Making the most of the time we have: "it's refreshing to have a doctor who's a little more realistic and understanding of my situation."

Journal of Family Practice, May, 2005 by Monika M. Safford

Mr P was my last patient of the day, as usual. A busy executive, he always scheduled visits late to minimize waiting. When he had first come to see me 6 months ago, he had felt pretty bad. We discovered he had uncontrolled diabetes. He had suspected as much but waited to seek medical attention until the exhaustion interfered with work.

He gladly took the medicines I recommended. He and the diabetes educator strategized, but anything that required extra time was off the table. They focused on how to make better fast-food choices than his favorite bacon-cheese Whoppers.

I was therefore a bit surprised when he announced at this visit that he wanted to start an exercise program. "Mr P," I said, "you work from 7 AM to 8 I'm and commute 45 minutes. When will you exercise?" He said seriously, "After I get home." I shook my head as I ordered a stress test before letting him loose on his exercise bike. Clearly, he wanted to do what I recommended, but I wondered, when?

A few months later, Mr P returned, sheepishly admitting he hadn't started exercising. Although his blood pressure and sugars were under excellent control, he felt tired and had gained weight on the medication. Although I feel frustrated when patients return not having followed my advice, in this case I had expected that Mr P wouldn't exercise. I looked at the long list of diabetes self-care tasks and I realized he, and probably most of my patients, couldn't possibly have time to accomplish it all. I also noted that some recommendations likely would improve his risk-factor profile more than others. For example, he had good sensation in his feet, so spending a lot of time on foot care at this point was not as important as increasing physical activity.

We discussed his most important diabetes-related goals. He wanted to feel better and minimize risk for heart attack or stroke. Then I asked him how much time he could realistically devote to his diabetes care. He hesitated and watched my face tentatively for a reaction as he admitted it was probably no more than 30 minutes daily. This made my job a lot easier. We spent the rest of the visit in a practical discussion about how to spend that half hour, focusing on diet and exercise. I reassured him that monitoring sugar less often was OK at this point. Mr P left the office with a bounce in his gait.

I mulled over this visit. I certainly felt a lot better than I had at the previous visit, and I knew he did too. I liked this idea of prioritizing tasks with him; if we didn't do it this way, he would set his own priorities. Without my input, his choices might not maximize the impact on his health. But I was struck by how very little guidance there is for physicians and patients in conducting such discussions. The guidelines I knew of detailed the many elements of comprehensive care without prioritization. Although cost-effectiveness analyses could potentially help, most of these focus on individual medications, and few compare numerous interventions side by side. It also struck me that, as the time requirements of self-care tasks become a rate-limiting step, "time-effectiveness" analysis might not be such a bad idea.

Furthermore, I was a little nervous about telling Mr P about the limits of what we could do. How was I going to broach this subject? How was he going to react? I worried about how much important information was currently missing. What is the comparative impact on quality of life, for example, of the meal exchange program (and the attendant time it takes to follow it), exercising, or controlling blood pressure through medications? How can I communicate the relative benefits of each of these if they are not even quantified and systematically compared?

At our next visit, Mr P was genuinely excited. He had managed to incorporate many suggestions from our last visit, although he quickly admitted to having trouble with the diet part. One of his favorite new habits was a brisk walk around the block to one of the street vendors to buy his lunch. Now we had to work on his favorite choice, a Philly cheese steak.

With some trepidation, I brought up the issue of his risks and how our efforts could not eliminate them. In fact, for many of the interventions I was recommending, I couldn't tell him how much benefit he could expect to derive. He looked at me, puzzled. "I know that!" he exclaimed. He quickly added that he appreciated the information, even if science doesn't yet provide all the answers.

Soon after this, I changed jobs. I ran into Mr P before I left, and he accosted me about my leaving. "How could you desert me like this?" he half-joked. We talked a bit, and then, obviously somewhat uncomfortable with what he was about to say, he blurted out, "You know, I'll miss you. You never made me feel too guilty, though God knows I probably should. It's refreshing to have a doctor who's a little more realistic and understanding of my situation."

"Thanks, Mr P. It was a pleasure working with you," I answered. "You helped me think through some issues, and I wanted to thank you for that. I'll miss you, too."