Why Doctors Interrupt

A few weeks ago I called a neurosurgeon to discuss a patient’s recent headaches.  My patient had been seen in the emergency room several days prior with the worst headache of his life. A complete work-up had not revealed a cause for the headache.  Although he was found to have a small aneurysm on CT angiogram, there was no evidence of bleeding by lumbar puncture.  The story, however, was slightly more complex than this. There had been several other findings that remained unexplained.  One of the findings led me to discuss the patient’s case with a cardiologist.  My patient had also undergone cervical spine decompression surgery several months prior to treat cervical myelopathy.  I wanted to engage the neurosurgeon and get his professional opinion about my patient’s headache, which had now recurred several days after his ER visit.

The surgeon was cordial, but about 5 seconds into my story he seemed inpatient and interrupted me.  “I heard about this guy,” he said, “What he needs is to be seen by one of our neurovascular specialists.”  I had more I wanted to say, but the doctor did not seem to want to listen.  I raised my voice slightly, interrupted him before he had a chance to end the conversation, and bulldozed through, telling the rest of the story in about two minutes.  “Now we’re talking,” he said, as I explained further about a family history of clotting and my concern about a dural thrombus as a potential etiology.  Together we formulated a plan that I was satisfied with--though the interaction left me with a feeling of unease. 

Interruption is a pervasive communication style with doctors.  In a well known study by Beckman and Frankel patients were allowed to complete their opening statement expressing their agenda in its entirety in only 23% of physician interviews.  The average time to interruption was 18 seconds.  This study’s findings have been replicated by several others.  In a more recent study of primary care residents, patients were allowed to speak for only 12 seconds on average before they were interrupted.  Female patients experience interruption more frequently than males. In contrast, studies have suggested higher rates of patient satisfaction with physician visits during which patients and doctors interrupt at similar frequency and also with visits in which there is more “reflective” silent time during the conversation.  Perhaps the tendency to interrupt extends to all physician derived professional communications, as in my case with the neurosurgeon on the phone.  

Why do physicians interrupt?  In practical terms, throughout the course of a given day a physician may be tasked with listening to twenty to thirty patient derived histories and with solving difficult problems for each of these patients in a matter of ten to fifteen minutes. This is a tough, if not impossible job.  Consequently, once a physician believes that the meat of the story is out there, he or she may respond and interrupt before hearing details that the patient (or colleague) feels are important.  In more abstract terms interruption is a communication strategy that reinforces physician dominance in the hierarchy of the patient-physician relationship.

The most frequent complaint that I hear from patients about other physicians is that a physician did not “listen,” or did not “seem to care” about their problem.  My advice to physicians and medical trainees: sit down, bite your tongue and wait. If you do interrupt, do so with brief questions allowing your patient to return to his or her agenda.  You might be surprised and learn something, and no doubt you’ll certainly have happier patients (and colleagues).

Who Should Take Aspirin for Prevention?

The answer is not entirely straightforward.  Aspirin has been shown to reduce the risk of cardiovascular disease, including heart attack and stroke. Aspirin inhibits the function of platelets, the blood cell line responsible for clot formation.  When a heart attack or stroke occur the cholesterol plaque that lines an artery ruptures and platelets aggregate, resulting in a cascade that results in acute occlusion of a blood vessel.  Patients who are treated with aspirin are less likely to clot.  However, the effects of aspirin are not entirely benign. With its platelet inhibition it also confers a higher risk of bleeding—in particular gastrointestinal bleeding and hemorrhagic stroke, which also may be life threatening.

Clinical trials have looked at aspirin intake, cardiovascular outcomes, and bleeding risk. Aspirin for acute cardiovascular events and for “secondary prevention” (prevention after the diagnosis of coronary artery disease or cerebrovascular disease has been established) is undisputed.  Trials suggest that the benefits of therapy outweigh the risks of bleeding. 

However, whether or not aspirin should be prescribed for “primary prevention” (prevention in a person who is disease-free) is more ambiguous.  In 2009 a meta-analysis of existing study data looking at this question was published in Lancet.  The analysis found that aspirin reduced the risk of non-fatal myocardial infarction by one fifth, but that aspirin therapy also significantly increased risk of major gastrointestinal and extracranial bleeding and did not improve overall mortality.  In 2009 the US Preventive Services Task Force (USPSTF) reviewed the existing data and concluded that while aspirin reduces the risk of myocardial infarction in men and ischemic stroke in women, it increases the risk of major extracranial bleeding.  The USPSTF recommended that the decision to use aspirin therapy for the purpose of primary prevention should take into account an individualized assessment of cardiovascular risk and also bleeding risk. Patients with higher cardiovascular risk may benefit most from therapy.  

Patients considering aspirin therapy for primary prevention should assess their cardiovascular risk profile with their personal physician. The Framingham Risk Calculator is a recommended tool for estimating one’s ten year risk of having a major cardiovascular event.   However, Framingham may not be as useful for women as it is for men, and some recommend use of the Reynolds Risk Calculator. The Reynolds Calculator incorporates the inflammatory marker hs-crp into its calculation of ten year risk.

In a similar vein, in 2010 the American Diabetes Association, the American Heart Association, and the American College of Cardiology issued a joint statement revising their recommendations for use of aspirin for thepurpose of primary prevention amongst diabetic patients.  In contrast to old guidelines, the new recommendations do not advise that all diabetics over age 40 receive aspirin therapy.  Rather, they advise aspirin therapy for primary prevention in male diabetics under 50 and female diabetics under 60 only if one additional cardiac risk factor is present (hypertension, high cholesterol, smoking, family history, microalbuminuria) The new recommendation is based in part on a subgroup analyses of diabetic patients in the meta-analysis of the Antithrombotic Trialists’ Collaboration showing  that diabetic patients benefited less from aspirin therapy than non-diabetics. In addition, several smaller studies conducted specifically on diabetics and looking at primary prevention failed to demonstrate a significant benefit of aspirin therapy in those without diagnosed cardiovascular disease.  Further study is ongoing to research the issue of primary prevention of cardiovascular disease with aspirin in diabetic patients.  For now the therapy is recommended for diabetics who are determined to be intermediate to high risk (Framingham risk of 10% or higher).

Who is most likely to suffer a complication related to daily use of aspirin? Risk factors for gastrointestinal bleeding with aspirin therapy have been identified:

• Non-steroid anti-inflammatory (NSAID) use (in particular, high dose NSAID use)
• Chronic steroid use
• Prior history of peptic ulcer disease (PUD)
• Advanced age (>60-65 years old)
• GERD or dyspepsia (less risk than PUD)
• Concomitant use of another anti-coagulant

Treatment with a proton pump inhibitor, or the prostaglandin E analog misoprostol, can reduce one’s risk of gastrointestinal bleeding from NSAIDS.  By contrast, H2 blockers are not effective in this regard.  In addition, using enteric coated aspirin does not reduce its gastrointestinal toxicity.  It is unclear what dose of aspirin is best for primary prevention, but most recommend low dose aspirin (81-162mg), which appears to be equal in efficacy to higher doses (though it has not been demonstrated to be safer).

It’s interesting to me that simultaneous with a growing emphasis on incorporating population-based strategies into healthcare delivery we are also becoming increasingly aware of the importance of identifying personalized risk factors in order to best counsel individual patients on medical care and prevention.  Aspirin therapy for primary prevention is an example of how a one-size-fits-all population-based strategy is hard to apply.  We have seen similar recent trends with mammography screening recommendations, using PSA for prostate cancer screening, and will likely soon be hearing more about using a personalized approach to recommending statins for the purpose of primary prevention of cardiovascular disease (given recent associations between statin use and reversible cognitive complaints and diabetes). How population medicine, its associated quality reporting, and pay-for-performance on the one hand, and personalized medicine on the other, are reconciled in medical practice will be a challenge to be dealt on the level of policy, practice, and reimbursement in years to come.

Intuitive Eating and More

Recently Personalized Primary Care Atlanta hosted an evening workshop reviewing some of today’s popular diets.  Nutritionist, David Orozco, RD  presented an overview of popular diets including: Atkins, South Beach, Paleo, Sugar Busters, DASH, Mediterranean, Zone, Weight Watcher’s, and the HCG diet, among others. 

In his talk Mr. Orozco briefly described some key elements of “fad” diets to beware of: 

• A magic bullet (i.e. the hormone HCG, which, when given with a 500 kcal per day diet, results in weight loss)
• Diet phases or stages, such as “Rapid Detox” and “Maintenance” phases
• Celebrity testimonials and endorsements

Medical professionals agree that the DASH diet and the Mediterranean diet have the most scientific evidence to back up their potential benefit in terms of health related outcomes such as hypertension and metabolic syndrome. These two diets are also ranked #1 and #2 respectively by a US News ranking of "Best Diets." WebMD’s diet comparison tool comes very highly recommended if you are sorting through diet options.

However, Mr. Orozco advocates a different approach to dieting: “Intuitive Eating,” or “Mindful Eating.” These concepts involve gaining an understanding of one’s relationship with food and then healing it, such that an individual gains a heightened responsiveness to his or her own body signals.  The premise, a kind of psychotherapeutic approach, is that intuitive eating will result in better food equilibrium and eventual healthy weight maintenance.  I’ll admit that I have not yet read the book, but am eager to do so.

As I listened to the talk, I brought to the table my own perspective—I have never struggled with my weight, I am a relatively compulsive exerciser, and I enjoy cooking and eating out.  Exercise alone has been shown to be an effective technique to help with weight maintenance.  My personal experience (I’ve been about the same weight since age 18) is testimony to this. However, the one time that I did lose 15 pounds, I did it through calorie counting.  Since then (twenty years ago), I’ll admit that I do have a conscious awareness of the caloric value of most food that I ingest.  Do I eat chips, chocolate, an occasional Quarter Pounder and fries? Absolutely; but when the scale tips up five pounds I am quick to take action and cut back.  For dinner tonight—homemade lentil soup with kielbasa, bacon, and carrots, brown rice, green salad with blue cheese, and a glass of Argentine Malbec; for dessert: a sliver of lemon pound cake topped with coconut gelato.

I have found that with my patients who want to achieve more than ten pounds of weight loss, a structured approach is essential—a specific action plan.  Vague plans to cut back and “eat healthier” tend not to be effective. Over the years I have asked my patients who have successfully lost weight what their strategy was.  Though the strategies that my patients describe are as diverse as are the array of diets on the market,  a common thread seems that those who have been successful are able to articulate a clear plan of action that led to the weight loss.

I am an advocated of calorie counting and Weight Watchers (whose point system is essentially like calorie counting).  My viewpoint is that for weight loss, it’s not so much the content of the food that matters, but rather the quantity and caloric value.  However, there is some evidence that low carbohydrate diets may produce more weight loss than very low fat diets (i.e. the Ornish Diet) though this finding has not yet been definitively proven. A pound of fat is equal to 3500 kcal. It’s hard to lose more than a pound of fat every 7 to 10 days, and I don’t recommend it.  I personally consume about 2000-2500 kcal per day (with 30-60 minutes of exercise on most days).

Here are some of my own weight loss tips: 

• Eat smaller portions, but don’t skip meals
• Count and record your calories for at least 1-2 weeks when you begin to diet
• Don’t reduce your caloric intake by more than 500 kcal per day below baseline intake (it’s too hard to maintain)
• Don’t drink diet drinks and don’t drink any beverage all day long (including water)
• Do have coffee or tea following a meal if you are not quite satisfied
• Do enjoy a mealtime ritual at least once a day-- set the table and play some music while you dine, enjoy your oatmeal and coffee while reading the paper
• Don’t snack more than once per day
• Do allow yourself to feel hunger for a couple of hours before you eat
• Limit refined carbohydrates and add healthy fats, but forget margarine, it’s no substitute for butter
• Don’t eliminate your favorite food, save it as a treat a day or two per week
• Treat yourself to meals out, but split your portion with a companion or eat an appetizer instead of an entree
• Exercise 3-4 times per week, but keep in mind that adding exercise alone rarely works to achieve more than 5 to 10 pounds of weight loss 
• Don’t chastise yourself if you are unable to exercise, most of weight loss comes through alterations in one’s diet not through exercise
• Cook at least three times per week using whole food ingredients and cook enough for two meals so that you can have leftovers
• Pack your lunch and bring it to work

Once your desired weight loss is reached, this is where intuitive or mindful eating becomes important—retraining oneself toward a healthier relationship with food.  Weight maintenance is the hard part. Some of you may have read a recent New York Times Magazine cover article entitled “The Fat Trap” by weekly health columnist and author of the NYT "Well" blog Tara Parker-Pope.  Ms. Parker-Pope makes the case that powerful metabolic and hormonal factors make it very difficult to maintain weight loss.  I personally find Ms. Parker-Pope’s viewpoint overly nihilistic, though she brings to light interesting information.  A petitioned response to Ms. Parker-Pope’s piece, authored Gary Taubes and Peter Attia, MD, argues that Ms. Parker-Pope’s article neglected the important effect of insulin resistance on obesity.  The authors maintain that restriction of refined carbohydrates, as opposed to overall caloric restriction, can allow overweight patients to successfully bypass some of the metabolic impediments to weight loss by reducing insulin resistance, while all the while suppressing hunger through increased protein and fat consumption.  Indeed there is some medical evidence to support low carbohydrate diets.

In my own practice I have seen numerous patients lose weight successfully.  The metabolic effects on cholesterol, blood sugar and blood pressure are typically profound.  Remember, if you are overweight or obese, weight loss in itself is as important of a goal as is healthy eating.

How did you lose weight? Were you able to maintain it? What do you think of the intuitive eating concept? I welcome you to share your own lessons and help others. 

*To learn more about intuitive eating contact David Orozco RD of T+D Wellness in Atlanta at 404-228-9704.