Habits

Well, I've managed to fall out of the habit of blogging again for a while.  It's easy to do, especially this time of year.  We're busy at the residency program saying good-byes toour graduates, and we're busy orienting the new interns who will start next week.  We're reassessing curricula, tallying patient numbers, and trying to prepare for what the Accreditation Council of Graduate Medical Education will throw at us next.

Getting and staying in the habit of blogging on a regular basis has been tough for me.  I don't think I've ever had more than a 3-4 month stretch of regular blogging since I first started doing this 2 and 1/2 years ago.  And, yes, academic medicine is not for the faint of heart, but why can't I stay in the habit of blogging consistently?

The noun "habit" has several definitions, but here are the ones of interest to me lately:

* a settled tendency or usual manner of behavior <her habit of taking a morning walk>
* a behavior pattern acquired by frequent repetition or physiologic exposure that shows itself in regularity or increased facility of performance
*an acquired mode of behavior that has become nearly or completely involuntary <got up early from force of habit>

(Thanks, Merriam-Webster!)

For me, at least, I think my failure to maintain a regular blogging habit all comes down to how I use the hours of each day.  So, I've been seeking out advice about how to better manage my time.  I recently read a book called Early to Rise, and the author challenges readers to consider how waking up an hour or two earlier every day (and then going to bed earlier, too) enables better use of the 16 or so hours we're awake each day.

After reading it, I had to admit that, despite my best intentions, I often lack motivation to do the things I promise to myself to do in the evenings - exercise, writing, connecting with family and friends.  I also have been consistently sleeping in until the last possible minute before rushing through my morning to get to work on time.

So, I figured I'd give it a try for 30 days.  I'm currently on day 8 of waking at 5:30 am to allow time for prayer, writing, and exercise most mornings before work.  Ungh.  (My bedtime has shifted back to 9:30 pm.  Double ungh.)  It is not fun, but I have to admit that I am getting a very satisfying start to my day by accomplishing so much even before I leave the house - not to mention that my evenings are more relaxing instead of a guilt-fest regarding what I "should" be doing.

Do I miss sleeping until 6:30-7 every morning?  You betcha.  Will this 5:30 thing become a habit?  I'm not sure yet.

But here's a new post, at least, that suggests it's might be doing me some good.

Shared decision making

(The following was originally posted on the The AFP Community Blog on 4-22-13.)

Let’s say you’re seeing a healthy 21-year-old woman in your office for contraception management.  She takes no other medicines, has no personal or family history of blood clots, and has no contraindications to estrogen.  She is interested in a long-acting contraceptive that she won’t have to worry about remembering every day.  IUD, subdermal progesterone implant, q 3 months injectable progesterone – how do you choose?

Or, how about this: a 45-year-old man presents with frequent migraine headaches.  You review the best evidence for migraine prophylaxis in adults and are stuck deciding between propranolol and amitriptyline.   Which do you use?

Gray areas like these abound in Family Medicine, even with the ever-growing primary care evidence base.  In both of these scenarios, no one option is clearly superior to the other.  All of those contraceptive options would be efficacious for the 21-year-old woman, and, likewise, the efficacy of propranolol versus amitriptyline for the migraineur is probably a toss-up.

These types of situations, where multiple reasonable treatment options exist, provide an opportunity to involve the patient in the decision.  Shared decision making (SDM) brings the patient’s preferences into the conversation and gives them some ownership over the final choice. 

I wish that I could tell you that SDM has a rigorous evidence base behind it, but like many behavioral interventions, few quality studies exist to suggest patient benefit.  A study last week in the Annals of Internal Medicine, however, may help to reinforce SDM’s value.  Weiner et al engaged patients who surreptitiously recorded their office visits with Internal Medicine residents.  The residents who adapted their care plan to meet their specific patient’s preferences had, in return, improved compliance from their patients. 

This study was small and needs to be replicated in bigger settings, but its finding makes intuitive sense: patients invited to be involved in treatment decisions tend to have better adherence with those treatments.  

You can ease the loss of the extra time it takes to do SDM by billing for the time spent in counseling (10 min = 99212, 15 min = 99213, and 25 min = 99214).  Just be sure to document as such in your encounter note.

In 2010, AFP also published a nice SDM review, along with a helpful framework for the office.  You can find that Curbside Consultation here: http://www.aafp.org/afp/2010/0301/p645.html.

I welcome your thoughts on the practical use of SDM in the busy family doc’s practice.