The ethics of nagging people

Robbie/James/Ben

Today’s post is a little different from some of my others – today I’m asking you, the readers to tell me what you think.  There is no right or wrong answer to this problem but I’d be keen to know how other paramedics and student paramedics have tackled the problem and what their thoughts are.

Chronic disease.  It’s what we do.  I know that we all signed up intending to treat people who had suffered horrendous trauma or massive cardiac events, and sometimes we do.  However it’s relatively rare.  The vast majority of our time and effort is spent on treating people who have long-standing disease of the chronic Western variety.  We’re usually attending because of an exacerbation of an existing problem and our treatment, combined with the hospital’s, is aimed at reducing symptoms enough for the patient to return home.     It’s not glamorous but it’s a large part of our job.

It’s no secret that chronic disease is usually caused by or contributed to by lifestyle factors.  I personally hate that phrase because it implies that there’s no autonomy involved, as if you didn’t choose the diabetes life, the diabetes life chose you.  But it’s the one in general use so we just have to understand that “lifestyle factors” means eating sugary junk, doing no exercise, drinking to excess and smoking.  There’s a mountain of evidence out there that these are exactly the behaviours you want to avoid if you want to live a a long and healthy life.  One estimate that I read indicated that the total burden of disease caused by smoking is equivalent to the healthcare benefit provided by the entirety of modern medicine. *  Amazing.

Knowing this, what can we as ambos do?  Are we, as notionally emergency healthcare providers, in a position to be giving advice and trying to change people’s behaviour?  Is it even possible?  After all, when people get to the stage of calling an ambulance they’re usually pretty far down the road of disease progression and changing behaviours may not cause any significant improvement.  Also, badgering the elderly non-English-speaking patient about their chocolate habit makes you look (and feel) like a jerk.

On the other hand perhaps we have an ethical obligation to at least suggest the issue?  There is plenty of research to indicate that physician advice to cease smoking has a measurable effect.**  Perhaps this effect is cumulative and an ambo providing their two cents improves the outcome?  In any event given that we are healthcare providers treating medical problems, are we not obliged to provide lifestyle advice as part of our treatment?

I’m torn between these two options.  I sometimes bring it up with patients but usually only if they’re young enough to benefit and receptive to my advice. My preference is a person in their thirties or forties who has some kind of probably-not-cardiac chest pain and who is spooked already.  In that setting I find that they are usually receptive to a gentle suggestion, chiefly because they are highly motivated due to fear of death and because they already know what they need to do.  Lose 20 kilos.  Stop smoking. Go for a walk.  They’re not stupid, they just need a push.

So what do you, the reader, do in this situation?  Are you a softly-softly type who doesn’t want to rock the boat and possibly destroy your professional relationship?  Or are you in people’s faces about their bad habits and bugger the consequences?  I’m all ears.

Diabeetus.  You has it.

Diabeetus. You has it.

* Burch, Druin. Taking the Medicine: A Short History of Medicine’s Beautiful Idea, and our Difficulty Swallowing It, Random House 2009.

** Stead LF, Buitrago D, Preciado N, Sanchez G, Hartmann-Boyce J, Lancaster T. Physician advice for smoking cessation. Cochrane Database of Systematic Reviews 2013, Issue 5. Art. No.: CD000165. DOI: 10.1002/14651858.CD000165.pub4.

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3 Responses to The ethics of nagging people

  1. Joel says:

    I take the middling approach in that I try to gauge how effective the “nagging” may be on a patient by patient basis. The COPDer who calls for difficulty breathing and meets me with a smoke in his mouth I won’t waste my breath, let alone his, with a lecture.

    On the other hand, the slightly obese fellow who calls for “high blood pressure” and relates a history of “pre-diabetes” I’ll probably have a chat with about some mild life style changes.

    In general I try to impart a small amount of common sense/wisdom to every patient I meet… If it’s appropriate to do so and the patient seems open to it.

    Who knows, our little conversation may spark a bigger one between the patient and their primary GP. That’s not going to happen if I don’t at least try to have one en route to the hospital.

    Besides, I have nothing else to talk about on the ride… I know nothing I sports and little about current events.

    Thanks for a great article on a little talked about subject.

  2. Rotovegas Paramedic says:

    Nice thought provoking post James. It’s a bit of an enigma really. Why do folk call us and what is their expectation? My feeling is that there is a growing divide between our expectation and our consumer expectation. More often than not, the consumer is the patient, however in a broader sense; it refers to family members, neighbours, bystanders, nurses, general practitioners…in a nutshell, just about anybody we encounter at the scene and/or whoever has called us. That’s because, like or not they all have an expectation.

    It would be fair to say that our expectation is that an ambulance should be used “appropriately”. Many would say that the appropriate use of a frontline emergency ambulance should be for a time critical, emergent illness or injury necessitating prompt definitive prehospital management to mitigate worsening illness or injury and urgent transport to an appropriate medical facility. Our expectation may also be that if someone calls for an ambulance, it should be on the basis that we can actually “do something”. In other words, we can open the green kit and do some definitive skill or administer an appropriate medication. Our expectation may be that in order to be used appropriately, we need to “treat” patients. We like to “treat” people don’t we? We like to do interventions. We like to practice our skills. If we do lots of stuff, then it’s often deemed “a good job”. Many of us have been known to keep mental tallies of how many skills we have performed recently and compare that with colleague’s tallies. It can become quite competitive. However….here is my point. Why as an emerging profession do we base our worth based on a skill set? You don’t hear nurses comparing tallies on how many Foley catheters they have introduced recently. The mark of a profession is based on a mindset, not a skill set.

    I feel we need to adjust our attitude and our mindset to reflect the reality of life as an ambo in 2014. We need to ask ourselves…”how can I care for this patient?”…that is the very essence of it.

    For what it’s worth, here are a few of my random thoughts on expectation using cognitive empathy skills. Nowadays, for whatever reason, our consumers call us because they are having a bad day and don’t know what to do. They are concerned about something that is troubling them. These days, GP surgeries are getting busier and busier and it’s hard to get an appointment in the short term. Doctors don’t do house calls. In many urban areas there has been a fragmentation of community support networks. So, if your socially isolated, marginalised, poor, have a mental health problem or find it difficult to problem solve your complex health concerns…you might ask yourself this question. ”Who does house calls these days?”…”who can I call and who turns up promptly?” Bit of a no brainer really.

    Faced with our new reality, our emerging role in this landscape is to gauge their expectation. In other words, try to figure out why they have called us. What is their expectation? If they are having a bad day, they might want us to listen to their concerns. Or they might be a bit befuddled and are merely be looking for a bit of guidance. They might have called us because they want to go somewhere or they might want us to provide something in the way of definitive care. Our new role is to discover their expectation and decide whether it is a realistic or unrealistic expectation and problem solve it, if we can. This requires a mindset.

    As for your original enquiry about health advice? I guess it comes down to how receptive they are to advice. Lifestyle modification is part of the solution, but hard to change the mindset of engrained patterns of behaviour. Guess I’m a pragmatist. Help those, who want to be helped and put the “works burgers” in the too hard basket and hope that someone else likes “a good challenge”

  3. R says:

    I think clinictions with a familiarity with Cognitive Behavioral Therapy ( frequently abbreviated CBT which can also have a rather kinky definition) and Motivational Interviewing are probably much better equipped to make effective interventions. It’s too late at night for me to go find PubMed citations but I’m aware of good evidence supporting the efficacy of brief counseling interventions around tobacco use during clinic visits and alcohol use for trauma patients. If one can maintain a non-judgmental attitude and be friendly about the interaction it may be a worthwhile conversation.

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