For Frank Domino, M.D., of Worcester, Mass., a quick glance at his patient roster for the week reminds him of just how unhealthy Americans have become -- eight of the 13 patients scheduled for the day -- a Tuesday -- need to lose weight, exercise or both, says Domino in an interview with AAFP News Now. "On Wednesday afternoon, 100 percent need to lose weight, exercise or both.”
Domino estimates that on any given day, 14 of 15 patients he sees need help with wellness issues.
Most patients want to lose weight but have difficulty doing so, says Domino, who is an associate professor at the University of Massachusetts Medical School and director of the school's family medicine clerkship.
That's why this family physician uses a different tactic with his patients. "Feeling better is an easy goal to reach," says Domino, and so that has become his focus with his patients.
He employs motivational interviewing to help patients self-identify actions they can take to enhance their health. And, he notes, wellness can't be rushed; he works with patients over the course of many months to achieve small milestones.
It may sound like baby steps, but Domino prefers his approach to that of relying on medications for a quick fix.
"Medications alone don't improve outcomes," says Domino, especially when he is trying to lower blood sugar levels in a patient with diabetes type 2. "Although most docs focus on the numbers … numbers don't make people better; getting them to change does," he says.
Patients have to commit to hard work, but it's the job of physicians and others on the health care team to coach them on how to increase their fiber intake, replace soda and juice with water, and get off the couch and move, notes Domino.
At West Lake Family Practice in Austin, Texas, Jill Grimes, M.D., says she's no different from the vast majority of family physicians who prefer to focus on prevention and who aim to keep their patients in the "well-visit" column.
"I'd much rather teach people behavior modification than give them the latest purple pill they saw on a TV ad," says Grimes, who has been in private practice for 15 years.
She begins every patient physical with a two-minute exercise she calls the "24-hour dietary recall."
"I simply ask patients to tell me everything they ate yesterday starting with breakfast," says Grimes. People who think they eat really well are often shocked at hearing their own responses. They squirm when Grimes gently points out that last night's fast-food splurge because of ballet class, soccer practice or church choir happens every Wednesday evening.
The recall is an important tool and a good starting point. After Grimes has a good idea of what a patient is eating, she proceeds to her "I want you to do MORE" statement. Grimes created the easy-to-remember mnemonic to encourage patients to eat
- More fruits and vegetables,
- Organize snacks,
- Ramp up fiber, and
- Exercise daily.
She doesn't hesitate to include other health care professionals in her patients' care, either. "I encourage anybody who will do it to meet with a dietitian," particularly if the patient has been diagnosed with a chronic disease, such as diabetes or hypertension, says Grimes. The staff nurse fills out a referral form; the patient is responsible for making the phone call.
Patients without insurance coverage may balk at paying $50 for half an hour with a dietitian. "But the same people will spend as much or more money to get their hair highlighted," says Grimes. "As physicians, we have to say (to patients), 'This is the single most important thing you can do for your health.'"
"That white coat is a powerful tool," says Grimes, and spending a little time during an annual physical to focus on lifestyle issues "tells your patients that you're serious."
Before a patient leaves the visit, ask him or her to commit to one specific behavior modification, says Grimes. Maybe he or she could try to eat at least five servings of fruits and vegetables a day, or limit meals out to twice a week.
Grimes advises that FPs should see the patient again in six to eight weeks to check on his or her progress. "I actually put it in the 'plan' portion of my note so I can follow up on it next visit," she says. "It's important to bring the patient back in rather than say, 'Next year, I want to see you down 20 pounds.'"
FP Steven Masley, M.D., clinical assistant professor at the University of South Florida in St. Petersburg, would like to see a fitness expert on every FP's wellness and prevention team, even if that means sending patients out to a local gym once a year to have their fitness numbers collected.
"We measure cholesterol and blood pressure, but we don't measure fitness," he says.
According to Masley, counting push-ups and sit-ups and measuring a patient's aerobic capacity, strength and flexibility should be a part of every patient's yearly physical. "I would guess that 85 percent of family physicians have a gym within 15-20 miles of their patients' homes," and could forge partnerships with fitness trainers, says Masley.
As president of the Masley Optimal Health Center and medical director of the Ten Years Younger Program, Masley performs in-depth health assessments for a small number of people each day and is lucky enough to have an exercise physiologist on-site.
But he's also worked in more traditional health care settings and understands the time constraints that busy family physicians face as they try to squeeze good counsel on wellness into an already overloaded schedule.
He suggests saving precious exam room time by having patients fill out nutrition and exercise questionnaires at check-in. Masley also discourages mixing acute care and wellness visits. Head off any attempts by the patient to derail the focus of the visit by saying upfront, "I'm seeing you today for tendonitis in your elbow. By the way, are you current on your yearly health assessment? You're not? Well, let's get that scheduled today."
Brian Unwin, M.D., encourages his patients to focus less on weight and more on fitness. He stresses that a fit person carrying some extra pounds is less likely to suffer medical emergencies, such as a heart attack or stroke, than a person who is overweight and inactive.
"It would be great if we were all perfectly shaped … but if we can be physically fit, we'll be healthier," says Unwin.
And that concept applies to those who've reached retirement age and beyond, he adds.
A U.S. Army colonel, Unwin is a clinician, instructor and interim chair of the department of family medicine at the Uniformed Services University in Bethesda, Md. With a fellowship in geriatrics, Unwin wants his patients to maintain good health and fitness as they move from middle age into older age, such as age 65 and older.
Statistics show that in the military, fitness levels decrease with age. Unwin says about 12 percent of active-duty soldiers are considered obese, although body mass index criteria don't take into account that a majority of soldiers are extremely muscular and physically fit.
That percentage skyrockets to about 33 percent after retirement, or in the 50-65 age range, according to Unwin.
With those folks, Unwin embraces a concept he calls "preventive gerontology." He reminds patients that entering older age at a higher fitness level will give them "physiological reserves" that can stave off maladies such as depression, dementia, frailty and other age-related syndromes and chronic illnesses.