Doctor’s Orders - Annals of Internal Medicine: Fresh Look Blog


Wednesday, February 17, 2021

Doctor’s Orders

On my first day of residency orientation, I was given multiple lectures, a tour, and perhaps most unusual for me, a prescription pad with my name on it. The pad, with its nondescript sans serif font on a faded blue background, seemed just as important to my ongoing journey as my recent medical degree. I had grown up seeing my pediatrician scribble on one of these pads, his rotund belly shaking as he told a joke to my parents, easing their worries about their sick child. I even had a lecture in medical school from a pharmacist on how to write on a prescription pad. On that first day of residency orientation, I was finally in possession of my own prescription pad and quickly stashed it in my bag.

One of my first patients in my primary care clinic the next week was Ms. S, a 54-year-old woman.

It had been 20 years since she had seen a doctor, but after an unexpected hospitalization, she came to my clinic determined to improve her life. In our first 2 visits, we went through the battery of tests for her “health care maintenance”: hemoglobin A1c, complete blood count, basic metabolic panel, Papanicolaou smear, mammography, and colonoscopy.

A few weeks later, we began tackling tougher issues. Looking through her chart, I noted she had been overweight for most of her adult life. I brought up weight loss timidly, as I was more comfortable prescribing medications than counseling on lifestyle modifications, something I later learned was common among clinicians (1).

“You know, I’ve been thinking I need to lose some weight.”

I replied, “Have you thought about how you’d do so?”

Our conversation revealed that she would love to try a low-carbohydrate diet because her best friend was doing so and was losing weight. After setting a goal together, I clicked the button for follow-up in 3 months and walked Ms. S to the exit, reminding her to say “Hi” to her family for me.

At the next visit, she returned 5 lbs lighter. After I congratulated her, she told me that this was the hardest thing she has done, made even more difficult by her family. She explained to me that she learned pork rinds were low carbohydrate, and when she felt like cheating on her diet, she would have a bag of pork rinds. Her family thought this was a ludicrous idea; a diet, in their eyes, did not consist of pork rinds.

Noticing her frustration, I left the room to find my bag. I found my prescription pad where I had shoved it after orientation and wrote, “One small bag pork rinds, daily as needed for cravings.”

I returned to the room and handed her the prescription, encouraging her to keep up the good work. I told her that if her family asked about the pork rinds, show them the prescription—eating the pork rinds was the doctor’s orders.

Over the years, I have seen Ms. S on good and bad days. After her mother died, she came in grieving her loss. During our visit, she talked about how she was driving to see her father nearly every day, helping her sister, all the while still managing her work and home.

I sat, listened, and again found my pad and wrote, “10 minutes of self-care, daily.” She smiled and told me that she knew she needed to go on her daily walks again, if only to clear her head.

I did not give orders to Ms. S. Her desire to change has driven her entire transformation. However, what started as a joke between us has now become a tradition. As Janke and colleagues pointed out, although lifestyle modifications play a large role in the management of many chronic disease, such as hypertension, diabetes, and obesity, many physicians do not counsel patients on them (1). My prescription pad serves as my reminder that behavior changes can be as important as medication changes.

For Ms. S, the pad signified that I, her doctor, cared just as much about combating cravings or her engaging in self-care as I did about her hemoglobin A1c level and blood pressure. For other patients, it provides a connection to their doctors before an electronic medical record. Finally, for me, it serves as a reminder that small changes can be as strong as pills.


  1. Janke EA, Richardson C, Schneider KL; Society of Behavioral Medicine Executive Committee. Beyond pharmacotherapy: lifestyle counseling guidance needed for hypertension. Ann Intern Med. 2019;170:195-196. [PMID: 30615779] doi:10.7326/M18-2361

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