Besides reimbursement, few challenges vex physicians more than noncompliant patients. For primary care physicians, treating individuals who fail to lose weight, exercise or stop smoking has always been frustrating.
But with patient outcomes taking on increasing importance in today’s pay-for-performance environment, patients who don’t heed their doctors’ recommendations can have a direct impact on physician income.
What can osteopathic physicians do to improve patient compliance? Several members of the profession offer advice.
“Throughout my career, I’ve been involved with helping people find health, which is a fundamental aspect of osteopathic medicine’s philosophy,” says Kari A. Hortos, DO, an endocrinologist in Macomb, Mich.
Dr. Hortos urges DOs not to simply tell patients to stop smoking, avoid certain foods and be less sedentary. “All adult patients know the things they shouldn’t do,” she says. “It’s not a matter of them having an insufficient knowledge base. Rather, the key is to teach patients how to change their behavior.”
Physicians need to recognize that patients’ harmful habits meet deeply held needs, Dr. Hortos says. “When we as physicians acknowledge that patients have needs beyond achieving better health, we have a better chance of helping them,” she says.
Instead of just lecturing on all the conditions triggered by obesity or all the reasons tobacco is harmful, Dr. Hortos advises physicians to listen to their patients. She urges using what she calls a “one-minute motivator,” asking patients to respond to a series of four questions:
- What would you like to have happen?
- What needs to happen?
- Can you do those things to make it happen?
- Will you?
“You need to get patients to talk because their motivation to change has to come from within,” Dr. Hortos says.
Getting adult patients to eat well is even more challenging than getting them to stop smoking, Dr. Hortos contends. While people can quit smoking cold turkey, food consumption is obviously not an all-or-nothing proposition. Patients need to eat every day, and unhealthful food is everywhere.
To encourage obese patients to lose weight and make better food choices, she suggests that they keep track of everything they eat for a week or more. Keeping a food diary builds awareness of what one is consuming and improves self-control.
“For example,” explains Dr. Hortos, “a patient may know she is supposed to eat more fruits and vegetables, but she craves macaroni and cheese because it is a comfort food for her, and she is upset. That’s fine; she can have it. But by writing it down, she may choose to have one cup of macaroni and cheese rather than two cups.”
A self-described pragmatist when it comes to nutrition, Dr. Hortos advocates “everything in moderation,” while suggesting that patients favor fresh over processed foods and join Weight Watchers or Overeaters Anonymous for nutritional guidance and peer support.
A family physician in Scottsdale, Ariz., Arthur J. Mollen, DO, also has his patients keep a food diary, but he has stricter recommendations for what his overweight patients should and shouldn’t eat. Besides encouraging them to eat more fruits and vegetables and to choose fish and chicken over red meat, he asks patients to eliminate starchy food, such as pasta, rice, potatoes and bread, from their diet.
The author of several books related to wellness and fitness, he may give a patient a copy of Dr. Mollen’s Anti-Aging Diet or The Mollen Method: A 30-Day Program to Lifetime Health Addiction to convince them of the need not just for dietary change but for lifestyle transformation. To Dr. Mollen, integrating exercise into one’s life is of utmost importance.
“Most people are overeating out of stress or boredom,” he says. “Exercise reduces stress, and exercise reduces boredom.”
Small, measurable goals
Patients are more likely to be successful at losing weight and carrying out exercise routines if they set small, measurable goals for themselves, according to Dr. Hortos. “If they feel they need to lose 100 pounds, they should take it 5 pounds at a time or even 2 pounds at a time,” she says.
Dr. Mollen also champions an incremental approach to weight loss and sometimes even gives patients free office visits for lost pounds. “I’ll bet them that if they can lose 2 to 3 pounds between office visits, I won’t charge for the next visit,” he says. This incentive makes the weight-loss process more fun.
When it comes to exercise, Dr. Hortos recommends small steps as well.
“I have encouraged patients to take what I call ‘activity snacks,’ rather than engage in long periods of exercise,” she says. “I’m like that myself. I know I’m not going to exercise for 45 minutes straight. But I can talk myself into 10 minutes of exercise at a time—on my rowing machine or my treadmill. If you chunk it up like that a few times a day, you don’t have to go to a gym and wear Lycra.”
Dr. Mollen expects his out-of-shape patients to gradually increase their exercise. They can start off by exercising 10 minutes a day for a month, then 15 minutes a day, working up to an hour or more of daily aerobic activity. He recommends brisk walking, running, cycling, swimming and dancing to get the heart rate up.
The Mollen Clinic, which has personal trainers on staff, has had success in fighting obesity and improving wellness, according to Dr. Mollen.
“I’ve had patients who weighed more than 400 pounds get down to 200 pounds,” he says. “One of them even beat me in a triathlon.”
Leading by example
To sway patients to make changes, physicians must adopt healthful lifestyles themselves, Dr. Hortos and Dr. Mollen insist.
Dr. Hortos cites a study published in Obesity in May 2012 of 500 primary care physicians, just over half of whom were overweight or obese. “The study showed that physicians who are of normal weight are more likely to provide recommended obesity care to patients than those who are not,” she says.
Instilling healthful habits in physicians requires educating future doctors about nutrition and exercise while they are still students, Dr. Hortos believes. To this end, she has conducted a pilot study of 20 students at the Michigan State University College of Osteopathic Medicine in East Lansing. The students, not all overweight, took part in a Weight Watchers at Work program for eight weeks.
“The idea was to help the students improve their health-related fitness and nutrition whether they needed to lose weight or not,” Dr. Hortos says.
“Before the study, many of the students suspected it would be very difficult to change one’s dietary habits,” Dr. Hortos reports. “During the study, the students realized that change isn’t easy, but it’s doable. Through their own self-efficacy, they came to understand that you can encourage people to make small behavioral modifications.
“By learning such techniques as how to prepare and eat healthful meals when on the go, they are going to be better coaches for their patients.”
Dr. Mollen’s patients know that he leads the lifestyle he touts. He regularly wakes up at 5 a.m. to run or ride a bike and then lift weights. And he swims a mile in a pool in the evening.
Dr. Mollen tells patients that they are more likely to stick with a fitness program if they exercise in the morning rather than at night, when they are likely to make excuses about being tired. But it is best to exercise both at the beginning and the end of the day if possible, he says.
“I’m tired when I get into the pool at night, but I feel so much better after I swim,” he says. “I exercise 90% for my mind and 10% for my body.” In addition to experiencing many other health benefits, patients who exercise regularly report improved digestion, sleep and alertness, he says.
Dr. Mollen believes in using positive reinforcement to effect change. “I’ll tell patients, ‘You can be on fewer meds if you alter your lifestyle,’ ” he says.
But family physician Christopher A. Schnurer, DO, of Clinton Township, Mich., has found that a tougher approach is needed for the indigent, uninsured patients who seek care from the Mount Clemens (Mich.) Regional Medical Center’s mobile medical clinic.
“Essentially we hit them with a stick because the carrots didn’t work,” says Dr. Schnurer, who previously served as the clinic’s medical director and now oversees its staff as the hospital’s director of medical education.
Based out of a 40-foot truck, the mobile clinic operates three days a week, making stops throughout Michigan’s Macomb County.
“Basic medical care and medications are free because the hospital has agreed to underwrite the costs,” Dr. Schnurer says. “We tell the patients, we can treat you at no charge, but you need to be compliant.”
For example, to help patients stop smoking, the outreach clinic will provide smoking cessation medication. Patients will need to submit to blood tests periodically to assure the clinic that they are avoiding tobacco.
The clinic is particularly strict with patients who have a smoking-related illness, such as chronic obstructive pulmonary disease.
“If we have someone on an inhaler for COPD who still smokes, that’s when the stick comes out,” Dr. Schnurer says. “We’ll say, ‘If we give you medications, you are not going to smoke.’ ”
To persuade patients with cardiovascular disease or diabetes mellitus to exercise and improve their diets, the clinic staff doesn’t mince words.
“We’ll say, ‘You are supposed to lose weight, and you’re not,’ ” Dr. Schnurer says. “ ‘What’s going on? You’ve got to be more compliant, or you’re not going to get better.
“ ‘If you listen to us, we’ll get you to a point where you feel better and you won’t have to go to the emergency department, you won’t develop heart disease, and you won’t go blind or lose your feet to diabetes.’ ”
Whatever the motivation technique, physicians need to do more to inspire patients to change their lifestyles, Dr. Mollen says.