I will always remember Janice. She was a sincere, likeable person whose many ailments made her visits lengthy. I cared for her starting in her early 20s, and seldom managed to advise smoking cessation. Other issues seemed more pressing.
This was not unique; I did not routinely advise smoking cessation mainly because of time limitations. My schedule had been filled with challenging patients for years. I knew that my responsibility was to help all the patients in my practice who smoked, regardless of how many other problems they had or how much time they took, but I rarely did.
At age 37, Janice developed a persistent cough and was found to have metastatic lung cancer. I was heartbroken because I had not addressed her most important problem.
I met with her and her husband soon after her initial oncology visit. Afterward her husband stopped me in the hallway. He looked devastated. “She may die in the next few months?” he asked.
“Yes,” I said. I had failed. I had imagined myself to be a physician who took good care of patients. But this time that was not the case. Janice died 8 months later.
I resolved to do better. I became more aware of the varied smoking histories of my patients and counseled more patients who smoked. Still, I was reluctant to introduce the topic when I was behind schedule or with talkative patients who might require significant counseling time. Despite my determination, I could not counsel consistently. I was discouraged.
Then I met Leif Solberg, MD, a faculty physician, who introduced me to the system that he and his colleague used in their practice. The intervention included staff assessment of tobacco use status, brief physician cessation advice at every visit, and registered nurse (RN) counseling. A study showed that this team approach was effective.1 When I visited Dr Solberg’s office, I was convinced that the intervention would succeed in my practice.
Our office had five dedicated and hardworking physicians who’d worked together for years. Yet when I presented the proposed system, they were unconvinced. They appreciated the need for more smoking cessation services but worried that the system would take too much time. We had a tradition of being thorough and had difficulty staying on time. We worked long hours and our borderline productivity had been addressed in our parent multispecialty group. My colleagues argued that we could not slow the pace of care any further. We could easily implement the RN counseling dimension of the program because we already had a helpful RN-based hypertensive program, but the group was concerned about involving the medical assistants when most smoked themselves. Imposing this system might irritate them, and they might become less cooperative.
I was discouraged. After more than a year since Janice’s death, I continued to feel guilty about failing to provide her with this critical service. The sting of regret stayed with me and was a powerful motivator. I wanted to take better care of my patients who smoked. I believed that the new system was workable. We had a cooperative staff who were used to working as a team and, because of the availability of RN counseling, the required additional physician time would be minimal. Usually when our group rejected a proposal, there was no further discussion. But this time, despite my colleagues’ thoughtful objections, I persevered. I asked for another meeting.
After further discussion and a helpful visit with Dr Solberg himself, we agreed to start the system. I felt I was discharging at least a small part of the debt I owed to Janice.
The intervention started and I found it easier to advise cessation consistently with medical assistant encouragement and RN counseling. Still, initially, I felt uneasy at times. When a patient expressed no interest in quitting, it felt disrespectful to address the issue again a few months later, especially in the face of multiple other issues. Over time, however, patients became accustomed to tobacco-related discussions and I became more comfortable introducing the topic.
At first there was no obvious change in patient smoking. I wondered whether the work was worth the effort. However, our office team was practicing better. The medical assistant gave cessation support, I offered brief advice, and our RN counseled.
Then, after many months, I began to see improvement. A long-standing, quiet patient who smoked came with his wife for a walk-in visit. Albert had a history of a thoracic aneurysm and his blood pressure had been significantly elevated earlier in the day. On his previous visit he complained of chest pain, but cardiac testing was negative. His wife, Mary, usually accompanied him and did most of the talking. She occasionally expressed dissatisfaction with his care. This time, when the medical assistant asked about smoking, she complained that, on the previous visit her husband wanted to talk more about chest pain, but I also had emphasized cessation.
“My husband is going to find another doctor!” she exclaimed.
The assistant explained that all doctors encouraged patients to stop smoking, but Mary remained upset. I adjusted Albert’s medications and suggested an RN blood pressure visit. He nodded approval. Then his wife angrily repeated her complaint. I felt angry as well. How could she be so unconcerned about her husband’s smoking? Managing my own emotions, I apologized for not having asked his permission to talk about smoking, but added that cessation was critical to his care. She was so furious that I assumed that they wouldn’t return. I was disappointed, as I liked Albert and would miss him. Surprisingly, a week later they both returned to see our RN; she addressed Albert’s blood pressure, counseled him about smoking, and noted that his wife also smoked, an issue we’d not known previously. The patient continued to return and eventually stopped smoking!
Other patients also quit. A study showed that 25 of 142 patients who smoked in my practice had given up tobacco.2 The team approach was a vast improvement. My responsibility toward Janice, which had burdened me since her death, was finally fulfilled.