Doctors’ Bad Habits

by Danielle Ofri
New York Times Op-ed

Recently I was talking with a patient about her glucose levels that have been inching their way up to diabetes level. She was honest that she was eating too much junk food and candy, with nary a leaf nor green in sight. She was a college graduate and certainly knew that her diet was not doing her health any favors.

We spent some time talking about the specific circumstances of her daily life, and together came up with the plan that she would try to eat one fruit or one vegetable every day, and concomitantly try to cut out one serving of junk food. It was a modest goal, but seemed potentially obtainable. A perfect example of shared decision-making.

After she left, I glanced back at my previous note in the chart and saw that we’d negotiated the exact same fruit/vegetable/junk-food compromise last time. Scrolling back a few more notes, and I could see that at every visit we covered the same nutritional territory and each time I must have congratulated myself on the excellent patient-centered care.

Unfortunately, all of this ideal medical care wasn’t getting us anywhere. Her mode of eating hadn’t budged, despite all of our discussions, despite the looming health consequences.

We doctors constantly lament how difficult it is get our patients to change their behaviors. We rant about our patients who won’t take their meds, who won’t quit smoking, who never exercise, who live on McDonalds, who refuse to get screening tests. But the truth is, we doctors are equally—and impressively—intransigent when it comes to our own behaviors as caregivers.

Clinical practice guidelines are a common way of summarizing the standard-of-care recommendations for particular medical conditions. There are guidelines for cancer screening, treating hypertension, whether an ankle sprain needs an x-ray, how to promote breastfeeding, how to prevent bedsores, whether to give antibiotics for bronchitis, how to use genetic screening. (The National Guideline Clearinghouse currently lists 2,663 different guidelines.)

Good guidelines summarize the current state of medical knowledge and help standardize medical care across the vast field of doctors and nurses and their patients. Guidelines are supposed to make it easier for the individual caregiver who doesn’t have time to read every journal and wade through conflicting data to formulate a best-practice plan. Most doctors and nurses think that well-researched guidelines are an excellent idea. Most agree with the recommendations of the guidelines.

The problem is, most of us are just like our patients—we continue to do the same thing we’ve always done, despite having all this wonderful information at hand. Now there are many reasons why clinicians do not adopt the behaviors recommended by guidelines—sometimes the guidelines are unwieldy, the patients in the clinical trials may be very different from our particular patients, the logistics or economics may be impractical, or we may simply disagree with the guidelines.

But even we agree with the guidelines and wholeheartedly support the conclusions, our rate of behavior change would not set any world records.

I thought about this as I read the latest recommendations from the Choosing Wisely campaign—a project from the American Board of Internal Medicine and the National Physicians Alliance that tries to steer doctors and patients away from overused and ineffective tests and treatments. Professional medical groups from all specialties were asked to come up with a list of five things in their field that were commonly over-utilized but didn’t offer much benefit.

This month, recommendations were released from my own specialty group—the Society for General Internal Medicine—so I read them with special interest, wondering how much we doctors—and our patients—might change our habits.

One of the recommendations was: “Don’t perform routine general health checks for asymptomatic adults.” This runs counter to a basic pillar in medicine—the annual check-up.  Doctors and patients alike remain strongly attached to the annual visit. The scientific evidence to date, however, doesn’t show overall benefit, and in fact there may be some harm.

Yet, I still do it. This week in clinic, for each of the healthy patients I’d seen—those without major chronic illnesses—I closed the visit by saying, “See you in a year.” It’s a reflex.

Earlier this year, I’d grappled with the evidence, or lack thereof, reaching a conclusion that I mainly still supported the annual visit. Establishing a doctor-patient relationship is of value, and this can certainly make things easier if illness shows up later. And, anecdotally, we all can cite examples of when annual visits picked up serious illness.

But seeing these new recommendations, which remind me that, on balance, the harm of annual visits—over-diagnosis, over-treatment, excess costs—can outweigh the benefits, I may have to rethink my conclusion. At the very least, I should stop myself before I reflexively recommend the annual visit and take a moment to think through what I am doing.

I suspect that most of us doctors will continue recommending the annual visit. Human beings are creatures of habit. Our default is to continue along the same path we’ve always trod. But it should it should give us a moment’s pause and a dose empathy for our patients, who are struggling with the same challenges when it comes to changing behavior.