I am of the view that doctors need to be circumspect in the way they may introduce into the consultation an agenda that is other than that of the patient. The reason for this is that - particularly with regard to a 'first presentation' the consultation is the patient's arena. I mean that it is her or his property, and to introduce topics that are not immediately concerned with what the patient wishes the doctor to hear or what he (she) wishes to discuss is to intrude on that patient's patch. Therefore I think it inappropriate for a doctor to comment upon, offer an opinion and give relevant advice about the fact that a patient is obese he has come to discuss a matter upon which his obesity can have no bearing. Similarly, a patient who wishes to discuss her partner's drug dependancy should not have her concerns railroaded by being asked about her own smoking habits.
I have no problem with health education per se but believe it has only a very restricted role in the one-to-one patient initiated consultation. I do believe it has an important place in the primary care setting (for example, the local health centre). But general practitioners should not be its main providers by any means. It simply does not require the level of skills and knowledge possessed by doctors. It could just as well be given (as it often is) by nurses trained in the task. And why not receptionists and other 'non-qualified' people, for goodness' sake? No - the doctor's role is to help the patient to understand what is happening to her, why it is happening, and to quide and advise upon possible options to deal with the situation. What the patient actually does with this information and opinion is entirely up to her, and she should be supported in whatever decision she takes. Even if she does continue to engage in a lifestyle that is harming her health or may harm it in the future.
I well remember a patient who for many years had been unwilling or unable to take on advice given to him by both doctors and nurses on his obesity and smoking habits (advice that could just as well have been given to him by his grandmother). The turning point for him was when he had a heart attack from which fortunately he recovered. I did not see him for about a year after that. When I did see him I did not recognise him. He looked great - slimmer, fitter and altogether about 10 years younger. He would be the first to admit that he might have been saved an awful lot of hassle had he taken the advice in the first place that he followed, after his coronary, when he started to attend our nurse run cardiac rehabilitation clinic at the surgery. The blunt fact is that he just was not ready to make those changes. And for goodness' sake, why should he have done so at all if he didn't want to? Many people are perfectly well aware of the risks that their lifestyle presents to them, and that includes mountains climbers and me. For if my doctor - where I am a patient it is actually usually a nurse - were to say to me that for every black pudding I eat I will knock 5 minutes off my life expectancy, then I will continue with the black puddings, thank you very much.
Some, I know, will harp on about what they perceive as the ethical concern in such scenarios: I really don't go much on that. You know - the persistent smoker has a duty to quit because of the ultimate drain on health service resources that his behaviour will result in. I'm not a smoker, I'm not fat. But I have no objection to others being smokers or being fat, so long as the smokers do not do it where I can smell them or the fatties are sat next to me on a long haul flight which are cramped enough as it is.
I see no difference between those risking life and limb by engaging in hazardous sports - just because sports are deemed 'healthy' - and those doing it by taking recreational drugs (the only immoral thing about taking recreational drugs is that it gives a lifelihood to some of the most vicious criminals on the planet), smoking, gluttony etc.
The fact - and I base this on what I have seen with my own eyes and heard with my own ears - is that the Health Service is rife with what Petr Skrabanek in his brilliant book "The Death of Humane Medicine and the Rise of Coercive Healthism" calls 'Lifestyle Surveillance'. With its obsession for preventative medicine (laudable enough if it is offered rather than imposed) the patient who is ill or worried about illness has his agenda sidelined in the consulting room and the health centre and a new emphasis placed upon his presumed responsibility to "stay well".
Worse - there has come into being a massive industry purveying "wellness". You have only to look on the shelves of every book retailer to see the burgeoning sections on matters pertaining to health and lifestyle. Best to look upon these for what they really are: little enough altruistic concern for those who fork out and buy the stuff - a good many of those flogging this system of excercise or that diet have made a tidy fortune from doing so. And that was why they did it in the first place - not because they were concerned in any very serious way that you or I should live long, healthy and happy lives. Worst of all are those fringe practitioners and sellers of quack remedies who prey upon the credulous and foolish, relieving them of money that they can ill afford to lose and giving only false hope in return. The author and journalist John Diamond had plenty to say on these characters in his book Snake Oil and Other Preoccupations while he was dying from throat cancer. But perhaps more of that in a future posting.