On change (or the lack thereof)

There’s a level of pain and anguish that is necessary for profound change. You don’t give up smoking after a pack a day for fifteen years because of a television commercial. You don’t begin a movement journey after a decade of couch-based deconditioning because of a post on social media. A relative low in order to get the shock to change.

Sometimes that shock might be a readmission after 24hrs of discharge. Maybe it is devastating news regarding a loved one. Whatever it is, the splash of cold water leads to change, to a re-evaluation of your decisions and your overall trajectory.

On Thursday, I interviewed a man about my age that presented with penile discomfort after beginning unprotected sex with a new partner. We talked about the potential complications for gonorrhea and chlamydia, especially for females and complications to their fertility.

And surprisingly, we had a very productive conversation about smoking cessation. He mentioned that he wants to quit but works as a chef and everyone around him smokes regularly. I told him about the breath sounds I heard on pulmonary auscultation and the progression of chronic obstructive pulmonary disease. I reinforced that quitting smoking is something you should do before you need to, because otherwise it’s mostly too late.

And on Monday, I spoke with a woman in her late fifties with severe arthritis and back pain. She had tried Tai Chi as a movement practice but found it frustrating and confusing, even after a class a week for eight weeks. Otherwise, she was going to her local gym twice or three times a week to move on the elliptical or rowing machine.

I told her that these are great practices but ultimately will not help her regain much mobility or decrease her risk of falls compared to the practice of Tai Chi. The addition of regularly pivoting and shifting her weight would complement the cardiovascular benefits of her current movement. When I told her this, I could see the obvious signs of resistance: her lips pursed just enough to show the wrinkles around her mouth, she avoided eye contact, and her overall posture stiffened. Before concluding my interview and bringing in my attending physician for the final low-down, I told her that it is ultimately up to her. It’s her movement choice. She relaxed a bit and agreed.

When I came back with the attending, we briefly reviewed her other co-morbidities and various medications. As we began to wrap up the encounter, she asked about her arthritis and about her back pain: would it get any better, would another steroid shot help her?

The attending said he hopes so. The shot might help, might not. A series of three shots would determine her overall response, and this’ll be third. He hopes so because the next option would be surgery and he wanted to avoid that as much as possible. She recoiled at the mention of back surgery and expressed a quiet air of desperation.

I hope that she reconsiders Tai Chi as her movement practice, after that cold shock of surgical possibility. My gentle nudge and poke can work for the folks that are already on the contemplation or planning phase, but ultimately ineffective for individuals that are pre-contemplative or resistant to change. I can easily guide the tobacco cessation discussion when the mind already leans that way, but as soon as I see pursed lips, I back off.

As a medical student, the tool of a cold bucket of water feels just out of reach: I don’t yet feel comfortable making my patients intentionally uncomfortable even if I know it will put them in the right mind space to accept change. So far, I’ve allowed circumstance or my attending physicians complete that task for me.

I know this is a tool and not an indiscriminate tool. I need to build a relationship and a rapport before I can prescribe life change to a person trusting me with their health. I look forward to the day when I have the confidence to do so.

Perhaps I’ll need a cold bucket of water myself, a missed opportunity with unfortunate consequences, to prompt that change.


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