Rule 6: The interview is the beginning of treatment
In a world where behavior increasingly drives pathology, words should be the focus of treatment - not pills.
I hope you had a great thanksgiving! I took the week to celebrate with some family time and turkey time. During the time off I had the opportunity to talk with some family and friends about the medical system, and I immediately thought about Dr. Meador’s 6th rule from his great book - “the interview is the beginning of treatment.” What follows is an investigation into that rule and what we can learn as providers and patients.
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Does this sound familiar?
You get to the doctor’s office and you wait. Then someone comes out to get you - they weigh you, take your vital signs, ask you some questions, then leave you in a room to wait. Then someone else comes into the room you’ve been stored in. They turn on their computer and talk to you. Maybe they examine you. Then they say the doctor will be in shortly and leave you to wait. You wait. You finally see the doc, but for about ten minutes. Judging from what they learned from their associates, they know your diagnosis and are ready to move forward with treatment. You’re not quite sure what you have or how or why you have it.
This is an exaggeration, but my guess is you can identify with some aspects of this scenario. That’s because you’ve experienced assembly line medical care.
What is assembly line medical care?
Corporations that run both hospitals and outpatient clinics are interested in patient volume. This isn’t necessarily a bad thing. Sure, docs and hospitals get paid with the more patients they see, but the flip side of that is a doctor can see more people. More people seen = more people treated = more people helped. That’s a good thing. This system requires an “assembly line” to operate efficiently. Here’s how it works:
In comes a patient with symptoms
They’re brought down the line meeting different people with different tasks (receptionists, medical assistants, nurses, etc.)
Their symptoms are diagnosed by the doctor
They exit the line with their prescription and a follow-up date
However, a side effect of this (and yes, I mean side effect) is that this system emphasizes treatment - usually a pill - as a product given in response to symptoms presented. The system equates treatment with pharmaceuticals. It looks at a part of you - your symptoms - and seeks to treat that part of you. This, again, isn’t necessarily a bad thing and works for some patients. Especially those who’ve found themselves in an acute medical situation like a gout flareup or a back spasm.
From a patient perspective, one of the troubles with this system is that it treats all medical visits with this mechanized “one-size-fits-all” approach to care. Yet, not all medical problems respond to this approach. It fails to take into account the therapeutic role of the patient interview, for as Dr. Meador puts it, “the interview is the beginning of treatment.” This is especially important for chronic medical conditions that are heavily influenced by behavior and a patient’s environment. Since society in today’s day and age is dominated by these kinds of conditions, like obesity, the patient interview should be emphasized more than pharmaceuticals.
The Interview is Talking is Treatment
Before talking about how the patient interview is therapeutic, let’s establish specifics of “the interview.”
Also known as “getting a history,” the interview serves as a time to gather information about your patient. Questions regarding your patient’s current reason for visiting, past medical history, medications, smoking habits, eating habits, their living situation, etc., are all commonplace. It’s also an opportunity to address any unhealthy life choices (in medical school, the most common example used is tobacco use).
Ok got it. So why is the interview considered treatment?
The interview is part of treatment because it treats patients as people to be helped, not as machines to be repaired.
When I hear “assembly line” I think cars. You may think of something similar. This is because Henry Ford is the one who invented the assembly line, producing more cars faster than ever before. It not only changed manufacturing, but it changed the world, literally. (U.S. manufacturing is one of the reasons the Allies got the win in WWII). Anyway…the assembly line is effective in producing cars because cars are solely material objects. There is nothing immaterial about cars.
People, on the other hand, are material and immaterial. We are flesh and bone, but we also experience love, fear, joy, desire - things that are immaterial. The interview is a necessary component of treatment because it recognizes that a person is, in fact, NOT a machine and addresses the immaterial things that contribute to disease processes and treatment efficacy. Assembly line care is equipped solely to deal with the material realities of disease, not the immaterial.
Grappling with this further, many medical problems in today’s world are behavior-based. The modern medicine machine is ill-equipped to treat these conditions - like metabolic syndrome. In a world where behavior drives pathology more and more, words are invaluable for treatment, not pills. Let’s draw this out with a hypothetical.
Meet Heraldina, our Patient
Say we have an obese 45 year old woman named Heraldina for a patient. She’s been feeling thirstier than usual, voiding more frequently, and after some time she admits she has to void more frequently at night. As the doc, alarm bells ring out for type 2 diabetes. So, if you suspect type 2 diabetes, what would the next step be after interviewing your patient and performing a physical exam? You must confirm your suspicion, i.e. diagnose the problem, so diabetic lab tests would be an appropriate next step. You order a blood glucose (amount of sugar in the blood), an A1C (another blood test), and a urinalysis (screen for sugar in the urine and evidence of kidney damage). Heraldina’s labs come back and they confirm diabetes (random glucose above 200 mg/dL and/or A1C equal to or above 6.5%, etc.).
Side note: based on her presentation in conjunction with her obesity, this is almost certainly type 2, however if you’re unsure there is additional testing to differentiate between type 1 and 2.
This then begs the question: why does Heraldina have diabetes? If you were her, you may hear something like “you’re insulin resistant” and/or “have impaired insulin secretion” leading to increased blood sugar. You may hear that your obesity is contributing to your high blood sugar. You maybe told your kidneys trying to expel excess sugar in your urine → which needs more water to make → which makes you need to void more frequently → which leads to more water lost → which makes you dehydrated. All of this is true, HOWEVER…
This is less a cause of your symptoms and more an explanation. And no, the two aren’t the same. “Diabetes,” as explained in the previous paragraph, fails to explain WHY there is more sugar in your blood or WHY there is more sugar in your urine. We know the pathology – insulin resistance, impaired insulin secretion, etc – but WHY is she insulin-resistant?
This is the other reason why the interview is invaluable because it is necessary to identify and address the root of the problem. Is Heraldina living on pop tarts and cheetos? Is she leading a completely sedentary lifestyle? Does she have three kids and work three low-paying jobs and struggling to make ends meet? What is one thing she’s doing to perpetuate diabetes? What is one thing she’s not doing to combat it? To discuss these questions effectively is something not easily accomplished in a ten-to-twenty-minute visit. Doctors want to spend more time with their patients, but assembly line care limits that ability and, therefore, is a system unable to adequately address these issues.
Change-Blazing and Action-Taking
Yes, Metformin is an effective treatment. Yes, Ozempic is an effective treatment. I’m not saying pharmaceuticals don’t have a part to play in treatment. They certainly do, in the sense that they tackle the material pathologic process. However, as we established earlier, there is a cause behind the cause - an underappreciated immaterial cause. And that cause can only be effectively treated with behavior and lifestyle change on a patient’s end. It is rare to see a non-obese exerciser with diabetes and medication; it is common to see obese non-exercisers with diabetes and medication. I’m not saying this to shame those who are obese or with diabetes - on the contrary - I’m saying this to point out that medications rarely work alone. To be maximally effective, they must work in concert with lifestyle change.
There is no pill that will cause someone to eat fewer processed foods just like there is no pill that will cause someone to exercise more frequently. There is no pill that can cause better life choices, more disciplined behavior, and/or an improved mindset. There is no pill that can tackle the fear a patient may feel, or despair, or stagnation, or apathy towards their problem.
From the provider view, this is where the interview can be deployed for maximum effect. Like a preacher at the pulpit, the interview is an opportunity for you to set your patients ABLAZE with the motivation and belief that they CAN GET better and CAN DO better. With whatever time you have at your disposal, the interview is where you leave your patient reflecting on their life and themselves - what “is” and what “could be.” This is your opportunity to blaze the pathway to change, enable your patients to see it, and encourage them to take necessary action NOW. Whatever their struggle - obesity, finances, drugs, alcohol - they should come away with the knowledge to change their circumstances, and the courage to do so.
Now I’m going to speak directly to you, the patient. Everyone’s a patient. I’m a patient. Doctors are patients. If you’ve never heard this from a doctor, or anyone for that matter, then hear it now and hear it clearly.
You are worthy the time and energy of change. You are worthy of the time and energy of improvement. You are a worthy investment for your own effort.
What’s the one thing you don’t want to work on? The one thing holding you back? Do you feel fear? Do you feel stuck? Be brave, take action, face that thing and overcome it. You can do it - and you are worth it
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Special thanks to my Nashville family for inspiring this post. As always, thanks to Dr. Meador, his legacy, and his tremendous book of rules.
Excellent Blog, Dr Tyler!! Everyone is worthy of help to better their health and life habits. You've nailed it! Reading this reignites my "fire" to keep up with my own health and wellness changes I've made recently! You have a special way of inspiring people/patients to be their best selves. Excellent!
This is an excellent blog. A person goes to the doctor to find relief and help, but you walk out of the room still wondering what you are supposed to do to help yourself. I think of my brother Donnie who also ha sborderline Type 2 diabetes. He controls his by diet. He has researched online and follows some of those ideas and Lorrie bakes special breads and other things to support that diet. He is not on any of the medictions that Gramps is on because he is like me. Thinks there is a better way than taking all that medicine. So it is like self diagnosis. I am glad you are questioning some of these "normal" methods of diagnosis. I like that very much. It is good to quetion the so called "normal". Great blog!!!