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William Cayley: Measurement—at the expense of success

12 Sep, 13 | by BMJ

bill_cayley“Doc, how’s my blood pressure? What about my cholesterol? How about my weight?”

“There’s room for improvement,” I say. “How much do you exercise? How many fruits and vegetables do you eat?”

“Oh, I’m too busy right now for exercise—and I have to eat what I can get when I’m on the road. But I just wanted to get things checked to be sure I’m OK.”

That conversation, repeated with some variation over and over, has me wondering how much we’ve taught our patients to focus on the wrong things.

For years, we’ve advocated the “annual physical,” which has many people expecting some sort of annual checkup—even though there are serious questions about the efficacy of this approach. Go to the doctor, get yourself measured and tested, and find out how you are doing. Unfortunately, this focus on testing, checking, and measuring often ends up being just that—tests are done, measures are taken, but often not much else may happen. The behavior change that is essential to changing one’s health status or health risks gets lost in the numbers and the data. The focus becomes “how am I doing,” not “what can I do to get better?”

I think part of the problem is that as physicians, we find it easy to focus on numbers. Vital signs, blood tests, imaging studies—these are all easy to get, measure, and quantify. They also lend themselves fairly well to measurement for “quality” reporting purposes. But the problem with this, then, is that we end up equating quality with obtaining something to measure. So, we focus on surrogate markers of disease, rather than on what the patient may or may not be doing to address the underlying causes or the possible treatments for that disease.

Patients have learned well from our example. They come for their tests, they come to get measured, but they find it much harder to engage in discussion or exploration of the changes that might help improve their long term risks or their health. For example:

  • The person who wants to find out again, if they have high blood sugar—but there is no willingness to exercise.
  • The person who wants testing for sexually transmitted infections, but has no interest in adopting different behaviors.
  • The person who says: “I know smoking is bad for me, but I can’t quit right now.”
  • The person who can’t sleep, and has no energy, but is reluctant to see a counselor or explore what might be causing depression.

Yes, our patients, and we ourselves as physicians, have plenty of social and emotional barriers that can impede our desire for the type of change that might improve health, and it is true that the growing literature on Motivational Interviewing (“a method for encouraging people to make behavioral changes to improve health outcomes”) suggests this approach may hold promise for encouraging behavior change.

Nevertheless, the fundamental issue of focus remains a challenge. Are we teaching our patients to focus on testing and measuring our health, or to actually do something about it?

Perhaps a better approach is to leave the measurement aside, and focus on what is being done. So, when met with the questions of:

“Doc, how’s my blood pressure? What about my cholesterol? How about my weight?”
Perhaps the response should be:

“We’ll come to those in a minute, but first let’s talk about you. How are you feeling? What are you eating? How much are you exercising? How are your relationships?”

No profound questions, but hopefully a shift from looking at what is, or might be, wrong, to what is being done well and what can be done better.

Competing interests:
“I declare that that I have read and understood the BMJ Group policy on declaration of interests and I have no relevant interests to declare.”
William E Cayley Jr MD MDiv

William E Cayley Jr practises at the Augusta Family Medicine Clinic, teaches at the Eau Claire Family Medicine Residency, and is a professor at the University of Wisconsin, Department of Family Medicine.

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