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Mindful EM

Mindful EM

Are Emergency Physicians Obligated to Prevent Disease?

Hazan, Alberto MD; Haber, Jordana MD

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doi: 10.1097/01.EEM.0000480788.85254.55

    Two of every three American adults are overweight; one in 20 is morbidly obese. (Int J Obes [Lond] 2013;37[6]:889.) What's worse, one in every three American children born after 2000 will develop diabetes. (The odds are worse for minorities. Half of African American and Hispanic children will develop diabetes.) (WebMD, Diabetes Health Center, 2003;

    The majority of diabetics will eventually end up with at least one complication: blindness, leg amputation, massive stroke, heart attack, kidney failure, sepsis, or cancer. Before they do, most suffer from neuropathy, a debilitating, chronic, unrelenting pain disorder for which there is no cure.

    Diabetes is not the only issue, either. An epidemic of chronic illnesses and other health issues are growing around the world. Each generation has an increased prevalence of these issues, such as high blood pressure, heart disease, stroke, depression, chronic pain, and cancer. The causes are multifactorial: poor diet and sedentary lifestyle, exposure to industrial pollutants and chemicals, limited exposure to sunlight and fresh air, stress, and genetics.

    We know that preventive medicine works. Many diseases are avoidable through education and lifestyle modification. If a simple conversation can potentially save thousands of patients from debilitating disease, shouldn't we as emergency physicians push ourselves to start the dialogue?

    After all, emergency physicians are often the only medical practitioners that many of our patients will ever see. It's critical, therefore, that we take each encounter as an opportunity to save our patients from the long-term sequelae of these debilitating illnesses.

    So why don't most of us do this?

    Lack of time: Emergency physicians are overwhelmed with responsibilities. They just don't have enough time to address preventive medicine measures in the emergency department. Too many patients are often sick with life-threatening illnesses, and acute management has to take precedence over conversations about lifestyle habits. Some physicians believe that taking the time in the ED to talk about the importance of a proper diet and exercise, of stopping smoking and alcohol cessation, of instituting dental hygiene and injury prevention, and performing cancer and domestic violence screening is unrealistic. (Am J Public Health 2003;93[4]:635.)

    Not their responsibility: Some physicians feel that having these conversations really isn't their job even if they had the time. Physicians' main obligation working in the emergency department is to rule out life- or limb-threatening illness, stabilize the sick, and ensure a patient's illness does not require immediate surgical or medical intervention. For other medical issues, including health education, a primary practitioner should be consulted. After all, they are the ones who will be following up with these patients in the long term.

    Stigma: Addressing a person's lifestyle habits seems to be a stigma in traditional medicine, especially when it comes to proper eating. Many physicians don't want to offend obese patients by telling them to lose weight and start exercising. There is often a disconnect between what a patient believes to be an unhealthy weight and what is medically recommended. It takes finesse to point out the issue in an empathetic manner without being perceived as insensitive or insulting. (J Gen Intern Med 2006;21[10]:1086.)

    The problem is that we often make a terrible assumption when we tell patients to follow up (because most of them won't) with a physician (which most don't have or can't see or who doesn't have the time to address these important issues). Emergency physicians are overwhelmed with clinical responsibilities, but addressing some of these issues should be an integral part of our job. It doesn't take much to make a difference; simply addressing the topic can lead to significant lifestyle modifications and changes. “Repeated, brief, diplomatic advice increases quit rates,” according to John R. Hughes, MD, a lead researcher on smoking cessation. The same strategy applies to addressing obesity, alcohol and drug abuse, and medication compliance. (J Gen Intern Med 2003;18[12]:1053.)

    We do not have to get into any sort of lengthy discussion with our patients. Just a sentence or two addressing the topic will likely raise awareness. It also shows that you care and consider the choices they make about their health to be paramount. Simple things like telling a smoker to quit, encouraging our overweight population to avoid processed foods and start a walking program, reminding high-risk women to get a yearly Pap smear, and reminding those with a family history of cancer of the importance of screening will save lives.

    Even if those interventions aren't as successful as you'd expect, it's still important to start the dialogue because in doing so, you show what patients want: compassion. Besides listening and having a competent doctor, patients want a doctor who cares.

    Let's start the dialogue. Take the opportunity to make a difference. Try to save lives the simplest way we can.

    By starting the conversation.

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