The Evolving Patient-Doctor Relationship

Dr. Davidicus Wong with patients, Donna and Albert Gomes

Dr. Davidicus Wong with patients, Donna and Albert Gomes

Medicine is a calling. For dedicated physicians, our responsibility to our patients, profession and society extend beyond regular working hours and occupy our minds outside of both hospital and clinic.

Traditionally, the sacred moment is the time we spend with each of our patients, our attention focussed on their wellbeing. Yet the patient-doctor relationship continues to evolve.

In the past, physicians used to give orders – for their patients to lose weight, exercise, eat better, quit smoking, limit alcohol and take their prescription medications, and when their patients would return many months later not having followed those orders, they would be labelled “noncompliant” and the doctor would repeat the same orders.

We no longer use that term; it harks back to the days of medical paternalism. The doctor doesn’t always know best. We have expertise in the science of medicine and experience in what has worked for most patients; however, patients are the experts on their own lives, their values and their priorities.

When patients fail to follow through on goals we have set together, I don’t blame them. Rather I question whether I had helped them choose the best goals for them. Were they the goals that matter most to the individual? Did I provide sufficient support for success?

Those old doctor’s orders were actually good recommendations for activities that would promote health, but achievable goals must appeal to the patients’ values and be appropriate to their circumstances. They must be tailored to the individual.

The Practice Support Program has been teaching family physicians new tools to help our patients make lasting positive changes. When most people think of health care, they think of the tip of an iceberg – acute care in the hospital, and that is where a large proportion of our tax dollars is spent. Yet 90% of professional organized health care takes place in the community, for example, in primary care clinics. Family physicians provide much of the medical care for most patients.

But professional health care itself is just the tip of an even greater iceberg. Self-management is the care that patients provide to themselves through the monitoring of their chronic conditions, nutrition, physical activity and self-education.

The key to improved health is to better support patients in their self-care.

The doctor-patient relationship continues to evolve with the advent of the Divisions of Family Practice throughout the province. With the support of the General Practice Services Committee, family physicians have formed non-profit organizations to improve primary care in their communities.

Dr. Shelley Ross leading the WWYD pack

Dr. Shelley Ross leading the WWYD pack

On Saturday, May 3rd, the Doctors of B.C. (formerly the B.C. Medical Association) will demonstrate their care and commitment to our patients and community with a free and fun 2 km walk at Kitsilano Beach Park in Vancouver at 9:30 am. I’ll be there with many of my colleagues along with our patients.

Even if your doctor isn’t there, you’re welcome to attend. All members of the public are invited, but come early to get your free pedometer. For more information about this event, check online at www.bcma.org/walk-with-your-doc.

Dr. Davidicus Wong is a family physician and Physician Lead of the Burnaby Division of Family Practice.

Drs. Davidicus Wong, Karime Mitha and Shelley Ross at the BCMA's Walk With Your Doc May 4th, 2013

Drs. Davidicus Wong, Karime Mitha and Shelley Ross at the BCMA’s Walk With Your Doc May 4th, 2013

 

Posted in Burnaby Division of Family Practice, Empowering Healthcare, Exercise, Healthy Living, patient-doctor relationship, Physical Activity, Positive Change, Preventive Health | Tagged , , , , , , , | Leave a comment

Doctors Prescribe Exercise: The Benefits of Physical Activity

During the week of May 3rd to 11th, 2014, doctors throughout British Columbia will be promoting physical activity and literally walking the talk with their patients in a variety of community events.

On Saturday, May 3rd, the Doctors of B.C. (formerly the B.C. Medical Association) will kick off the week with a free and fun 2 km walk at Kitsilano Beach Park in Vancouver at 9:30 am. I’ll be there with many of my colleagues along with our patients.

Even if your doctor isn’t there, you’re welcome to attend. All members of the public are invited, but come early to get your free pedometer. For more information about this event, check online at www.bcma.org/walk-with-your-doc.

Throughout this month, doctors across the province will be writing prescriptions for exercise, encouraging patients of every age to be physically active.

To celebrate the World Health Organization’s Move for Health Day on Saturday, May 10th, the City of Burnaby has organized a large number of free events including community walks in many of our neighbourhoods, canoe lessons, boot camp, swimming and the grand opening of the outdoor fitness circuit at Central Park. For more information check the City’s website at http://www.burnaby.ca.

Why the big push for everyone to be more active?

Here are 7 proven benefits of regular physical activity.

1. It decreases your risk for heart disease, stroke, high blood pressure, diabetes and cancer. Exercise also plays an important role in managing and improving chronic health conditions.

2. Physical activity prevents weight gain and can help maintain a healthy weight. It complements healthy nutrition.

3. It improves the fitness of your heart, lungs and muscles. Regular physical activity conditions your body to function better making everyday activities easier.

4. Regular physical activity prevents falls and improves cognition in older adults. When your limbs and brain are accustomed to movement, your balance, agility and ability to react improve. When blood flows better throughout your body, it also provides better circulation to the brain. A healthy body promotes a healthy brain.

5. Weight bearing activity (i.e. walking) helps maintain bone density, reducing your risk for osteoporosis and fractures.

6. Exercise improves sleep. Although vigorous exercise just before hopping into bed may be too stimulating, activity earlier in the day can improve the quality of your sleep.

7. Physical activity improves emotional wellbeing. For a number of years, psychiatrists have been prescribing exercise to their patients suffering from the symptoms of depression and anxiety.

Exercise has been shown to reduce stress hormones, such as cortisol, and increase endorphins which are natural painkillers and feel-good chemicals. Exercise also promotes a sense of accomplishment and self-confidence. Physical activity can provide social benefits; you can meet regularly with friends to keep you motivated or make new like-minded friends while enjoying your spin class, swim or Zumba sessions.

Our bodies were meant to move. When we don’t, our health suffers; when we do, we thrive.

Over the next week, look for simple ways you can increase your level of physical activity. You could walk or bike to school or work – or simply get off the bus a few blocks further from your destination. You could buy a bright new umbrella, embrace our rainy days and choose to do an extra walk each day. Take the stairs when you can.

At home, walk while you talk on the phone. Spend less time in front of the computer or TV but move around while you watch your favourite shows. Dance with the music you love.

In upcoming columns, I’ll discuss specific exercise recommendations, the risks of exercise and tips on staying motivated and achieving your fitness goals.

Drs. Davidicus Wong, Karime Mitha and Shelley Ross at the BCMA's Walk With Your Doc May 4th, 2013

 

Posted in Balance, Emotions, Empowering Healthcare, Exercise, patient-doctor relationship, Physical Activity, Positive Change, Preventive Health, Your Goals | Tagged , , , , , , | 1 Comment

What’s your story?

Imagine running into an old friend whom you had not seen since childhood. What story would you tell? Where are you now, and what has brought you to this point in your life?

Whether we recognize it or not, we make sense of our lives through our personal stories. Our stories help us make sense of our world and provide meaning and continuity.

Stories may also limit how we see our lives, others and our selves. To be conscious of the unwritten stories of our lives is to open up our potential for more positive experiences and growth in every area of our lives.

We inherit the stories told by our families. They may be of struggle against adversity, reactions to negative experiences, mistreatment by others and often a simplified approach to history, politics and people who are different from them.

The stories of our parents can form the foundation of our personal stories that are also influenced by personal experiences, how we react to them and – most importantly – how we conceptualize them.

Our stories may empower us, enhance our relationships, promote healthy living and foster happiness. Our stories may limit our experiences, get us stuck and be the ultimate source of our unhappiness.

Although we do not control every aspect of our lives, we are at least coauthors of our own life stories. We are not responsible for every event and circumstance, but we are responsible for how we meet them and how we act.

Totems in Alaska - Davidicus Wong

Totems in Alaska – Davidicus Wong

In medicine, I have the privilege of hearing many personal stories. My wisest and happiest patients have shared those that are infused with three key features: appreciation, empowerment and purpose.

The happiest people accept the good and bad aspects of their lives but reflect back with appreciation for what has been right in their lives. Engaging each day with an attitude of positivity and gratitude, they give forward.

They are able to let go of self-limiting feelings of resentment and embrace their personal responsibility to choose their own thoughts and actions. They recognize the aspects of their lives that they can control in a positive way.

The wisest storytellers are able to reflect back on their lives, learn and look forward beyond their own self-interests. They find meaning in the past and present – and purpose for a positive future.

In the story of your life, where have you found meaning? What has been your calling at each stage of your life? Your story is never finished, and you remain its author today.

The Tapestry Foundation for Health Care www.tapestryfoundation.cais hosting a public forum, Stories of Aging at the Vancouver Convention Centre. I will be part of a panel sharing unique perspectives on aging at 7 pm on Friday, April 4th.

Dr. Davidicus Wong is a family physician. He will be speaking on “Achieving Your Positive Potential in Life: Finding Meaning & Fulfillment in Every stage of Your Life” at the Douglas Park Community Centre at their Young at Heart program’s Wellness Show on Saturday, April 5th. For more information, call (604) 257-8130.

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You’re not as old as you think you are . . . 4 myths about aging

My earliest memories as a toddler and preschooler were of my family’s home on West 20th in Vancouver. We lived there before moving to Burnaby. Across the street was expansive Douglas Park with its towering trees, playing fields, playground . . . and my nursery school.
My first traumatic memory was of falling head first from the monkey bars and losing my two front teeth. In those days, monkey bars were stainless steel towers built over cement foundations. I waited years to grow up and grow new front teeth.
Not knowing my painful past association with Douglas Park, the community centre has asked me back to speak at their Young at Heart program’s Wellness Show on Saturday, April 5th. I’ll present “Achieving Your Positive Potential in Life: Finding Meaning & Fulfillment in Every stage of Your Life.”
Now at the midpoint of life, I note our mixed messages about growth and aging and the changing connotations of “growing older.” Growing older is a good thing if you’re a child – getting taller and stronger, learning more and maturing.
Growing older is not quite as desirable to most past 40. They associate it with a loss of youth, vigour, opportunity and growth.
Every week, an older patient will tell me, “Don’t every grow old.” I used to think this “advice” was an unintentioned curse. Isn’t it better than the alternative? At the time, I thought the only alternative was to die young.
But I know that they were referring to the conditions we associate with advancing years: the chronic pain of osteoarthritis, the progression of multiple chronic conditions such as diabetes, atherosclerosis, and the decline in cardiac and kidney function.
Seniors are the frequent flyers in the health care system because of their increasing needs, and for many, much of their days revolve around the scheduling of tests and appointments and the taking of multiple medications.
With the passage of time, we witness the loss of old friends and loved ones, and reminisce about the days of youth and promise.
Yet growing older not a downhill decline. Many of my patients age well and are ever happy with each passing year. They recognize the realities of their physical health, appreciate growth in their relationships, and remain engaged and empowered in every aspect of their daily lives.
They see through some of the Myths of Aging.
1. Myth: You are your age. This is only a partial truth. Your chronological age is based on the date of your birth. Different organs age at different rates depending on use, abuse and genetics. I have to remind some patients that although their knees may be worn down, their other joints are working like new. It’s also nice to point out to many that their kidneys and livers are functioning as if they were 20 years younger.
The cells of your body are constantly being renewed. The cells of your skin are continually being replaced. None of your red blood cells is over 120 days old. It wouldn’t be a lie to say you were younger than your chronological age . . . or that parts of you are newborn.
2. Myth: You can’t teach an old dog new tricks. Although dementia is more likely as we age, it is not inevitable for most of us. There tends to be a decline in short-term memory with age (The last things learned are the easiest to forget).
Although we may have a gradual decline in the number of neurons in the brain in adulthood, it is the connections between neurons that influence cognitive function. In the process of neuroplasticity, with new experiences and new learning, each of us is capable of developing increasingly complex connections between neurons.
At any age, you could learn a new language, dance or musical instrument.
3. Myth: Becoming physically weak and inactive is inevitable.
Our bodies were meant to move . . . at every age. With disuse and inactivity, we lose strength, flexibility and balance. Daily physical activity, including walking is a mainstay of continued fitness.
Studies have demonstrated that seniors can increase both strength and muscle mass with safe resistance exercises, such as supervised seniors weight training programs.
4. Myth: Old people repeat the same old stories.
If you are lucky enough to have older relatives, you will remember hearing the same stories multiple times. We are creatures of habit and our brains like to be efficient in following the same neural pathways ad infinitum.
But new research in neuroplasticity shows that the human brain can change itself. We can create new connections between neurons, and this translates into new more positive habits and new ways of seeing others, our world and our selves.
If you’re a child, never stop growing up. If you’re an adult, never grow old. Instead, grow stronger, grow wiser, grow new interests and points of view, and grow in your relationships. Remain an active participant in the story of your life.
The Tapestry Foundation for Health Care is a non-profit organization that raises funds for Providence Health Care facilities, including  Mt St Joseph, Holy Family and St Michael’s Hospitals. Tapestry whose vision is to enhance the living and aging experience for patients and seniors is hosting a public forum, Dialogue on Aging.
I will be part of a panel moderated by writer, Peter McKnight at 7 pm on Friday, April 4th at the Vancouver Convention Centre. With our topic Stories of Aging, we will share unique perspectives on aging. For more information check Tapestry’s website at http://www.tapestryfoundation.ca.
Dr. Davidicus Wong is a family physician and Physician Lead of the Burnaby Division of Family Practice. For more information about the Douglas Park Community Centre programs, call (604) 257-8130. You can read more about achieving your positive potential in health at davidicuswong.wordpress.com.

Happy Birthday, Dad!

Happy Birthday, Dad!

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Writing Safer Prescriptions

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This week, I’ll be spending a few hours with second year medical students. As part of the Advanced Family Practice curriculum, family doctors take time from their own practices to meet with small groups of medical students to discuss topics including the management of diabetes, headaches and congestive heart failure.

This week’s topic is prescription writing.

No, this isn’t the class where budding young doctors learn to write illegibly. There’s actually no such course. Messy writing is a side effect of a doctor rushing to get things done.

I’ve spent many hours trying to help nurses decrypt the handwritten notes of colleagues. This is less of a problem in family practices where a growing number of doctors type or dictate all their notes into their computers in what we now call EMRs (electronic medical records) and send prescriptions wirelessly to a printer.

Occasionally, I might take out the old-fashioned prescription pad for old time’s sake (The feel of the paper has a pleasant nostalgic feel) . . . or when I encounter a computer problem.

Yet illegible writing remains a problem – and a risk to patients – in most hospitals.

In spite of technological advancements in other areas of inpatient care, doctors continue to put pen to paper in the writing of their chart notes and their orders. Fortunately, most consultations are dictated and eventually hospitals may eliminate handwritten orders.

In the meantime, our hospitals have banned some of our traditional medical abbreviations.

As medical students, we loved to learn the abbreviations of Greek and Latin words along with the vocabulary of the language of medicine. Sometimes, a handwritten prescription may not make sense to a layperson because of our abbreviations rather than handwriting.

If a medication is to be taken before meals, we would write ac for ante cibium, meaning “before meals”. Similarly, pc means post cibium or “after meals”. A bedtime medication would be followed by hs (hora somni). Orders for a drug taken by mouth, would include the abbreviation po (per os). One for drops for the right eye would include od for oculus dexter.

The abbreviation, od may also mean “once daily”.

Hospitals are now banning more easily misinterpreted abbreviations. The alternative abbreviation, qd intended to mean “each day” may be confused with qid which means “four times a day”. QOD may be intended to mean “every other day” but may be misinterpreted as “every day”. In both cases, the patients would take the drug too frequently.

Similarly, we now avoid “U” because when handwritten it may be misinterpreted as O or zero. Instead, the full word “unit” should be used.

In the case of dosing, a zero after a decimal point must be avoided. If the tiny decimal point isn’t noted, a patient may receive 30 mg instead of 3.0 mg.

Similarly, to avoid missing a leading decimal point, a zero should be written in front so that a dose of 0.5 mg will not be dispensed as 5 mg.

If you’re in the hospital, all this takes place behind the scenes without your awareness. As your healthcare providers, we have to be conscientious and write clear, unambiguous notes and orders. If we’re not absolutely sure what a doctor has written, we have to confirm the orders.

Outside of the hospital, it’s good to review your prescription before you leave the clinic to confirm the dosage of your medication and how you should be taking it.

 

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Setting goals with your family doctor

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In the “olden” days, doctors gave orders (“Take these medications, start exercising and go on a diet.”), and if patients failed to follow through, they were labelled as “noncompliant”.

That term literally meant that the patient did not bend to the will of the doctor, and since M.D.s are neither gods nor psychic surgeons, that should not be our goal at all.

The term, noncompliant has now been replaced by the somewhat better term nonadherent, which means that the patient did not stick to the plan.

We now recognize that the majority of an individual’s medical care is his or her own responsibility – what is done in the huge expanse of time between medical visits: habits, physical activity, diet and the taking of medication. We use the term, self-management to describe the many ways that a patient provides self-care for general health or chronic conditions such as diabetes, atherosclerosis, heart failure or high blood pressure.

At the heart of this new approach is a renewed respect for patient autonomy or independence. The patient always has a choice to do those activities that best help achieve their goals. But to make informed choices, health care providers, including physicians, have to act in collaboration with individuals, providing relevant information about their medical conditions and support to make positive changes in their lives.

Though doctors may be up to date about the evidence-based management of medical conditions, patients know their lives better and every individual has unique personal goals and their own ways of finding meaning in their lives.

Through B.C.’s Practice Support Program, family physicians have been learning new approaches to support patients in the self-management of their own health – what I call facilitating positive change.

One key is that the choice of goal should be the individual’s. The doctor may ask, “Is there anything you would like to change in your life in the next two weeks – a specific goal you would like to achieve?”

If the patient cannot come up with one out of the blue, the doctor may offer some suggestions based on their personal health status. What may be offered is a menu of choices, perhaps involving eating, physical activity, stress management, smoking cessation, sleep or medication.

One useful tool is the acronym SMART. It reminds the physician of the essential elements of goal setting: specific, measurable, achievable, relevant and timed.

By specific, we mean what exactly does the patient want to do? If the big goal is to become more physically active, what specific activity will the individual begin? When would it be done? How often? Where? With whom? An example could be walking for 15 minutes during lunch breaks with a coworker on Mondays and Fridays around the park close to the office.

In addition to the specifics and measurables, the goal must be achievable or doable for the individual. To jump from doing no exercise to training for the Sun Run may be too great a leap. We will often ask the patient after setting a preliminary goal how confident they are that they can achieve that goal. With a confidence level less than 6 on a scale of 10, we should adjust the goal to something more realistic and achievable. Better to start a little lower and go a little slower than to risk early injury, failure and discouragement.

The goal that an individual agrees to must be relevant – not only to the improvement of their health but to their lives. It must be important to the patient. Every change requires personal motivation.

A patient with early osteoarthritis of the knees may be motivated to exercise to lose weight so that he can continue to work and support his family. Another may want to quit smoking to create a healthier environment for her children.

After helping a patient choose a personal goal, the effective physician coach will discuss the timing of follow-up. When should we check up on how you’re doing with your goal? If a patient has not been successful, we can discuss the obstacles we may not have anticipated, problem-solve and modify the goal. If patients have made positive changes, with growing confidence they can create new goals – walk or run a little longer or more often or make changes in other areas of  their life.

Posted in Burnaby Division of Family Practice, Empowering Healthcare, Exercise, Healthy Living, patient-doctor relationship, Physical Activity, Positive Change, Positive Potential, Preventive Health, Your Goals | Tagged , , , , , , , , | 2 Comments

Getting the most from your doctor’s visit

Have you ever left your doctor’s office having forgotten to ask an important question . . . or arrived home not totally clear about everything you had discussed during your visit?

This happens all too frequently and it doesn’t mean that you have dementia or you weren’t paying attention. Yet what we missed may be bad for your health.

The information you didn’t share with your doctor may have been as important as anything else you had discussed at your visit. If you are not clear on your plan of management, you’re unlikely to get the best results.

Old-time doctors used to call patients “noncompliant” when they failed to start an exercise program, eat a healthier diet or take their medications as prescribed. Enlightened doctors today recognize that when a patient doesn’t follow through with the plan, it means one of three things: (1) we weren’t prepared for obstacles to success, (2) we didn’t effectively communicate the management plan, or (3) the plan was the doctor’s and not the patient’s.

Effective communication in the form of dialogue is crucial to every relationship. In your personal relationships at home, it’s the key to happiness. In the professional relationship with your doctor, it’s crucial for health.

That communication begins with your call to book an appointment. The medical office assistant will ask for the reason of your visit. If there is more than one, give them all when you’re booking.

The medical office assistant is part of your health care team and can be trusted with your confidentiality. She or he helps the office run more smoothly so that all patients can be well served.

Being human, we may pick up an infection or discover new problems before we see the doctor. If you do, advise the medical office assistant when you arrive. This will ensure that the doctor is best prepared for your visit.

Some problems require specific instruments, gowns or other preparations. Work-related or MVA-related injuries may require important detailed information and specific forms.

If you are suffering from depression, anxiety or a stressful situation, additional time may be required for counselling.

The first few minutes of your visit is the best time to clarify everything you need to address. Your doctor may have some additional items to discuss with you, including the results of recent investigations or screening tests that are due. It’s important to agree on your shared agenda at the beginning of your visit just as you would at the beginning of a meeting at work.

Each problem you present requires the doctor to take a thorough history including the asking of crucial questions and to perform a physical examination to rule in or out important conditions. When the working diagnosis is clear, the doctor may propose a management plan and alternative choices for treatment. You need the opportunity to ask questions and to get all the information you need to make informed choices.

Obviously, if your doctor has to work through this process sequentially as you pull a series of problems from your pocket one at a time, a 10 or 15 minute appointment can turn into an hour, sabotaging the medical office assistant’s mission of keeping the office running smoothly to serve all patients well.

So the first thing you can do to get the most of your doctor’s visit is to come prepared. Write your list of problems and bring it with any other information that may assist your doctor. Share it with the medical office assistant – your ally in the office – and your family physician.

In upcoming columns, I’ll address the management plan and the crucial information you need to know about any medication, investigation or treatment in order to make an informed choice and remain in the driver’s seat in your own health care.

On Monday, February 17th, I will be speaking at the Metrotown branch of the Burnaby Public Library on “The Patient-Doctor Relationship: making the most of each visit with your family doctor.” For more information, please phone the Metrotown branch at (604) 436-5400 or register online at http://www.bpl.bc.ca/events.Image

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