by Danielle Ofri
New York Times Op-ed
Recently, I was talking with a patient about her glucose levels, which have been inching their way toward diabetes. She was honest that she was eating too much junk and knew perfectly well that her diet was not doing her health any favors.
We talked about the circumstances of her daily life, and together came up with the plan: she would try to eat one fruit or vegetable every day, while cutting out one serving of junk food. It was a modest goal, but seemed obtainable. A perfect example of shared decision making.
But after she left, I glanced back at my previous notes and saw that we’d negotiated the exact same compromise during her last appointment. Scrolling back, 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, it wasn’t getting us anywhere. Her diet hadn’t budged.
We doctors constantly lament how difficult it is get our patients to change their behavior. We rant about those who won’t take their meds, who won’t quit smoking, who never exercise. But the truth is, we are equally intransigent when it comes to changing our own behaviors as caregivers.
Clinical practice guidelines are a common way of summarizing the standard recommendations for medical conditions. There are thousands of guidelines, for everything from genetic screening to bedsore prevention. Most doctors and nurses think that well-researched guidelines are an excellent idea. Most agree with their recommendations.
The problem is, most of us are just like our patients — we often ignore good advice when it conflicts with what we’ve always done.
I thought about this as I read the latest recommendations from the Choosing Wisely campaign — a project led by the American Board of Internal Medicine to inform doctors and patients about overused and ineffective tests and treatments. Medical groups were asked to list five things in their field that are often overutilized but don’t offer much benefit.
Last month, my specialty group — the Society of General Internal Medicine — released its Choosing Wisely recommendations. No. 2 was: “Don’t perform routine general health checks for asymptomatic adults.”
This runs counter to a basic pillar in medicine that doctors and patients remain strongly attached to: the annual checkup. This is our chance to do screening tests and vaccinations and to discuss a healthy lifestyle. Anecdotally, we all can cite examples of checkups that uncovered serious illness. But the scientific evidence shows that on balance, the harm of annual visits — overdiagnosis, overtreatment, excess costs — can outweigh the benefits.
Yet, I still do them. Each time I see a healthy patient, I close the visit by saying, “See you in a year.” It’s a reflex.
After the research was initially published last year, I grappled with the evidence, or lack thereof, reaching a conclusion that I mainly still supported the annual visit, if only because it establishes a solid doctor-patient relationship. But seeing these new, strongly worded recommendations, I may have to re-evaluate. At the very least, I should take a moment to think before I reflexively recommend the annual visit. But I know that I might still end up doing the same thing, despite the evidence.
Humans are creatures of habit. Our default is to continue on the path we’ve always trod. If we doctors can recognize that impulse in ourselves, it will give us a dose of empathy for our patients, who are struggling with the same challenges when it comes to changing behavior.