to smile. I couldn’t help it, as I thought about it: the absurdity of the situation, the complete stupidity in forgetting the scalpel, me sawing away with a kitchen utensil; and the farmer and his wife so gracious and thankful. The smile became a good belly laugh, and I laughed and laughed until tears rolled down my cheeks.

I was still laughing as I drove down the long driveway. Only in rural practice! I thought how I was going to tell everyone back in my own world about the day’s events: “Y’ know, I’m probably the only doctor in the world to perform a circumcision with an eight-inch steak knife. . . .”

(Excerpted and used with permission, published in The Country Doctor Revisited, KSU, 2010)

Medicine demands we think outside the box and find creative solutions. Iit may be very concrete—identifying physical substitutions or it may be more abstract, making emotional or metal links. To secure the scalpel, Dr. Gibes had a 25 minute drive. He deemed that to be impossible. He made do. He reflects that that is often true in international settings. It can be rewarding to see how folks in low resource countries make do with what they have. Listening to fetal heart tones with a cone constructed from cardboard, feeding infants from a cup or by dipping one’s finger in the milk and then dripping it into the infant’s mouth, washing and drying gloves as the way to deal with limited supplies. Such expansion of your normal experience is often humbling  and  gratifying. You realize what you take for granted in our life and you can pat yourself on the back for your problem solving. And sometimes it results in a good belly laugh.

Helping patients change to healthier behaviors often demands creative mental and emotional gymnastics. Instead of lecturing a patient about what they should do, it often works better to help them explore the pros and cons to making a change. If we use motivational interviewing techniques we ask questions that help patients see the ambiguity in their thinking—what benefits do you get from your cigarettes? What else in your life provides that benefit? Which cigarette is the least meaningful to you during your day?

Do you like walking, what do you like about walking? How could you manage to do a little more? Such questioning demands that the provider follow the patient’s lead and explore the same old thing in a new way. That way we might bring obstacles and resistance into the sunlight as well as assets. Uncovering new angles or feelings might facilitate and empower the patient to try again to change. It may be more time efficient to give a lecture, but we already know that our lectures rarely change a patient’s behavior.

Think about a situation where you saw one of your preceptors bring creative thinking to patient care or when you did so yourself. What did you learn? Was there an “ah-ha” moment for the patient?