It pays to be positive

Clinical practice guidelines are important, but some patients will always have trouble meeting recommended goals or coming in for preventive treatment. What motivation do they need? Soapbox lectures, cajoling, warnings, and rebukes have never worked well for me. Instead, during patient encounters I always add a hefty dose of positive reinforcement. Doing so is simple; it improves patient compliance; it alleviates anxiety; and it works with patients of all ages-even teenagers. Here are some examples.

The serial dieter. "Doctor, I've been on diets from around the world. Now my sister has me on one called 'sensible.' "

Bernie Metcalf (I'm not using real names) chuckled. Over the years he had tried multiple weight-loss regimens. All were unsuccessful. Even a gastric bypass in the 1970s had failed. "The only thing I lost was my gallbladder," he ruefully told me.

"I guess sisters know some things," Mr. Metcalf said, smiling.

The working woman. "I have to drive." The emphatic speaker was Joanne Leland, a patient who drove 18-wheelers for a living. "If I have to take insulin shots I can't drive."

Even though Mrs. Leland looked strong enough to single-handedly change tires on her rig, federal law bars drivers with insulin-dependent diabetes from operating commercial motor vehicles. Only people maintained on oral medications and diet qualify.

Mrs. Leland got off the exam table and started pacing. "If I can't work, it doesn't matter what diet I'm supposed to follow because I won't be able to afford food, much less medicines."

"Mrs. Leland," I interjected, "I have good news. You don't have to start insulin injections. Your blood work shows that you've been doing well on your diet. You only need a small adjustment in your medications." Her HbAlc level was 10 percent, which was much higher than the clinical practice guideline goal. But her previous HbAlc level had been 11.5 percent.

The improvement bought her some time, and allowed her to keep her job.

The apprehensive kindergartener. "Hi, Maggie," I said as I entered the room. My patient, who was 5 years old and needed immunizations, was sitting motionless on the exam table.

"Say hello to Dr. McCormick," Maggie's mother prompted.

"Hello," Maggie whispered, without turning her head.

"Maggie," I said, "your fingernails sure are pretty."

"I did it myself!" Maggie exclaimed as she emerged from still life to animation.

With polish extending proximally and distally off her nails, it was apparent that Maggie was her own cosmetologist. Now that she was focused on something other than the dreaded shots, I could take care of her and send her on her way.

The jittery baseball fan. "George, I like your cap."

The baseball cap I was admiring was signed by Major League pitching ace Roger Clemens. The owner was 15 years old and here for immunizations. Like Maggie, he hated needles.

"I got it a few years ago when we visited my aunt and uncle," he told me.