She came to me with complaints of weight gain. I gave her a pill and she shed 200 lbs in 2 weeks. No, of course not. There is no such pill.
Mrs Lopez did not lose weight. At her follow up 4 months later, she had gained 11 pounds. I went back to my note, and it clearly said that I “counseled her about healthy diet”.
I remember. That was after we discussed optimal management of her diabetes, addressed some of her depression, talked about an asthma action plan, and… I probably asked her to watch her diet when she was ready to leave.
Or maybe I don’t remember. Maybe I just thought of writing that under the diagnosis of “obesity, body mass index of 30-35”, some 40-60 patients later during my “admin time”. Because that’s probably what I told her, or would have told any patient suffering with obesity.
Whether I spoke those words or not, it really doesn’t matter. It matters to the quality metrics perhaps, but not to Mrs Lopez.
I do not deploy coronary stents to restore flow to an ischemic myocardium, but as a primary care provider I am still programmed to document my interventions. What did I do for Mrs Lopez? I told her what she needed to do, and I documented that.
At her 4-month follow up, Mrs Lopez showed she was “non compliant” with my weight loss plan.
My intervention did not empower her. Should it?
Drizzle MD 