How Would You Answer ‘The Penis Question’?
— Motivate patients by being an agitator, not an irritator
This article is a repost which originally appeared on MEDPAGE TODAY
Edited for content
“How do I make my penis bigger?”
As a urologist, I have fielded this question from men on countless occasions. Several years ago, when a middle-aged patient raised the question with me for perhaps the ten-thousandth time, I blurted out a simple answer for him, which could apply to nearly half of American men.
Mr. Boudreaux (not his real name) was obese, with a BMI of 30. He was taking seven medications a day, and suffered from diabetes and long-standing hypertension.
“Mr. Boudreaux,” I said, “if I could give you a pill that would give you more energy, improve your erections, increase your sex drive, decrease your blood pressure, improve your diabetes, decrease your risk of arthritis, decrease your risk of colon and prostate cancer, and make your penis one and a half inches longer, would you take the pill?”
Mr. Boudreaux’s face broke into a smile. He quickly responded, “Yes, please give me that prescription!”
“Mr. Boudreaux, it’s not a pill. It’s exercise!”
His smile faded. “But how would that make my penis bigger?”
I told Mr. Boudreaux that if he lost weight, all those things could happen, plus his panniculus would decrease and his penis would appear longer. He seemed game to try, so I arranged for him to see a nutritionist and start an exercise program.
His goal was to lose 2 pounds a week. Four months later at a follow-up appointment, Mr. Boudreaux reported that he had lost 30 pounds, his blood pressure had decreased enough to forego hypertension medication, and his HbA1c had significantly declined. And, yes, he reported gleefully that his penis had “grown” by nearly 2 inches!
As physicians, we routinely must propose very unpleasant options for patients’ health. Over the years I have always been disappointed that my advice on lifestyle changes has generally led to too few behavioral differences. This is especially true for obesity, which affects 42.4% of all Americans, according to the CDC.
A doctor’s usual advice to a hypertensive patient is to lose weight, exercise 20 minutes a day, take antihypertensive medication, and reduce dietary salt. The usual result in a 2-month follow-up appointment is no improvements in blood pressure, weight loss, or exercise habits.
Where, the doctor asks herself or himself, did I go wrong?
After years of pondering this question, it occurred to me that there is a distinction between irritation and agitation.
An irritator is a physician who prods patients to do something she wants them to do. The agitator, on the other hand, is an enlightened doctor who motivates patients to do something they want to do. An agitator, in essence, is as much of a coach as a director.
In my experience, irritation is not effective, at least not in the long run. But by gently agitating the patient through learning what he or she wants, the healthcare provider may unleash motivation more likely to result in improvement in compliance, health outcomes, and perhaps even a decrease in the cost of care.
How do we agitate patients to improve health habits? A Greek philosopher named Epictetus said nearly 2,000 years ago, “Nature hath given men one tongue but two ears, that we may hear from others twice as much as we speak.”
His advice applies forcefully to contemporary doctors. Most of us probably need to increase use of our ears. This is not easy for physicians to do, myself included.
I believe practiced and skilled listening lie at the core of success in shared decision-making, a growing trend in medicine over the last decade or two. Shared decision-making has been defined as “an approach where physicians and patients share the best available evidence when faced with the task of making decisions.”
In a popularly cited article on shared decision-making published in the Journal of General Internal Medicine, the authors proposed a three-step model. In step one, the provider presents the patient with a choice, commonly a stark one between changing behavior or paying a price in decline in health. Step two is a matter of discussing available options, and step three is helping the patient make a well-reasoned decision.
Take note of the third step. The ideal outcome, of course, is that a patient is more fully invested in a plan that fits his interests and motivations and thus feels it is as much his idea as the doctor’s. To achieve this goal, the physician must yield enough of the conversation to the patient to hear the patient’s motivators and align them to improved health. In the end, agitating can only happen effectively through active listening.
Bottom Line: There is seldom one way to manage a patient. It has been my experience that functioning more as an agitator than an irritator motivates patients to lead healthier lifestyles.
Neil Baum, MD, is a physician in New Orleans, corporate medical officer of Vanguard Communications, and co-editor of The Complete Business Guide for a Successful Medical Practice.