Apply folk wisdom to your family practice patients

“The best defense is a good offense.”

This folk wisdom is variously attributed to Sun Tzu, Carl von Clausewitz, Mae Zedong, and the heavyweight prizefighter Jack Dempsey. Regardless of origin, it deserves its place in the pantheon of behavioral truths.

During a recent conversation with a patient about her irritable bowel syndrome, I asked about possible stressors.

“So, tell me, I know it’s hard to manage both full time school and a part time job, but I wonder if there are any other things going on for you that you wish you could change?”

“It’s my Dad. He won’t leave me alone.”

After a moment of panic (she assured me there was no physical or sexual abuse going on) she went on to describe him as always making comments and suggestions to help her get better grades, eat better, drive more safely, find a better job or negotiate for a higher salary.  I told her I could think of three solutions.

First, she could move out.

“No, I can’t afford both rent and tuition.”

Second, she could just let it go.

“That’s what my boyfriend says. I’m trying but it obviously isn’t working.”

“Ok, then,” I said. “Here’s what you do. See how often you can start a conversation about something in your life, something from school or work. Tell him a bit about how you understand it and then ask for his perspective. Don’t ask him what to do – frame it as a discussion of the issue, not a request for a recipe. Do some active listening and ask him questions about what he says. Consider asking him for examples of how this has worked for him. Have a mental list of things to ask about and pick your times, but try to do this several times a week.”

Three weeks later we spoke on the phone. The amitriptyline was helping her sleep and had mitigated her diarrhea.

“And how about things with your Dad?”

“Oh, much better,” she said. “My Dad seems to really like it when I ask him questions. He hardly ever pesters me any more – and guess what? He’s a lot smarter than I thought. He has lots of pretty good ideas.”

***

Late in my family practice residency – and very early in my parenting career – I had mentioned the persistent and sometimes uncomfortably intrusive suggestions offered by my mother and mother-in-law. One of our faculty, a seasoned pediatrician and parent, made the suggestion that I call both sets of grandparents regularly and ask for advice. He pointed out that their motivation (to be helpful and involved) was beyond reproach and that they probably had valuable insights to offer, if I could just reframe it to protect my own need to be autonomous and masterful. It worked like magic. The unsolicited advice nearly disappeared – and I learned a great deal from our conversations. The grandparents felt needed. I benefitted. And so did my kids.

Over the years, I have found it a valuable life strategy, and it comes up fairly frequently in practice:

  • I tell all new parents at my first opportunity that they should each call their in-laws regularly to discuss parenting concerns and ask for suggestions, pointing out that the investment in making them feel like a valued contributor will pay huge dividends over time, and making sure that they realize that asking for advice will make it easier to ignore it.
  • I suggest to parents that they play various versions of the “what if” game with their kids, getting the kids to help decide how best to set rules, reward success, and punish transgressions.
  • I tell young adults starting a marriage (or other long term relationship – times have changed) that they should make a point of asking their partner’s opinion and advice often and sincerely, to build a comfortable platform of sharing.
  • I suggest proactive questions and requests for feedback when I see people with job stresses.
  • When patients are diagnosed with a serious illness for which others will be directing their care (cancer, degenerative neurologic disease), I tell them we are going to be proactive rather than reactive, and schedule regular appointments to discuss their progress and concerns. This makes sure that they understand I want to remain involved, and I avoid having to deal with crises and questions in a vacuum. (Since we often have a long term relationship, I also find that they need to have me tell them the same things the specialist has said to understand it and believe it.)
  • When patients reach an age and health status where they are declining and vulnerable, I suggest that we schedule regular visits to talk about how things have gone and what problems we might expect, rather than waiting to things to go wrong.

Try it!

Peter Elias is a family physician who blogs at his self-titled site, PeterEliasMD.

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  • houriganterry

    I have an extra house next door. It has a coffee machine and a 10 year old Volkswagen.
    Can we work something out? Oh, do you live near NYC?

    Terry

  • John C. Key MD

    Good post. Helpful suggestions always valuable.

  • http://www.facebook.com/jill.m.herr Jill Herr

    Wonderful advice. Thanks, Peter! I was very fortunate to have you as an attending physician, and I appreciate your insight even more now.