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Burnaby Division of Family Practice Empowering Healthcare Exercise Healthy Living patient-doctor relationship Physical Activity Positive Change Positive Potential Preventive Health Your Goals

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The term, noncompliant has now been replaced by the somewhat better term nonadherent, which means that the patient did not stick to the plan.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

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Burnaby Division of Family Practice Empowering Healthcare patient-doctor relationship

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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Empowering Healthcare Healthy Living Physical Activity Preventive Health Relationships stress management

Creating Healthier Communities

Walkway, ED Pool - Davidicus Wong

What are the key factors that influence your health and the health of others in our community?

Most of us think first about the health care system and your access to quality care.

In the 2009 report of the Senate Subcommittee on Public Health, only 25% of the health of the population was attributable to the health care system. 15% was due to individual biology (i.e. genetics) and 10% to environmental factors such as air quality and civic infrastructure.

The remaining 50% was due to a variety of social determinants, including poverty, work conditions, housing, diet and community factors.

In the winter and spring of 2013, the Canadian Medical Association held town hall meetings in cities across the country and consulted widely online. The CMA’s report – Healthcare in Canada: What Makes Us Sick? – was released in July 2013. Poverty was found to be the most significant determinant of illness. Other significant determinants included access to affordable and safe housing, early childhood development and education.

Most of us have a good idea of what we need to do in order to live healthier lives.

Exercise, eat a healthy diet, maintain a healthy weight, don’t smoke or use recreational drugs, limit alcohol, reduce stress and maintain good relationships.

Yet for most of us, there are barriers to doing all the right things.

Due to poverty, many families struggle to get food on the table. To eat 5 or more fruits or vegetables a day is not affordable. Others are unable to find safe and affordable housing. Some neighbourhoods do not have easy access to transit, community centres, parks or safe areas to walk.

The global healthy cities and community movement is working to engage communities, cities and governments to address the social determinants of health and to work together to improve the health of the population.

You now have an opportunity to get involved. My Health My Community is a major public survey currently being conducted by the Vancouver Coastal Health and Fraser Health authorities. The online survey is seeking to identify the health supports you need in your neighbourhood. It will identify the barriers to healthy living, including access to services, housing, recreational facilities, affordable food, mobility, transportation and language.

The six main areas covered in the survey are (1) sociodemographics, (2) health status, (3) lifestyle, (4) health care access, (5) the built environment and (6) community belonging.

In this project, the health authorities are partnering with local government and community organizations as the survey will provide a greater understanding of the needs of our communities and allow informed action to address them.

For more information and to take the survey, go to https://www.myhealthmycommunity.orgStanley Park - Davidicus Wong

We are all responsible for the health of our community.