What are your health goals for the coming year? [PODCAST]

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“Yearly physicals are usually afforded a longer time than regular visits. If I can use most of that time focusing the discussion on what a healthy life means to each of my patients and what they need to achieve it, I feel that I’ve accomplished more than doing palpation, range of motion, and auscultation. Discussing medications and finding opportunities for de-prescribing, and discussing annual routine labs’ futility is also an equally important and welcome part of my yearly rituals. As our population ages and we are faced with more chronic diseases, our goal is to maximize our patients’ abilities to function, relate to family and community, and live a life of purpose. Expanding the visit to discuss health status, strengths, weaknesses, and goals is a good time investment in achieving healthier people and enriching our relationship with patients. For my part, it also adds joy and purpose to my life.”

Alina Urriola is a family physician.

She shares her story and discusses her KevinMD article, “What are your health goals for the coming year?”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Alina Urriola. She is a family physician, and she wrote the KevinMD article “What are your health goals for the coming year?” Alina, welcome to the show.

Alina Urriola: Thank you, Kevin. It’s a pleasure to be here.

Kevin Pho: We’ll get into your article in a little bit, but first off, can you share your story and your journey to where you are today?

Alina Urriola: Sure. I’m a family physician. I’m originally from Panama. I went to medical school in Brazil. In Latin America, it’s six years from high school. I finished medical school, went back to Panama, and did my residency in family medicine. Initially, when I was in Brazil, I thought I was going to do infectious disease, because where I went to medical school, in order to serve the most, that was the primary concern and the primary need. But then when I went to Panama, back to my country, infectious disease in the early ’80s were antibiotic consultants and then AIDS physicians. So it was very limited, and it didn’t have that broad sense that I wanted. I wanted to help the most.

So I discovered family medicine and did my residency, and then migrated to the United States, did a residency again in St. Louis, and also finished a residency in preventive medicine, with a master’s in public health. I have been a family physician for almost three decades. I enjoy the breadth of the specialty, and especially the continuity of care, the contact with patients, the opportunity that I have to affect patients’ lives.

Kevin Pho: So you did your training in Latin America, and now you came up here to the United States. You’ve been in the United States for a while now. What would you say are the biggest differences that you’ve noticed practicing in the United States versus your home country?

Alina Urriola: So in my home country, family medicine is not fully recognized as a specialty. People still look for the specialist. I have to convince my mother that she doesn’t need an endocrinologist for her diabetes and a cardiologist for her hypertension. There’s still not the strength of the specialty and the confidence in the physicians. And I feel really fortunate to be able to practice to the breadth of the specialty and take care of all my patients’ needs.

Kevin Pho: So we’re talking in the beginning of February now, and hopefully the pandemic is beginning to die down with the advent of the vaccines. Tell me what you’re seeing through your lens as a family physician as it relates to the pandemic.

Alina Urriola: Where I am, in Seattle, we were, I mean, it was the first place where the infection was found, but the state of Washington was very quick at setting the rules of mask wearing and limiting the agglomeration of people. So we’ve been very fortunate here. I mean, we still are very careful.

Right now, I am doing locums on an Indian reservation in the state of Oregon, where they also, I mean, they were very caring for their community, and they have been quick to test everybody. The efforts for testing in this tribal group were very, very strong and very well coordinated, as well as the effort for immunizing their population. They are much more ahead of the rest of the country.

And I feel like here in Washington, we were also quick at separating primary care from acute respiratory care, so we were able to continue taking care of our diabetics, our chronic disease patients. So that was very important. It was a very important move that the state of Washington did, and where I’m working now in Oregon too, to continue the care of the patients who were not affected by the pandemic.

Kevin Pho: All right, so let’s transition now into your KevinMD article that you wrote in the beginning of January. It’s simply titled “What are your health goals for the coming year?” Now, for those who didn’t read that article, can you just walk my audience through it and share the story of why you decided to write it?

Alina Urriola: Yes. So, you know, in January, everybody sets goals and resolutions. I reminisce about my own medical practice, in which every year, when my patients come for their physical, after the regular introduction and whatever greetings, I ask, “So what are your goals for the coming year, your health course for the coming year?” And as I wrote in the article, that question was received with surprise, like, “What do you mean? Are you going to examine me?” So it’s like, “Well, let’s talk about it. This is your opportunity. This is your preventive visit, and this is your opportunity to examine what you value, what is important to you in terms of your health, your relationships. So let’s talk about what is important.”

And as I wrote in the article, invariably, it was so funny, Kevin, even 120-pound fit women said, “Oh, my goal is to lose weight.” And so in the beginning, I was like, “OK, weight loss is the goal.” But it’s like, “Wait a second. What did you achieve by losing weight? What are you really, who would you be if you lost weight? How will losing weight make you a better person?” And that’s when the conversation really started.

And I learned, you know, their functional status is very important, and nobody was willing to say, “I want to look good.” And by opening and giving permission to say, “I want to fit in my jeans, I want to wear a bathing suit, I want to disrobe in front of my loved one in plain light,” I mean, that’s powerful, getting into those intimate fears and needs and wants. So that’s when the conversation started.

Curiously enough, I mean, I’ve been doing this for three years, and every year I review the goals, and after a year or two, patients have focused on other things. I mean, they want to be stronger, or be better, or achieve things that are more important: sleep, which is very, very important, being able to meditate, being able to connect better. So that journey of getting to allow my patients to examine their values and see what is important to them was very enriching for me.

Kevin Pho: So when you ask patients, “What are your health goals for the year?” and they haven’t thought about it, they’re taken aback. What are some of the techniques that you use to really get them to think about their goals and to get the patients to open up to you in the exam room?

Alina Urriola: So it’s all about values, and because I have gone through that myself, examining my values. I mean, Kevin, I have a personal mission and vision statement. Elicit what is important to you, what you value in life. In our life, where everything is rush, rush, work, work, work, we’re not given the opportunity to sit back and examine our values.

And I mean, in medicine, you may argue that that’s not a doctor’s role, that I should be, you know, auscultating, “Lungs clear to auscultation, heart regular rate and rhythm,” you know, what we write in notes. But I think that one of the things that fascinates me the most is the power that people have to take care of their health, and they are not allowed, they are not given that permission, that they have the power to take care of their health, to set their own health goals.

I am one who asks permission of the patients: “What do you think about starting this medication? We can do this, or we can do that. We can do nothing. What do you think?” It’s engaging patients in the process of deciding what they want for their health, what their health is, because, Kevin, they close the door, they go, and they will do whatever they want. I can prescribe anything I feel they need, but if they are not engaged, they are not going to do it. So we are faced with a lack of compliance with medication, no-shows. All those things happen because patients are not empowered to be the owners of their own health.

By transmitting the message that they can take control, it’s like a permission that I give them to tell me what is the most important thing for them. And that permission allows them to say, “Well, yeah, this is important.” My patients have grown to value those things, and that’s what they come back for.

Kevin Pho: And I think it’s wonderful that you give patients that time so they can examine their values, and empower patients to take control of their own health. A lot of times in primary care, as you know, there’s more and more things for us physicians to do in the exam room. Electronic medical records require us to check boxes, and administrators are telling primary care physicians to see more patients in a decreasing amount of time. Now, a lot of what you’re saying takes some time in the exam room. So how do you manage, as a primary care physician, to have these conversations with patients in light of all the increasing pressures and stresses and dwindling time that primary care physicians face?

Alina Urriola: Well, that’s exactly it. So I think, I don’t think that I’m privileged, but I think that everybody is allotted a longer time for a physical. People work in 10s, 20s, and 40s. I work in 15s and 30s, and very rarely 45. A physical, like a physical exam, which we know there’s no evidence that a physical brings any benefit, we’re allotted 30 minutes. So we have time. We don’t have, I mean, other than the Pap smear every five years or a breast exam, we don’t have to examine a patient, so we have time to do that once a year.

In the rules for billing a physical exam, nowhere does it say that you have to examine the patient. It’s a yearly health maintenance, and that’s what we’re paid for. And I think that talking about health values is more important than disrobing a patient and examining. I mean, there are things that we have in the elderly. We need to examine gait. We have to examine range of motion, things that are related to their safety. But most people, we don’t have to examine.

Kevin Pho: We’re talking to Alina Urriola. She is a family physician, and she wrote the KevinMD article “What are your health goals for the coming year?” Alina, for my primary care clinician audience who may be listening to this podcast, what are some examples of questions that you ask patients in the exam room to get them to re-examine their values? Are there any specific go-to questions that you have that get them to open up?

Alina Urriola: I think that it’s very simple, just, “What is important to you? What does a healthy you look like?” Because, again, going back to the fixation, I mean, and I don’t, I think that weight is an epidemic. Obesity is an epidemic, and we have to address it. But the fact that patients only see that little part of themselves as something that they can achieve, to be different. So my question is, “What does a healthier you look like?” If it looks lighter, that’s good, but what else? So it’s very simple.

Kevin Pho: And my final question: What is your take-home message that you want to leave with the KevinMD audience?

Alina Urriola: Go beyond the task. Think about how you can better enhance patients’ lives. Get to know your patients. Thinking also, this is something that is fascinating to me, Kevin, is why people are, what is health? We have exhausted illness in medicine. We know everything about illness, but we know very little about health. So we need to get more curious about health: what people believe health is, where they want to get, bringing their life from where they are to their healthy self, what that is. And learn more about how we can create a health contagion, how we can make health transmissible, this condition, so we can promote well-being among our patients.

Kevin Pho: Well, thank you so much for sharing your time and insight, and thanks again for being on the show.

Alina Urriola: Thank you, Kevin.

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