‘Don’t drink, don’t smoke:’ Need a fresh way to talk to patients about risk?

Margot L. Waitz, DO, realized she needed to change the way she advised her patients on risky behaviors after several eye-opening encounters.

During one appointment, she warned a 15-year-old male patient from the inner city about the long-term health hazards of tobacco use. “He looked at me and said, ‘I don’t expect to live past 19, so what does it matter to me?’ ” says Dr. Waitz, who practices in Wilmington, Delaware. “I recall thinking, ‘That’s horrifying. I don’t have a comeback for this.'”

Dr. Waitz saw that she needed to take each individual’s circumstances and worldview into account when trying to effect behavioral change.

Instead of pointing out the increased risk of developing lung cancer, she’ll ask lower-income youth who smoke, “Can you really afford to spend so much money on cigarettes?” When discussing smoking with teenage girls, she may bring up the deleterious impact it has on personal hygiene.

“The fact that their hair stinks and their breath is lousy are immediate concerns that might motivate them to change,” Dr. Waitz says.

A patient’s age, gender, socioeconomic status and prior health history help physicians determine the specific risks to address and the best way to deliver the message, several DOs agree. Drawing on their personal experiences, these physicians offer tips for tackling difficult issues such as sexual behavior, substance abuse, gun safety and extreme sports.

Discussing sexual risk

Primary care physicians must broach the topic of sexual risk with all patients who are in early adolescence or older, notes Danielle Lynn Cooley, DO, who acknowledges that such discussions can be challenging.

Dr. Cooley speaks privately with her teenage patients about sex.

“We’ll have a friendly conversation,” says Dr. Cooley, a family physician in Mount Laurel, New Jersey. “If they tell me they haven’t had sex, I’ll suggest that they refrain from it. If they are already sexually active, I’ll emphasize that they need to protect themselves.”

Some teenage girls ask to go on birth control pills to minimize the frequency or symptoms of their menstrual periods. Dr. Cooley sees this as an opportunity to caution them about the risks of unsafe sex, including not using a condom and having multiple partners or partners they don’t know well.

John T. O’Connor, DO, MPH, advises physicians to ask patients of all ages and sexual orientations about their sexual behavior in a non-critical way.

“A physician should never say to a patient, ‘You don’t have unprotected sex, do you?’ ” says Dr. O’Connor, a family physician in Marietta, Oklahoma. “If I knew that an unmarried patient was sexually active, I might ask, ‘Have you had any questions that you wanted to ask somebody about birth control or STDs?’ Sometimes the patient might pretend to have a friend who has questions, and that’s OK because you are still able to give the patient the needed information.”

Physicians can consider prescribing Truvada, the only FDA-approved medication for preventing HIV infection, to sexually active patients who do not consistently use condoms.

Talking about guns

Gun safety can be even trickier to discuss with patients than sex, especially in parts of the U.S. where guns are ubiquitous, Dr. O’Connor says. Once he asked a female patient if she had any loaded guns in the house, and she responded yes. So he asked a follow-up question: How do you keep them safe?

“She didn’t know the answer, so she went home and asked her husband,” Dr. O’Connor remembers. “The next day he came into my office and confronted me because he thought I planned to report him to the authorities.”

Ultimately, Dr. O’Connor’s goal is to make sure patients and their families are protected from danger. “I don’t want patients to feel like I’m prying. I want them to feel that together, we’re going to make their homes safer,” he says.

While gun owners may know how to handle firearms safely, children and other adults who live in the home, as well as visitors, may not. Older guns may discharge accidentally if dropped.

Physicians have the responsibility to educate patients about such dangers, Dr. O’Connor believes. In 2013, the AOA House of Delegates passed three resolutions that endorse a physician’s right to talk about gun ownership and safety with patients.

Preventing injury

Emergency physicians may be more aware than other doctors of the breadth of hazards people face. But they have less time to counsel their patients about risks, says Steven T. Elsbecker, DO, an emergency physician at Lakeway (Texas) Regional Medical Center. Nevertheless, he tries to do what he can.

An avid motorcyclist, Dr. Elsbecker frequently finds himself offering advice to bikers who’ve been in collisions. He’ll use positive reinforcement when a patient brought into the emergency department is wearing the recommended protective gear—helmet, padded leather or Kevlar jacket and pants, boots reinforced to protect the ankle and toes, gloves with carbon-fiber knuckle protection.

When the patient isn’t wearing safety gear, Dr. Elsbecker typically treats much more severe injuries. “After the patient is stabilized, I will say something along the lines of, ‘Had you been wearing a helmet and protective clothing, these injuries might have been prevented,'” he says.

Sports medicine physician Patrick F. Leary, DO, similarly advises patients who plan to engage in extreme sports, such as aerial snowboarding or skateboarding, to wear all of the recommended protective gear. Dr. Leary emphasizes that such sports are too risky for middle-aged and older patients, who have much less musculoskeletal flexibility.

“I wouldn’t want 40- to 60-year-olds in a position where they would land or their head or neck,” says Dr. Leary, who is the president of the American Osteopathic Academy of Sports Medicine.

For patients who want to take up a potentially hazardous sport for the first time, Dr. Leary recommends a thorough pre-participation examination to make sure the activity is appropriate for the patient’s age, size, health status, strength and agility. In addition to conducting a detailed history and physical examination, he has patients undergo a functional movement screening, in which they are scored on such variables as shoulder mobility and trunk stability.

Tackling drug and alcohol abuse

Back in the ER, Dr. Elsbecker sometimes advises patients who have drug- or alcohol-related issues.

“I’ll assess whether the patient is someone who seems to be open and willing to change or someone who is going to drink alcohol or abuse drugs no matter what I say,” he explains. “Because my face-to-face time with each patient is so limited, I have to pick my battles. I tend to focus my efforts on those who realize that their substance-abuse problem is what landed them in the emergency room and that maybe it’s time to choose a new course.”

One patient Dr. Elsbecker helped has come to Lakeway’s emergency department on more than one occasion with subcutaneous abscesses from injecting methamphetamines.

“Each time she comes in, she is very remorseful about her drug use,” he says. “The last couple of times she came in to have the abscesses drained, I gave her a list of local resources, such as substance-abuse clinics and rehab centers. A social worker at our hospital helped her select which programs to call.”

When he saw the patient again in the ER, she mentioned that she was still waiting for her addiction clinic appointment. But she seems motivated to follow through, he says.

Although not all patients express appreciation for their physicians’ efforts to reduce their risks, doctors need to keep trying to make a difference, Dr. O’Connor stresses.

“Patients are going to do what they want to do,” he says. “But you can have influence, especially if you listen to them and show some empathy.”