Wednesday, September 03, 2008

Should Doctors Scold?


Okay, first I was scrolling through KevinMD's blog, and this caught my attention:
In Whoa! an Er Doc talks about psychiatric, pain, and obese patients in his ER. Regarding the obese patient in the ER, he writes:

However, many, many people are obese because they simply eat too much unhealthy food and do not exercise enough. Many of these people live in subcultures within America where obesity is not only tolerated (mostly in women), but is praised, despite the well known health hazards. Obese patients are treated with respect in my ER - however, if they are disrespectful to the staff, demanding, and make a nuisance in my shop, they will get rebuked,just like any one else. Additionally, just like with smoking, I feel it is a doctor’s duty to reprimand patients for unhealthy behaviour - and this includes unhealthy eating and subsequent obesity.

I'll refrain from rambling about people who blame overweight folks for their condition. Another post, another day. What grabbed my attention was this doctor's use of the word Reprimand. It's not just that he reprimands, oh my gosh, no, he feels a duty to reprimand. I think I missed that part of medical school.

Perhaps it's just the harsh terminology. He's talking about behaviors here: over-eating, under-exercising, smoking. Can I add drinking alcohol and using illicit drugs to the list? I do, however, sometimes feel a need to remind people that smoking is bad for your health (it seems to be one of the few behavioral issues we're fairly certain of) and it may well be that using illicit drugs makes it harder to stabilize one's mood. So far, very few people have changed their behavior simply because I've suggested it would be healthier. And fortunately, so far, very few people have left treatment when I've repeatedly suggested they change their behavior. Sometimes I add that if they don't do so, I may be limited in my ability to help them.

I do feel kind of obligated to state the obvious from time to time. I don't think I scold, and sometimes I wonder if I was firmer, more insistent, or more threatening, might I be more successful in getting people to change their behavior? The fact is, I don't have that in me, I don't really believe it would make a difference in anyone's motivation to give up their addictions, and I believe a physician's role is to treat illness and be compassionate, not to reprimand.

ClinkShrink, of course, just puts them in Lock Down.

26 comments:

Anonymous said...

yeah studies have shown that patients who are rebuked, reprimanded, told off and humiliated by their docs are very eager to come back and see the doc and follow all their instructions. i think they are now studying the beneficial effects of using cattle prods when regular scolding does not work. we know they have been used in the past. we just do not know if they are mildly useful or greatly useful. the govt is providing a billion dollars to fund the study. if the cattle prods prove very useful they will also consider sending one home with every new mother after discharge from hospital with her newborn as it is thought that this measure will assist parents in the scolding/rebuking/prodding escalation process that will take place as the child develops.it is also thought that it will help cut down on the number of teenage pregnancies in Alaska.

Rach said...

I don't think scolding's necessary. I think a cognitive behavioral approach is much better -- then again, I'm looking at it from a very psychotherapeutic pov.

Example: I'm a caffeine fiend. It's a topic that comes up regularly between me and my psychiatrist. I'll agree to stop drinking my lattes, but inevitably I'll slip. When I admit to it, he could turn around and respond with something like "told ya so! No wonder you're manic/not sleeping/agitated!", or he could say "do you remember the last time this happened? why? how did we fix it?" - taking a teamwork based, preventative AND reactive approach leads to change and results.

Scolding just leads to shame, hurt feelings and ultimately not wanting to come back - hence the problem not being solved.

Midwife with a Knife said...

Changing behavior is very hard. I honestly don't think that shame helps.

Particularly with respect to obesity. I've been overweight my entire life, pretty much. I'm also really active. I exercise five mornings a week, I go to tae-kwon do class 5-6 times a week (often for 2 hours at a time). I don't eat eight cheeseburgers for lunch (Yesterday I had soup and some bread, although it did take me 2 twix bars to get through the worst call ever yesterday). By all rights, I should be on the smaller side. The more I learn about obesity, the more I think most people's bodyweight is genetically determined within a certain range... say 30 lbs or so. My weight (pre-prednisone) seemed to have stabilized about 30 lbs from my lifetime high (during residency!). And there are people who just eat when they're hungry and don't exercise who have BMIs of 22.

Having said that, there are things you can do. Even if you're obese, and you know you're never going to be a size 0, you may not diet (I've done a lot of that, and the literature suggests it doesn't really work), but you need to exercise, and you need to try to eat healthily (Twix not withstanding). This is not easy for anybody. But it's really much tougher to exercise when you feel ashamed of your body. It's much easier to feel good about eating good-for-you food when you think about how you're doing something good for someone you care about (yourself).

Only doc (And one nurse practitioner) ever scolded me about my weight; he did so when I was complaining that I was hungry all the time (and gaining weight because I was waking up in the middle of the night needing snacks) on 40 mg of prednisone. His response? "You obviously need some self control."

That was not helpful. And I changed docs partly because of it.

At the same time, if someone keeps coming in to the ED drunk or high or having injuries because of these or with out of controlled diabetes, I think it's fine to kindly explain that their drinking, etc. is contributing to their problems and try to help them come up with a plan for it. If someone develops Type 2 diabetes, it's appropriate to emphasize lifestyle changes as part of the treatment for the disease. But all of these things should be done with compassion. It's also important to remind people that even if they can't loose 100lbs, that loosing 10% of their bodyweight has real benefits. But I really think that people have to feel ok (or maybe even good) about themselves to take good care of themselves. And I think that good self care (eating healthy food and getting exercise), doesn't work well in shame.

Hm.... I was going to go on, but maybe I'll save it for a blog post.

Anonymous said...

I think people usually know what they're doing that's unhealthy or counter-productive, and most of them won't change unless they develop some personal reason for wanting to.

I quit smoking 10 years ago because I was developing a chronic cough and shortness of breath at quite a young age (and low BMI), and figured it didn't portend well for my future.

Most of the lectures I'd gotten about quitting went in one ear and out the other. If they were humiliating enough, I just didn't go back to that provider.

I have noticed there's a major difference in attitude from ER or Primary Care doctors and psychiatrists (comparing bloggers, only) toward certain types of patients. Maybe if you're confronted with treating the health issues caused by obesity or smoking or whatever on a daily basis, you tend to become more jaded or cynical? Or maybe more empathetic people are drawn to psychiatry? Or maybe you're socialized differently in residency?

That's a huge generalization. I don't know...

Ryan - Psychology Today said...

MD's can scold - they're practically expected to. That's part of the medical model: you've got the problem, the MD has the answer. Therapy, however, is supposed to be more collaborative. The relationship is based more on equality and patient empowerment than a right/wrong differential. In order for effective therapy to occur, the client should feel internally motivated to change. Scolding is the beginning of the end of psychotherapy.

Anonymous said...

ryan--my md doesn't scold me. my md has no god complex and happens to have human failings as well. my md is on the young side. i think they graduate them differently these days, at least i hope they do.i respect my md's knowledge base and judgment and i get a sense that is some credit given to me for life experience , my own accomplishments and the fact that i know myself better than what can be summed up in a chart despite the fact that i am not an md.
i have been scolded by md's in the past (psychiatrists) for not following their med recommendations. glad i didn't though, they would have killed me.

Dr. R at Medical Jokes... said...

Should we scold doctors who scold their patients?
Doctor's can't change patients behavior but they can triage.

Shruti said...

Its very difficult to lose weight.
I am thinking same holds true for other addictions too.

Reprimand is kinda good.
It shakes the person a little.They might initially protest but at the end out of shame or whatever try to correct things.

Shruti

Anonymous said...

shruti, can you explain why there are plenty of overweight doctors and doctors who have addictions and doctors who have all the same troubles as the rest of the world and given that fact, how do you expect them to sit and scold their overweight, addicted patients?
at the end of shame is more shame and more self destructive behavior and if the weight is not linked to self destructive behavior but is linked to something else that is hard to control like a med side effect or thyroid or whatever, how is scolding going to help? even people who want to change have a terribly tough time of it. they don't need scolding and shaming and people who do not want to change will not change because someone said something in a harsh tone.
whatever else i have going on, weight is not my problem but my doctor could stand to lose a few. if anyone thinks scolding really works maybe i should bring it up at the next appointment. great doctor, it would be a shame to see him drop dead from weight related health issues if a good scolding would help. if it works, why should docs be the only ones who get to do it? like dinah said, they don't teach it in med school. we all learned it pretty young. that would be a very interesting appointment.

Kim said...

I've found that meeting people where they are & being empathetic is usually a lot more effective than being judgmental & offering "expert" advice & passionate "scolding".

People don't resist change -- they resist BEING CHANGED!

NeoNurseChic said...

This is an interesting topic that actually just came up in my last appointment. It wasn't with respect to a doctor scolding me, but rather my bf's constant comments about my organization and messiness. We were talking about how he manages to accomplish that, and he said that the problem with bullying or shaming is that it usually only works when the person doing the bullying or shaming is present, but the person being bullied or shamed has no personal desire to keep up that behavior once the person bullying them is not present. I thought that was very reasonable.

In that discussion, he said that he had no doubt in his mind that some part of me wants to become more organized, but that I resist it because of the feelings I connect to it. The more I get nagged, scolded, demeaned in some way, the more negative feelings I connect to that particular act, and the worse it gets. The messy room/desk is a simple superficial issue, but it has become such an issue (not just d/t bf) that I spend a lot of time sleeping rather than face the mess. I want to avoid the negative feelings I've now associated with it. Part of this is my explanation - part of it is his. I have actually worked very hard to change, and because I'm moving next week, I really have cleaned out/cleaned up a lot of things - but ultimately, I learned from that conversation that the ultimate question is whether or not my bf will love me even if I never change - and not only if I do change.

Scolding/shaming/bullying really is not an effective form of convincing someone to change, no matter what the habit. It doesn't matter if you are a doctor, psychiatrist, mother, boyfriend, etc. It simply is not the most effective method. I also don't feel that motivating by guilt or appealing to anger is a very good way to accomplish things either.

People change because they see that the alternative is ultimately better than what they have now. I'm not saying that you can change obesity to make the person thing, but I'm talking about the things you do have control over: eating habits, organization, smoking, drinking, drugs, etc. I bought several things to help organize my room because I was tired of building up so much clutter/losing things/the way it made me feel. I began to change because I wanted to and because I realized it would be beneficial - but the more I am nagged/bullied/shamed, the more I steel myself against this criticism by shutting down, and the less it effects real change.

I feel like I'm not really getting across the point. Ultimately I just don't feel that scolding, bullying or shaming someone is an effective way to treat them. Doctors are supposed to be empathetic, and I guarantee that most patients will not return to or respect a doctor who scolds them or shames them, versus the respect they will have for a doctor who works with them. I think a patient is more likely to listen to a doctor that helps the patient see how their life would be better if they changed a certain habit, rather than just yelling at them for it.

I almost hesitate to read the linked post, since it also mentions psychiatric and pain patients along with obese. And I know how ER docs tend to feel about those patients - what they say about them off the record, so to speak. Even pain is treated as something that the patient is doing themselves in some way - either for manipulation, gain in some way, etc. It always makes me upset to read those sorts of posts on blogs. Fortunately, I have a "team" of doctors that are, in fact, empathetic and work with me to relieve my pain and medical problems as much as possible. They don't do this by telling me the pain is in my head or that I'm doing it for attention - because they recognize that there is no beneficial outcome that can come out of that sort of treatment. I know some people use pain for secondary gain, drugs, manipulation, attention, etc - but pain is a real and difficult thing for many people to live with. It deserves empathy and understanding - not scolding, belittling, disbelief, poor treatment, and so on. But I am going ahead and commenting without actually reading the post. Just anticipating what it might say!

Take care,
Carrie :) (Who is having yet more neurosurgery next week for an infected nerve stimulator. My neurosurgeon is very committed to treating my pain, speaking of that! If in fact my nerve stimulator is removed on Tuesday, he will work with me to implant a new one in 3 months, once the infection clears up. He goes to pretty great lengths to help those in pain - quite admirable!)

NeoNurseChic said...

I take back my assumption on what the linked article might have had to say about chronic pain. I agree wholeheartedly with it, actually! This ER physician is pointing out the problematic chronic pain sufferers, not the ones who are genuinely suffering and genuinely going about the right methods to try to reduce their pain. He is right in saying that there are many chronic pain sufferers out there who are not seen in the ER because of proper management, or are only seen once in a blue moon. I agree completely and I think this is a respectful way to talk about chronic pain. What he is describing as problematic are the people who abuse "chronic pain" and ERs.

So I take back what I was assuming!!

Take care,
Carrie :)

Doc said...

It all depends on how we are defining scolding, etc.
I have told patients, "I am concerned that continuing to take drugs will harm you, and perhaps even kill you." Just as I warn people about the potential side effects of medications, I think it is important to warn people about the potential outcomes of their actions. This needs to be done with compassion, and preferably in a dialogue with the patient. I think that too commonly the unhealthy behaviors are either glossed over, ignored, minimized, or the patient is given a blunt and stern warning. The bottom line is to take time, and discuss concerns with patients. To do otherwise is, in my opinion, a disservice.

OCDCHICK said...

I don't think that physicians who scold a bit too march consider the long term effects on the patient's ability to trust them. I agree with Doc's statement about how to reprimand. But, in that case, I think it would be considered a kind and respectable warning about the health hazards of whatever the problem is. Now, if a doctor raises their voices at a patient unnecessarily, and uses words that you would not even say to a loved one...that really is bad.
I think if all those in healthcare had to take extra coursework in multicultural counseling, and the classes that psychologists and psychiatrists had to take in school, perhaps they would learn how to better deal with their patients. There are so many great docs out there. It is the bitter ones who are too rough that scare people away. I love the title of the blog and the topic. Will be reading more. Keep up the good work.
...Some of the nicest doctors I have ever met were psychiatrists. Only have known a few, but they were always the best in rapport and human compassion.

Midwife with a Knife said...

ocd chick: psychiatrists and other docs all take the same classes in school. I don't want any "multicultural education". Patients and doctors should treat each other with mutual respect. (I was told to f*ck off by a patient yesterday.... that's not a cultural problem, it's just rude).

OCDchick said...

I have added your site to my blog because you have high moral standards and are respectable.

ERP said...

Reprimand does not mean to belittle or to be unduly harsh in one's tone. However, I personally feel that you have to put the fear of God in some people. Not everyone responds the same way - but some folks really need to have it drummed into their head to stop smoking, taking drugs, eating poorly, etc. I usually describe in grisly detail the dangers of these activities from a medical perspective. Sometimes I feel like it sinks in. Other people just recoil. Still, if I just coddle them and say "Awwww, it's OK, you'll be fine but golly gee whiz, you should probably, maybe consider cutting down on eating at McDonalds" or "shooting up the H" , I feel like I have done them a disservice. The need straight talk. Of course once they make an effort to curb these behaviours, they often need the support of family, friends, and therapists/psychiatrists and PMD's.

Alison Cummins said...

My great-grandfather was a doctor in Mineville NY. A couple of decades ago when my father was in the area he asked a couple of old guys sitting out in the sun if they remembered old Doc Cummins. Yes, they did! With respect. When they were teenagers and getting into drunken knife fights and Doc Cummins was called out in the middle of the night to stitch them up, he would lecture them to stop fighting. “The next time you make me get up at two in the morning because you’re acting like a jackass, I’ll stitch you up just like I’m doing now but you won't be getting any anesthetic.”

Or something more-or-less to that effect. It was definitely a reprimand, but it was not about shame. More about being made aware of the effects of their behaviour on other people.

I think there can be a place for a reprimand in professional relationships, but it’s contingent on a lot of other factors. The relationship between a drunk teenager with an ER doctor they have never seen before and never expect to see again - and who is being paid to work a night shift whether or not that particular drunken teenager shows up - is different from their relationship with the family doctor who treats everyone in town and who probably knew them when they were little. That doesn’t mean that an effective reprimand can’t happen in a modern urban setting; but you can’t just go around shaking your finger at someone and thinking it will have an effect.

L said...
This comment has been removed by the author.
Aqua said...

Personally, my fear and belief that ER Drs would treat me like "Whoa" are the exact reason I would commit suicide before taking myself to the ER.

I know exactly what would happen...I would go to the ER. Because my mood is reactive I would seem fine to the ER Dr, they would send me home, or scold me for wasting their time, I would feel both humiliated and dismissed when I reached out and needed help the most.

I think some Dr's do not recognize how much pain can be going on evfen if someone has a smile on their face. I'm one of the people with a smile on my face any time I face an authority figure. I learned that because it was unsafe to be anything else around my Dad.

Have to laugh...the code word below (to post) is "Bloeewz"...it really does "blow" that I feel dying would be a better option than facing someone like "Dr" Whoa.

Alison Cummins said...

“Reprimand.” Dictionary.com Unabridged (v 1.1). Random House, Inc. 05 Sep. 2008. [Dictionary.com http://dictionary.reference.com/browse/Reprimand].

1. a severe reproof or rebuke, esp. a formal one by a person in authority.
–verb (used with object) 2. to reprove or rebuke severely, esp. in a formal way.

“Reprimand.” Kernerman English Multilingual Dictionary. K Dictionaries Ltd. 05 Sep. 2008. [Dictionary.com http://dictionary.reference.com/browse/Reprimand].

(especially of a person in authority) to speak or write angrily or severely to (someone) because he has done wrong; to rebuke
Example: The soldier was severely reprimanded for being drunk.


So yes, ERP, I would definitely say that “reprimand” does mean to “belittle or to be unduly harsh in one’s tone.” It’s a form of punishment.

If that’s not what you mean, then maybe you need another word, like “educate” or “offer a reality check to.”

Roy said...

No, I don't think I scold or reprimand patients, though I have made "you should" statements, which may come close. I prefer the approaches mentioned earlier... sharing facts and observations and letting that lead to moments of understanding and behavior change.

While I'm a firm believer in the saying, "you can lead a horse to water but you cannot make him drink," it is often important to get them close enough to the water so that they know where it is and how to get there when they finally become thirsty.

Anonymous said...

OK. I actually googled "doctors scolding patients" after a mind-boggling and upsetting visit with a doctor, a very obese one at that who sat and scolded both my fifteen year old son and I for his weight. Now this kid had been though major surgery and has had casts, braces and other devices on his legs for four years. He just got out of a wheelchair in June. She was so disrespectful. I initially behaved very defensively as a mother, but once my son began crying and said "I am lazy" that was enough. I ended up in tears too. This was a very traumatic visit and it has left me, as a licensed mental health clinician feeling that, as patients and CONSUMERS that doctors need to deliver their information in ways that make the patient and in this case, parent feel a part of the process. My son is trying. After going to his open house and seeing how much he walks at school he is my hero. I will refrain from posting this docs name, but every part of my being craves to do so. The doc may have well be scolding herself, as she is obese but was full of her own excuses.

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Anonymous said...

I know this is an old post but I must comment.
I was scolded by my Doctor today & personally it just pissed me off. I will now be changing doctors. I pay him, whether he likes to believe it or not he is in a Customer Service based Industry in his private practice. Therefore he better learn how to treat his patients/clients with compassion & kindness. I have a history of heart problems recently progressively worse. I am undergoing testing ordered through him. No results are back yet. I called him after hours today while on a 24hr halter monitor twice. 1st time the monitor stopped working because it slipped and pulled, his staff returned my call and issue was resolved. 2nd I call was because my blood pressure was very elevated and I had a friend retest it on his monitor & it confirmed my high readings. My friend was nervous for me & gave me aspirin & I called my doctor about my readings. I needed my doctors advise as what to do? When he finally returned my call 45 minutes later he quickly said my readings are impossible. I told him we verified the readings. I asked if he knew what all of them where & he said yes. Yet, due to his harsh tone & doubt, I repeated the readings to him and he said in an abrupt tone, "Double up on your Beta blocker and make an appointment for tomorrow." His tone was demeaning & harsh. He was on speaker phone, my friend was appalled and said after I hung up, that guy is a jerk. I feel I have genuine reason to be concerned and his lack of compassion and scolding tongue just raised my pressure more. Make an appointment, HA! that will be a cold day in hell. I am his patient & he acted as if I was interrupting his life, while I was frightened about mine. *From the mouth of a patient scold me for something like this and you will be getting an earful back & I will Never Trust My Life in Your hands again. News Travels Fast be Good to your clients You are Not above them. His degree obviously did not teach him manners. Despite his advice to double up my meds..*My friend took me to the ER & my RBC was elevated, Pulse very high and bp still high, I was dehydrated! They treated my BP & Dehydration. Follow up with my usual primary..I think NOT, I am too pissed. Time for a new Doctor.

Anonymous said...

I know this is an old post but I must comment.
I was scolded by my Doctor today & personally it just pissed me off. I will now be changing doctors. I pay him, whether he likes to believe it or not he is in a Customer Service based Industry in his private practice. Therefore he better learn how to treat his patients/clients with compassion & kindness. I have a history of heart problems recently progressively worse. I am undergoing testing ordered through him. No results are back yet. I called him after hours today while on a 24hr halter monitor twice. 1st time the monitor stopped working because it slipped and pulled, his staff returned my call and issue was resolved. 2nd I call was because my blood pressure was very elevated and I had a friend retest it on his monitor & it confirmed my high readings. My friend was nervous for me & gave me aspirin & I called my doctor about my readings. I needed my doctors advise as what to do? When he finally returned my call 45 minutes later he quickly said my readings are impossible. I told him we verified the readings. I asked if he knew what all of them where & he said yes. Yet, due to his harsh tone & doubt, I repeated the readings to him and he said in an abrupt tone, "Double up on your Beta blocker and make an appointment for tomorrow." His tone was demeaning & harsh. He was on speaker phone, my friend was appalled and said after I hung up, that guy is a jerk. I feel I have genuine reason to be concerned and his lack of compassion and scolding tongue just raised my pressure more. Make an appointment, HA! that will be a cold day in hell. I am his patient & he acted as if I was interrupting his life, while I was frightened about mine. *From the mouth of a patient scold me for something like this and you will be getting an earful back & I will Never Trust My Life in Your hands again. News Travels Fast be Good to your clients You are Not above them. His degree obviously did not teach him manners. Despite his advice to double up my meds..*My friend took me to the ER & my RBC was elevated, Pulse very high and bp still high, I was dehydrated! They treated my BP & Dehydration. Follow up with my usual primary..I think NOT, I am too pissed. Time for a new Doctor.