Nagging Never Works

During my time working in hospital I remember seeing a patient in the clinic who came for review after a spell as an in-patient. He had come in with his first episode of chest pain caused by heart disease and he had made a good recovery. What I remember most about him, however, was how emphatically he wanted me to pass on his thanks to the junior doctor who had admitted him:

‘She saved my life, doctor,’ he said. ‘She told me I’d die if I didn’t stop smoking. You know what I did? I handed over my packet of fags and haven’t touched one since; best thing that could’ve happened to me!’

I reassured him that I would certainly pass on his thanks to the doctor, and was glad for his success; what I did not tell him, however, was that my colleague had smoked every one of his cigarettes – ‘shame to waste them,’ she had told me.

What this incident illustrates is the fundamental difference between being in possession of medical knowledge and deciding to act upon it – or in the language of the cycle of change: moving from being pre-contemplative about change to actually contemplating doing something. My medical colleague undoubtedly knew more than most about the risks of smoking, yet she persisted despite the urgent advice she gave to her patient; the presence of crushing chest pain, however, was clearly capable of bringing the same advice into such sharp focus that it motivated radical change.

I often say to my patients that their two best opportunities to stop smoking are to get pregnant or to have a heart attack – a range of options which my male patients find disturbingly limiting. Timely advice from doctors can certainly increase the chance of success, but the studies included in the Cochrane review are of interventions when patients have made an appointment for other reasons. A different question entirely is whether or not we should screen for cardiovascular disease and then provide lifestyle interventions – and the answer to this has appeared in the BMJ recently, and appears to be a resounding ‘no’.

The Inter99 study is a significant piece of work – nearly 60 000 participants with interventions over 5 years and 10 year follow-up, and came to the overwhelming conclusion that screening for risk factors with regular lifestyle counselling had no impact on the incidence of ischaemic heart disease, stroke or mortality. We might be depressed at the poor return for such well-meant efforts, but we should not be surprised: despite the Government’s obsession with ‘making every contact count’, NHS health checks and annual demands in the GP contract to advise our patients again and again about smoking, nagging patients generally does not work.

We know nagging does not work because that is what patients say – receiving health advice when you are not ready for it simply creates resistance and can damage the doctor-patient relationship as this qualitative study in smokers makes clear; it is contrary to all the principles of Motivational Interviewing and against both our training and our experience in the consulting room. The question now is, will policy-makers listen? Will they be bold enough to follow the evidence and stop telling doctors to do things that don’t work, or will they just carry on regardless? Sadly, I think I might know the answer.

This post was first published in Pulse magazine (free subscription required)

The right not to be lectured to

I recognise the signs now. They vary, of course. Sometimes it is the slight drop of the shoulders, the hangdog expression, the look of learned helplessness and defeat. Or it might be the just opposite – the set jaw and steely look in the eye that says: ‘Go on, then! Just you try, I’m ready for you!’

It usually happens in the second half of the consultation. We have talked about the problem, looked at the offending body part that has caused the symptoms and begun to skirt around the cause or hint at solutions, but we both know it is coming. There is no way around it – we are going to have to talk about weight. The best thing we can do is get it over with as quickly and as painlessly as possible.

I feel for my overweight patients. You can lie to me about how much you drink and admit to only half the cigarettes you smoke. You can even claim to actually get your money’s worth from your gym subscription and I will happily believe you, but you cannot leave your weight at home when you visit me or pretend it isn’t there. You know your heartburn/diabetes/foot pain/arthritis is largely down to your weight and all you can do is steel yourself for a lecture while you sit in the waiting room.

And now the Government tells me we have to have this conversation every time you come to see me.  You might come about a cough, a cold or a wart on your finger and I am to talk to you about your weight. Burst into tears with depression,    troubled with your periods, stressed at work or worried about your elderly demented mother – if it looks like you might tip my scales then I am to make every contact count and talk about your weight. And while we are at it, what about your smoking, drinking and that underused gym subscription…?

The Government has accepted in full the recommendations of the NHS Future Forum which includes the concept of making every contact count – that all health professionals, whether GPs, pharmacists, dentists, nurses or anyone else that has a professional contact with patients, should promote healthy lifestyle measures every time they see someone, whatever the reason for the contact. What is more, the recommendation is that: ‘To emphasise the importance of this responsibility, the Secretary of State should seek to include it in the NHS Constitution.’

The NHS Constitution is a list of the rights and responsibilities of patients and professionals with respect to the NHS. It is an important and helpful document that shapes health policy rather like the Human Rights Acts shapes legal judgements. I don’t deny that there is a responsibility of health professionals to promote health and well-being, as well as to diagnose and treat ill-health and disease. However, where, alongside this responsibility and the patient’s right to receive lifestyle advice, is the patient’s equally important right not to be lectured to?

Like all GPs, I regularly talk to patients about their lifestyle – where it is appropriate. The idea that GPs should promote good health has been enshrined in the very fabric of the GP consultation since at least the 1970’s. I am not afraid to confront quite forcefully when it is needed, and I know it can make a huge difference to a patient who is ready to change. I will always remember seeing a man in a hospital clinic many years ago who had recently had a stay in hospital with his first episode of angina. ‘Can you thank that young doctor who admitted me?’ he said. ‘She so frightened me about my smoking that I handed her my packet of cigarettes and haven’t touched one since!’  I was only too pleased with the result, and to pass on his thanks. What I decided not to tell him, however, was that rather than waste his cigarettes she had smoked every one!

However, there is a major difference between challenging a patient when they are ready to consider change, and lecturing, nagging and bullying patients when they are not. The latter is not only irritating and stressful for the patient, but also counter productive in terms of psychological theory – one of the basic premises of which is that if someone is not receptive to change then you should stop pushing (you can find out more about this by reading about Motivational Interviewing if you are interested). If I have not seen someone for a while then it may well be worth raising the issue of smoking even if they have come in for a quick chat about something else – maybe they are ready and I can strike while the iron is hot – but many of my patients I know better than that. We will have talked about smoking, or weight, or whatever, many times before and sometimes they just need to know they can have a break – permission to see me without being told off, without feeling guilty.

I don’t think this paper will change anything at the moment, but I worry about where the Government will go with it. Once they start to enshrine it in the NHS Constitution it is only a step away from red tape and performance targets – nurses spending yet more time away from the patient while they tick the box marked ‘Making Every Contact Count’, GPs being paid according to how often they raise lifestyle issues regardless whether the patient wants it, pharmacists being incentivised to talk about lifestyle rather than actually answering the patient’s queries – and patients being afraid to come near us all for fear of yet another lecture.