I spend a great deal of my time as an emergency physician handing out Band-Aids. Those come in many different flavors: insulin for hyperglycemia, aspirin for chest pain, antiemetics for vomiting, migraine cocktails, GI cocktails, and even the occasional actual real Band-Aid.
I also give a lot of reassurance. Many times in my 10-year career I have said, “All of your results were normal today. I don't know why you are not feeling well, but it is something you can talk about with your primary care doctor. I am not concerned about it today.” The translation: “You are not sick enough to be here, or as we used to say where I trained when we were particularly burned out, “Pa la casa”—“to home.”
What if we changed our perspective on this? What if we actually provided even a small amount of information on the root cause of what is occurring and how the patient could improve his health? Let's be reasonable: A glucose of 250 is not normal, and neither is a blood pressure of 160/95 mm Hg. We normalize these values in our downstairs world because they do not lead to acute disease, at least not that day.
Lifestyle medicine provides a construct for improving not only the health of our patients but our own health as emergency physicians. Obviously, we can learn to improve our self-care by being better educated about nutrition, exercise, and sleep. But we become less dismissive of our patients if we apply these principles to patient care. We address truly abnormal values, and take some time to recognize the root causes of illness rather than simply prescribe Band-Aids. This offers an opportunity to provide us greater satisfaction in our practices because we have an impact on the often-disenfranchised populations for which we care.
You may not have heard of lifestyle medicine, but it's one of the newest subspecialties. The American Board of Lifestyle Medicine sets and maintains standards for assessment and credentialing. (https://ablm.co/.) Diplomates must first be board-certified by a medical specialty board recognized by the American Board of Medical Specialists or the American Osteopathic Association.
Lifestyle medicine is built on six pillars: nutrition (whole food plant-based diet), sleep, risky behavior reduction, stress reduction, social connectedness, and physical activity. (American College of Lifestyle Medicine; https://bit.ly/3dmtwfg.)
I know what you are thinking: You do not have time. I get it. It is daunting to think about adding something nonacute to your checklist of boxes. I am well versed in the busy urban ED; I have worked in five of them. But it's easier than you think and not that time-consuming. Try adding these lifestyle medicine principles to your practice:
- Your glucose was a little high today. It is extremely important that you follow up with your primary care doctor because this can lead to a lot of problems down the road. I have included a nutrition prescription for you: Please add one serving of dark green leafy vegetables to your diet every day for the next 30 days. Look at your meal and ask yourself: Did what is on my plate come out of the ground looking similar to how it does on my plate?
- You're here in the middle of the night. What is your usual sleep like? I have included a sleep prescription for you: Go to sleep at the same time every night (preferably before 11 pm) for the next seven days. You should sleep for at least seven hours. Then discuss with your primary care doctor how you felt before and after.
- Counseling on risky behaviors is already central to what we do as emergency physicians. Offer prescriptions for nicotine replacement or Suboxone (if waivered) or refer patients to local addiction services.
- We did not find a cause for your chest pain today, but you and I both think that anxiety may be playing a part. I have included for you a stress reduction prescription: Do five minutes of prayer, breathing exercises, or meditation within 30 minutes of waking up each day for the next 20 days.
- You mentioned having an argument with your partner. I have included a social prescription for you: Deliberately go out of your way once a day for the next 10 days to do a small act of kindness for your partner, like doing the dishes without being asked or simply telling her you love her.
- Your blood pressure was a little high today. It's not high enough to require medication today, but you must follow up with your primary care doctor. I have also included an exercise prescription: You should take a 20-minute moderate-intensity walk outside five days a week for the next four weeks.
Sick or Not Sick
Lifestyle medicine prescriptions should address one of the six pillars, and like a pharmaceutical prescription, they should be specific, offering a frequency, intensity or amount, type, and timeline (FITT or FATT). Primary care studies have validated this approach with exercise, and the same approach can be applied to any aspect of one's lifestyle. (Arch Intern Med. 2009;169:694; https://bit.ly/3rrW5gc.) The more specific the recommendations, the more likely a patient will be to achieve behavior change. (Am J Health Behav. 2009;33:277; https://bit.ly/3sysJ0N.) It is also likely that patients will initially respond better if the prescriptions are positive, so it is better to ask a patient to add something to his lifestyle rather than to take away something.
Many of us would argue that our role in medicine is the resuscitation of ill patients, but we know that our actual jobs require much more of us. The acute care setting of the emergency department may well position us to make an impact in the root cause of chronic illness. It is not far-fetched to believe that patients may be concerned that their chronic disease acutely contributed to why they came to the ED. You have a captive audience that is seeking and often begging that you make a difference. I urge you not to think just of Band-Aids, but to start to move to the root.
How many times do you ask yourself, sick or not sick? Not sick does not equal healthy. I think that is an easy assumption for us as emergency physicians to accept.
My challenge to you is to make the move from acute to root, and ask yourself: Sick or not sick? Not sick or healthy?
Dr. Harrison thanks Charles Mize, MD, and Mary Mulcare, MD, for their editorial review.
Dr. Harrisonis board emergency medicine and lifestyle medicine, and practices emergency medicine at Bridgeport Hospital-Yale New Haven Health. Learn more about the intersection of emergency medicine and lifestyle medicine by visiting her website atwww.acute2root.com. Find more information on the American College of Lifestyle Medicine athttps://www.lifestylemedicine.org. Follow her on Twitter@acute2root.