Tuesday, September 20, 2011

Diabetes prevention: don't just go through the motions

The first time I ever used an electronic medical record was 12 years ago, during my neurology rotation in medical school. Students were responsible for writing daily progress notes on each hospitalized patient that updated his or her treatment plan and list of ailments. A helpful senior doctor let me in on a time-saver: cut and paste. I could insert sections of the previous day's progress note into the current day's note, which I could then modify to account for any changes that had occurred.

He also unwittingly introduced a temptation: to document more than I had actually done. Perhaps I'd forgotten one day to urge a recovering stroke patient to stop smoking, for example, but had done so earlier in the week. Knowing that my final grade depended on covering all care guidelines, once or twice I might have cut-and-pasted, "Tobacco cessation counseling: Provided" into my notes when I technically hadn't, believing there was no harm done.

Today, electronic medical records– a novelty a decade ago – are used in most hospitals and many doctors' offices. The federal government touts their potential for improving the quality of medical care, from ensuring that all patients get recommended screening tests to improving care of chronic health problems such as diabetes. But as I first observed as a medical student, electronic progress notes have an important downside that – contrary to what I thought then – can and does harm patients.

In a recent study published in the Archives of Internal Medicine, researchers examined doctors' documentation of dietary and exercise counseling in the electronic medical charts of more than 5,000 patients with diabetes. Patients were divided into three groups: those in whom no counseling was documented; those whose progress notes appeared to have been cut-and-pasted from the previous visit; and those whose notes were distinct from notes made in previous visits. Only patients with "distinct" counseling language successfully lost weight and improved their diabetes control, while patients with cut-and-pasted language did no better than patients who received no counseling. That led authors to question whether their doctors were documenting imaginary conversations.

We know that lifestyle counseling is critical to preventing diabetes in millions of at-risk Americans. National data show that almost 30 percent of adults have prediabetes (blood sugar levels that are higher than normal, but lower than the diabetic range), but only 1 in 3 of them reports getting any dietary or exercise advice from their doctors in the previous year. (No information is available on how often doctors claim that counseling occurred.)

Recent research confirms the huge impact that convincing people to change their lifestyles can have on lowering their future diabetes risk. A study of more than 200,000 adults published last week in the Annals of Internal Medicine found that the odds of developing diabetes over an 11-year time frame were 30 to 40 percent lower for older adults with one or more good habits: healthy eating, moderate alcohol consumption, and being smoke-free and physically active.

For you to benefit personally from this research, though, you need to make sure that your doctor isn't just going through the motions of lifestyle counseling, electronic medical record or not. Given the myriad agenda-items doctors must squeeze into a 15-minute office visit, skipping counseling can be an easy way to cut corners and stay on schedule. Don't let it be. As the science clearly shows, there can be no better use of your visit than to discuss how to stay healthy and lower your risk of health problems down the road.


This post was first published on my Healthcare Headaches blog at USNews.com.