WELLNESS/PROBLEM PATIENT
From the 50th annual Postgraduate Symposium Family Medicine Update, sponsored by the San Diego Academy of Family
Physicians
| WELLNESS UPDATE—E. Lee Rice, DO, Associate Clinical Professor of Family and Preventive Medicine,
University of California, San Diego, School of Medicine, Clinical Professor, Department of Family Medicine,
Western University of Health Sciences, and CEO and Medical Director, Life Wellness Institute, San Diego, CA
|
| Health care costs: nearly 16% of US gross domestic product allocated to health care; yearly health care cost
per person ($4600) increasing; US health care costs projected to double between 2001 and 2012; large percentage
of money spent on preventable conditions; costly health conditions related to heart disease and stroke
(often related to behavior and lifestyle, eg, substance abuse, insomnia); between 1990 and 2004, number of
obese people in Massachusetts increased by 80%; for every 1% increase in body mass index (BMI), individual’s
health care costs increase by ≈$120; average employer health care costs per employee in 2001, $5000
(95% for diagnosis and treatment; <2% for prevention); each tobacco smoker costs the employer additional
$3800/yr in health care costs and lost productivity (average savings nearly $1000 per person [as shown in
smoking cessation program in which 67% of employees quit after 12 mo]); advocate prevention strategies;
yearly health care claims of people who exercise 1 to 2 times per week $350 less than those who do not
|
| Paradigm for wellness: concept of wellness—scale ranges from death or failure to live up to one’s wellness
potential (-10) to perfect health (+10); constant shifting between states of well-being; possible to improve
health and quality of life; role of primary physician—help patients improve wellness (role of physician not over
once patient has no signs or symptoms of disease; “people can always feel just a little bit better”); coach and
educate patients about decreasing risks, increasing energy, enjoying relationships, improving sleep, and having
more meaningful daytime experience; life expectancy—in 1900, average life expectancy in United States
≈50 yr of age; in 2006, ≈76.5 yr of age (4-5 more years in women than in men); “useful” or “healthy” life
expectancy—World Health Organization rated every country by subtracting number of years spent not being
productive or happy, or being dependent with poor quality of life; United States ranked number 26; average
American loses ≈7 yr of healthy life expectancy; Japan ranked number 1 (≈7 yr longer than in United States)
|
| Determinants of well lifestyle: genetics—predisposition to certain diseases; however, genetic code can be
highly modified by behavior and environment; epigenetics looks at how proteins switch gene sequencing on
or off to modify ability to protect, based on lifestyle; some studies suggest that ≤3% of how long we live determined
purely by genetics; on average, identical twins die up to 10 yr apart; proteomics, epigenetics, and lifestyle
affect plasticity of genetic code and outcomes; mind and body—plasticity of brain modified not only by
environment, but by thoughts; thoughts create chemicals in brain that change signaling mechanisms that affect
plasticity and immune response; when one nerve stimulated, up to 40,000 other nerve cells stimulated in
sequence; “neurons that fire together, wire together” (ie, neuron pathway patterned into “hard-wired rut”); behavior
conditioned, based on past responses; habit patterns continue (becomes difficult to behave differently;
strong emotional commitment and insight needed to help change patterns); controlled and balanced brain neurochemistry
needed for balanced function
|
| Key behaviors that help control wellness and disease: 1) mind; thoughts and how we choose to think; 2)
motion; “what we do with our bodies”; influence of body on brain; 3) meals; effective strategies for behavioral
changes—help people practice skill sets that lead to effective change; set specific goals; help patients generate
self-talk to alter brain messages that prevent them from changing; written or verbal behavioral contract to enhance
commitment; timely and regular review of behavioral goals; least effective strategies include arousing
fear, causing people to feel judged, and causing people to regret previous behaviors; provide inspiration, mentoring,
partnering, and coaching
|
| Stages of change: meet patients at their level and provide information appropriate for stage of change; inform
patients who are unaware of their need to change; inspire patients who are aware of their need for change;
provide hope and options for patients considering change; support and encourage patients planning to change;
provide coaching and hope for patients beginning process of change; hold patients accountable for changes;
monitor and redirect efforts when efforts fail; patients who relapse or stop succeeding need encouragement or
improved skills; celebrate and congratulate patients for success; processes should be educational, inspirational,
and fun; patients should understand purpose
|
| Key behaviors: exercise—30 min 5 to 6 times per week (accumulating 3 hr per week) minimum requirement
for affecting significant cardiovascular changes; strength training (1 set of 15 repetitions can prevent unnecessary
loss of lean body mass and sarcopenia); flexibility training; agility activities (greater variety improves
coordination); muscles and tendons become trained only in patterns repeated in practice; nutrition—water,
fruits and vegetables, whole grains, low- or nonfat dairy products, lean meats, and fish recommended; sugar,
saturated fats, trans fats, alcohol, caffeine, and salt should be consumed in moderation; supplements—baby aspirin
taken by women >50 yr of age (men >40 yr of age) can prevent heart disease and stroke, and lower incidence
of breast cancer, colon cancer, and senile dementia; calcium supplementation if dietary intake
inadequate; folic acid for women of childbearing age prevents neural tube defects; no significant benefit from
vitamin C supplementation; stress—affects mind-body connection; identify signs and symptoms; reduce
stress
|
| Health promotion: lower low-density lipoprotein (LDL; <70 mg/dL ideal); caffeine may be associated with
development of insulin resistance and type 2 diabetes (studies ongoing); magnetic resonance imaging (MRI)
more sensitive than mammography in high-risk women; genetic sequencing available for 7 chronic diseases;
1 of 19 pleomorphisms for lipoprotein a [Lp(a)] related to heart disease (high-dose niacin helpful); risk
factors—1 in 12 workers has used illegal drugs in last 30 days; 40% to 90% chance of developing breast cancer
by age 80 yr with BRCA 1 or BRCA 2 in genetic code; educate patients about risks of radiation, eg, from
64-slice computed tomography (CT) for heart disease
|
| Questions and answers: agility, coordination, and balance training for elderly—dancing; bowling; swimming;
cycling; greater variety of activities increases overall benefits; supplementation—fish oil supplements may be
appropriate for patients at high cardiac risk; ≥2 servings/wk of fish (eg, salmon) recommended (supplement
with 1000 mg of fish oil on days when fish not consumed); vitamin D and calcium helpful for bone density;
vitamin D supplementation may not be necessary with daily multivitamin and well-rounded diet; pay attention
to patients with osteoporosis or osteopenia
|
| THE PROBLEM PATIENT—Margaret E. McCahill, MD, Clinical Professor of Family Medicine and Psychiatry,
University of California, San Diego, School of Medicine, and Medical Director, St. Vincent de Paul Village,
San Diego
|
| Manipulation: due to disconnection between what physician thinks patient needs and what patient thinks he or
she needs; discuss reasons for needs and try to determine causes; due to sense of entitlement, anger, personality
disorders, guilt, and fear
|
| Entitlement: patients may feel entitled to disability income, subsistence entitlements, and insurance benefits;
pain patients may become manipulative to obtain drugs, disability income and drugs, or procedures and drugs
|
| Anger: discuss and acknowledge anger with patient; anger must be understood and directed in healthy manner;
determine reasons for anger and manipulation; identify who is target of patient’s anger and redirect if appropriate;
if unable to resolve anger, consider discontinuing therapeutic relationship with patient; patient may
feel trapped in managed care system; try to stay out of line of fire if possible; be honest with patient
|
| Guilt: often underlies demanding and manipulative behavior; parent or guardian of patient (ie, child) or adult
child of patient (ie, dependent elder) becomes demanding or manipulative due to guilt; give absolution for
guilty feelings when appropriate (eg, “no one could have predicted your mother would have a stroke while
you were away; we’ll do our best to get her taken care of”); be honest
|
| Patients with personality disorders: usually not schizoid, schizotypal, or “quiet sufferer” types; narcissistic
personality disorder—patient’s perception that “you don’t have anything else to do today that’s more important
than me”; histrionic personality disorder—patient’s point of view, “oh my God, look what’s happening to
me, what are you going to do about it?”; antisocial personality disorder—different from shyness or social anxiety
disorder; sociopath; criminal; user of people; borderline personality disorder—chronic instability in, eg, impulses,
relationships, judgment; chronic feelings of emptiness, avoidance, and abandonment; abandonment
can be real or imagined; patients may perceive referral from family physician to psychiatrist or other mental
health professional as abandonment; patients may be impulsive, self-damaging, or have recurrent suicidal behavior;
affect intense (“all good or all bad, no intermediate stages”); look out for “staff-splitting” (patient
talks to staff member about needs, and staff member addresses issues with you)
|
| Management of patients with borderline personality disorders: 4 Cs of soft-spoken limit-setting—1) stay
calm; 2) connect empathically; 3) give choices; forces patient to restore control; do not say “you do what I tell
you, or I am going to leave”; 4) crisis meets limit-setting without abandonment; 4 Cs ineffective when managing
psychotic patients (“their reality basis is different than yours”; seek help from mental health colleagues
or police department); antisocial personality disorder—4 Cs ineffective; patients with ultimate demand or manipulation
(eg, patient has gun or knife) do not care whether physician remains calm or empathic; armed patients
with antisocial personality disorder who hesitate to kill are thinking “of what use are you to me?”;
negotiating with patient (eg, “you shouldn’t kill me because my children will be orphaned”) ineffective; however,
making yourself “useful” to patient may work
|
| Fear-based manipulation: critical to determine patient’s underlying fear; patients often fear not having needs
met; providing assurance reduces manipulative behaviors in emotionally healthy patients
|
| What health care providers fear: being taken advantage of; loss of control of clinical situation; risks of prescribing
controlled substances
|
 | Abuse of controlled substances: take thorough substance abuse history and monitor use of pain medications;
physical dependence—does not cause addiction; tolerance—rarely drives dose escalation; does not cause addiction;
addiction—defined as loss of control of use of substance, compulsive use, and continued use despite
harm; diagnosed by observing behavior (aberrant drug-related behavior); pseudoaddiction—insufficient
pain control leads to increased drug-seeking behavior (consider reassessment); can coexist with addiction;
risk for addiction—highly unlikely in treatment of acute or cancer pain; surveys in chronic pain show mixed
results; monitoring outcomes—patients with chronic pain expect to be monitored for pain relief and side effects;
look for drug-related behaviors; maximize patient’s physical and psychosocial function despite fact
pain may continue
|
| Approach to manipulative patient with chronic pain and history of substance use: if aberrant drug-related behaviors
observed, determine whether patient has addiction disorder; differential diagnosis of aberrant drug-
related behavior includes addiction, pseudoaddiction, borderline personality disorder, other brain disorders,
family disturbances (eg, family member takes medication prescribed for patient), and criminal intent; addressing
aberrant drug-related behavior—know laws and regulations; communicate with patient about expectations;
structure therapy to match perceived risk; consult colleagues in addiction community; consider
more frequent prescriptions in smaller quantities (eg, 3 refills at no closer than 1-wk intervals; pharmacist
helps control)
|
| Questions and answers: contracts for chronic pain patients—may not be necessary if patient has no personal or
family history of substance use; speaker uses when patients have positive history for substance use or “if I
begin to get a sense”; discharging new difficult patient with borderline personality disorder—when seeing new patients,
perform history and physical examination; assess patient, and if unable to meet patient’s needs, consider
declining physician-patient relationship (eg, “this is beyond my expertise and I’m sorry I cannot serve
you as your physician”); borderline personality disorder may not present clearly on first visit; being consistent
with professional boundaries (eg, rule-exception boundaries) with all patients helps reinforce limits
when borderline personality disorder becomes obvious
|
Suggested Reading
Conroy DE et al: Coaching behaviors associated with changes in fear of failure: changes in self-talk and
need satisfaction as potential mechanisms. J Pers 75:383, 2007; Feske U et al: Borderline personality and
substance use in women. Am J Addict 15:131, 2006; Gross R et al: Borderline personality disorder in primary
care. Arch Intern Med 162:53, 2002; Hellwig JP: For improving fitness: less exercise better than none. Nurs
Womens Health 11:362, 2007; Martin GM et al: Genetic determinants of human health span and life span:
progress and new opportunities. PLoS Genet 3:e125, 2007; Waldinger RJ: The role of psychodynamic concepts
in the diagnosis of borderline personality disorder. Harv Rev Psychiatry 1:158, 1993; Wiedemer NL et
al: The opioid renewal clinic: a primary care, managed approach to opioid therapy in chronic pain patients at
risk for substance abuse. Pain Med 8:573, 2007.
Educational Objectives
| The goal of this program is to improve approaches to wellness management and management of difficult patients.
After hearing and assimilating this program, the participant will be better able to:
|
| Discuss the concept of wellness and the role the health care provider plays in its attainment.
|
| Counsel patients about behavioral changes that improve wellness.
|
| List causes of demanding and manipulative behavior.
|
| Take control when faced with demanding patients who have personality disorders.
|
| Address and prevent aberrant drug-related behavior.
|
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose
relevant financial relationships within the past 12 months that might create any personal conflicts of interest.
Any identified conflicts were resolved to ensure that this educational activity promotes quality in health
care and not a proprietary business or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Drs. Rice and McCahill spoke in San Diego, CA, at the 50th annual Postgraduate Symposium Family Medicine Update:
2007, presented August 3-5, 2007, by the San Diego Academy of Family Physicians. The Audio-Digest
Foundation thanks the speakers and the San Diego Academy of Family Physicians for their cooperation in the
production of this program.
|
