The two major counseling topics I learned about as a first-year medical student were alcohol and smoking cessation. These are incredibly important topics. Smoking leads to 1 in 5 deaths in the US. That’s right, 20% of deaths! You don’t need to be a doctor to understand what this CDC fact sheet on smoking is saying: smoking is bad, cut it out right now. What’s more is that there are huge, immediate benefits to quitting, like 90% reduction in smoking-related diseases.
But life is not a binary of you smoke or you don’t, you care about your health or you don’t. Effective counseling is tailored to the individual, and patients may take years to make changes.
One of my patients taught me this. She was a woman in her fifties with multiple sclerosis who had recently moved from New York to care for her mother. She chattered on and on about her life history, and had a baseline fine tremor that I noticed worsened when she talked about her mother, who had been emotionally abusive towards her in the past. She had taken the bus to the clinic, and had to get spare change from one of our social workers to afford the return trip home.
She had been a one-pack-a-day smoker since her twenties. I offered her cancer screening, screening blood tests, and talked with her for about twenty minutes about her smoking. Yes, she understood the dangers, yes, it was expensive for her, yes, she knew it could kill her one day–but she refused to give it up. “I’ve got so much going on right now,” she said. “It’s the only thing that makes me feel better. I think if I tried to quit smoking right now, I might just kill myself.”
And you know what? I was content to let her continue smoking.
What I learned was that there are bigger things in our patients’ lives than attending to all of their health needs and that preventive health needs to happen in baby steps. Good preventive health sometimes requires radical changes in a patient’s lifestyle, behaviors that they’ve never seen modeled for them. It’s okay to let the changes happen over time and let the waves rise gradually, rather than bowling them over with a tsunami. After all, that’s what follow up appointments and continuity of care are for.
I explained this to her and she started to cry. She said that she was grateful to have someone to talk to, that she was really stressed out at having to care for her mother, and that I wasn’t pressuring her to give up her comforts just yet. I warned her that we’d be talking about this in the future, and sent her out with a lab slip, an appointment for a mammogram, and a follow up with social work. It’s been months now, but I hope that through baby steps, we can accomplish more than even she believes is possible.