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The Art of Empathizing Without Enabling

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It seems many patients and referring clinicians assume gastroenterologists have an expansive, unlimited knowledge base regarding every aspect of metabolism, nutrition, food allergies/sensitivities, vitamins, nutritional supplements, and every diet in existence. After all, each category is, in some way, related to the GI tract, right? Hence, it seems a given we should be able to identify the obvious reasons certain diets fail to achieve both short- and long-term sustained goals for our patients (many of whom have struggled with these issues for years) within a 15-minute visit.

The funny thing is, many of these patients are so experienced and well-informed in these areas, their knowledge bases seem to rival our own. As many of us tend to live in carefully created comfort zones to shelter us from the challenging world we live in — food being a major component — these patients are often resistant to change, even if their behavior and results are suspect.

The mere suggestions of trying something different, and changing bad behaviors, can be hotly contested, with lifestyle choices tenaciously defended. As the visit clock keeps ticking and our waiting rooms fill with other patients (and we inevitably fall behind schedule), the pressure causes us clinicians to cave. We tell these individuals they are doing great, to keep up their efforts, and that we’ll see them back in six months, when the cycle repeats.

This ultimately equates to enabling unhealthy behaviors.

Over time, my background in nutrition and interest in diets and fitness has led me to carefully reflect on these visits. I’ve since discovered the best approach — not only in these encounters, but in every patient encounter — is to listen and empathize without enabling, thus allowing more creative and beneficial redirecting of overall patient management that ultimately results in more productive present and future visits.

At the start of a typical visit, patients go through the obligatory position that they can’t understand why they eat essentially no calories, yet can’t lose weight, perhaps even gaining weight in their efforts. They follow with the idea that they must have an “endocrine” or “metabolic” disorder. Many ask if there may be a “gluten problem.”

This is an opportune time to guide the conversation toward uncovering information that may provide the insight necessary for results. We must listen closely to a careful history, ensuring we  do not miss an important medical issue that requires further evaluation. At the same time, we must remain non-judgmental and empathetic to what may be an extremely sensitive issue, and perhaps a lifelong physical and psychological struggle. 

I ask patients to run through their actual diets, daily caloric intake, and activity levels. For most, it doesn’t take long to realize that, despite their diet plans, they continue overall poor dietary habits. Skipping daytime meals and consuming an abundance of calories late in the day or at night coexists with poor macronutrient choices, substituting what is in their original plan with “comfort foods,” which are more convenient, easier to obtain and prepare, less expensive, and high-calorie but of poor nutritional value.

I often discover significant unaccounted-for calories in beverages and relatively low activity levels. Despite their research, patients do not accurately track their total calorie intake or have an awareness of their basal metabolic rates (BMR). In fact, most don’t track calories at all. The majority of patients are honest about activity levels, but those that do participate in some level of physical activity overestimate its importance relative to nutrition and calories. They tend to over-reward fitness behavior by consuming excess calories relative to BMR. 

These conversations can be difficult. They come down to suggesting an individual leave their comfort zone in order to live a healthier lifestyle and the gamble that this sacrifice may lead to a greater quality of life. There is also wrestling with the concepts of possible calorie addictions and of using food as a coping mechanism to deal with deeper-seated psychological issues. If we attempt to break these complex barriers too quickly, it may seem as if we lack compassion and understanding, and it can undermine the true nature of the visit. 

This can ultimately prove detrimental to the patient/clinician relationship, disrupting trust and derailing insight and progress. It could also result in missing the crucial opportunity to have a positive impact. 

As clinicians, we are meant to lead patients in the direction of their best interest and health. Sometimes, we need to leave our own comfort zones by listening to those we care for more patiently and by supporting them without agreeing with their plans that aren't necessarily working.

Instead of reflexively referring them to a nutritionist or weight loss program in order to quickly move on to the next patient, maybe we could gently point out our observations and make suggestions they could work on until we meet again. After patients express their insights and experiences regarding prior efforts, I try to use phrases such as, “I like some of your ideas and approach, but have you considered…” and use the opportunity to gently introduce some of my own ideas regarding diet, nutrition, and fitness. This sets the stage for a more efficient and productive visit and future follow-ups.

This also encourages patients to “buy in” and consider a new approach while validating the team concept of management and providing the needed security that they are not alone without agreeing with or enabling previous unsuccessful approaches. I also try to avoid cutting patients off if I disagree with their concepts and pointing out or focusing on prior failures. Doing so could leave patients feeling discouraged, judged, and marginalized. Such negative reinforcement is rarely helpful, is a major factor predicting failure, and can lead to a patient’s reluctance to seek help from clinicians in the future regarding this and other medical issues.

When I conclude these visits, I always remind patients that I am their biggest fan and will be there to support them every step of the way, no matter what. I focus on future success rather than past failure. It still amazes me how in using this empathetic approach, patients don’t want to let me down and their success rates have increased exponentially!

How do you broach the topic of healthy eating with your patients? Share your strategies for a successful conversation in the comments below.

Joseph D. Pianka, MD, has been a board-certified practicing gastroenterologist for over 20 years. His ultimate goal is to help as many people as possible who struggle to find motivation in regards to health and fitness. All of his proceeds from his fitness guide and motivational book, It’s All in Your Head, will be donated to Ukraine relief.

Illustration by Jennifer Bogartz

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