You never know it’s coming until it’s right in front of you – a teachable moment, the chance to make a lasting impact in the life of another person.
Yesterday, I was working in urgent care. Rarely glamorous enough to be found on House or Grey’s Anatomy, urgent care is where busy primary care offices often schedule patients who need to be seen for acute complaints on a 24- to 48-hour basis. The vast majority of cases are upper respiratory illnesses (e.g., “my nose is running), acute musculoskeletal pain (“my back hurts”), or social issues ( “ran out of meds”). It can get busy, especially in the winter, and the pace is quick — get the story, figure out what they got, and send them on their way. Preventive issues are left for the full doctor visits; the focus here is on the problem at hand.
I was having a fairly typical afternoon as I headed in to see my fifth patient. The triage sheet listed “cough ” as the chief complaint, and the temp was recorded as 97.8. Glancing at the birthdate on the chart, I calculated that the patient was 53 as I marched into the examination room. From the doorway, it was clear she was having an upper respiratory illness. Her face was slightly swollen and red, and she was breathing through her mouth. She quickly offered that her symptoms actually started improving the night before, but that she didn’t want to cancel her appointment just in case. A bit more history confirmed the diagnosis — she had a routine cold. A minute later, nearing the end of my physical exam, examining her mouth, it hit me — the smell of cigarettes.
“You smoke?” I asked half-rhetorically.
“Yea doc, I smoke,” she said, shaking her head.
“That’s no good. You know smoking’s probably a major reason why you’re here, don’t ya? Smokers get the worst cases of the flu.”
I decided to leave it at that. Get the point across, plant the seed, and hope that the over time personalized messages like that push her from pre-contemplative to being serious about quitting.
When I presented the patient to the supervising attending doctor, I kept it simple: “URI, starting to get better.” Never sure how much to say, I quickly added, “though it’s a kind of a teachable moment — she’s a smoker.”
According to Wikipedia, a teachable moment is “the time at which learning a particular topic or idea becomes easiest or possible.”1 In medicine, the term is used similarly to describe a situation in which a patient is most apt to adopt a healthy behavior; for example, telling someone the importance of wearing seat belts during an ER visit for a car accident. Patient education is an essential component to being a doctor — the word “doctor” in fact comes from the Latin word “docere” meaning “to teach” – but in reality, without a meaningful context, it’s easy for patients to simply ignore a doctor’s advice. Teachable moments then become critical avenues to effectively communicate health information and affect behavior change.
Though I said it only half-seriously (“teachable moment” being a jargon term), my attending immediately answered the call. After emphasizing the benefits of quitting — not the least of which is to the pocketbook (“with the money you save, treat yourself to a vacation”) — my attending learned that over the past two weeks, while the patient was sick, she had cut down smoking from a pack a day to two cigarettes a day. Not myself realizing the significance of this, my attending pointed out to the patient that she had already gotten over the biggest hurdle to quitting – overcoming the awful symptoms of nicotine withdrawal. “Take these two miserable weeks you’ve had as an opportunity to change your life for the better.”
It was clear from the patient’s body language that the message was sticking. With my attending back seeing other patients, I pushed on and asked about her previous quit attempts. She had tried quitting in the past but would relapse after a week or so. Quitting made her stressed out and tired, which I explained were typical symptoms of nicotine withdrawal. She was definitely motivated. Both her brother and her father had passed away from lung cancer; they too were heavy smokers. But because of her failed past attempts she had given up hope that she could actually quit. I again encouraged her, saying that today doctors had more ways than ever to help people quit and stay quit. She had heard of Chantix (varenicline) and asked if it could help. I described how varenicline worked — how it reduced the cravings for cigarettes and blunted the chemical satisfaction of smoking. After advising her about its side effects (vivid dreams) and setting a quit date (next Wednesday), I wrote her a prescription, scheduled her a follow up appointment, and emailed her primary care doctor about the plan.
Though not 15 minutes earlier her mind was preoccupied with her cough, something that would have improved and gone without our help, here she was leaving with a plan to quit smoking, something that if successful would pay dividends the rest of her life.
After I wished her best of luck, she said aloud but really for herself, “I think I can do it… No. I have to. I have to do it.”