CARE

DOCTOR’S ORDERS

WRITER: RICHARD T. BOSSHARDT, M.D., FACS

Apediatric surgery colleague recently told me a story about a mother who called him at 2a.m. to report her 7-year-old son had just thrown up. Perplexed, still a little groggy, and knowing that kids throw up all the time, my friend asked why she was so concerned.

“My son had surgery for pyloric stenosis,” she answered. Pyloric stenosis is a condition in which a thickened muscle blocks the outlet of the stomach. Children with this condition have projectile vomiting (yes, it is exactly what you imagine), but it is easily fixed by a simple surgery. Because the problem becomes evident as soon as the infant begins to feed, surgery is done when the baby is still a newborn.

“Didn’t I do his surgery when he was a baby?” my friend asked.

“Yes,” replied the mother, “but the papers I received said to call if he vomits.” It was the first time the boy had vomited in seven years! She had kept her postoperative instruction sheet all those years and followed the instructions to the letter.

In a world where it seems patients go out of their way at times to not comply with our instructions, this degree of compliance and follow through, funny though it may be, is rare. The problem of non-compliance is so pervasive in medicine that some have labeled it an epidemic. Some studies show as many as half of patients fail to comply with instructions for something as simple as taking a medication for their blood pressure. Why is this?

Some of the blame lies with doctors themselves. Doctors are being squeezed by increasing regulatory demands on how they practice, lowered reimbursement from insurers for the care they render, an increasing population of older, sicker patients, and more. All these lead to crowded waiting rooms and less time with patients. Sometimes they fail to take the time to explain the treatment plan thoroughly and/or in a manner intelligible to patients who do not have a medical degree. Some doctors are simply poor communicators.

Paramedical personnel such as nurses, nurse practitioners, and physician’s assistants have helped. They take some of the burden off physicians and often tend to communicate better with patients.

However, patients bear a lot of the blame for non-compliance. Some of this is not their fault. Medicine has become more complex, and it is now more important than ever for patients to actively participate in their medical care. Patients who are invested in their medical care will likely be more compliant than those who expect their physician to shoulder the entire burden.

Many older patients are on multiple medications. Although people over 65 make up only about 13 percent of the population, they use 30 percent of all prescriptions. The average elderly person takes four to five prescription drugs plus several over-the-counter medications. This, coupled with the decreased intellectual capacity that often accompanies aging, can lead to inadvertent non-compliance.

Communication is a two-way street. Patients must listen to their physicians and make sure they understand the instructions. Cartoonist Gary Larson, whose syndicated cartoon the Far Side ran from 1980 to 1995, had a classic cartoon about communication. The first panel, titled “What we say to dogs,” showed an owner speaking sternly to his pet, Ginger, about staying out of the garbage. The second panel, titled “What they hear,” shows the dog hearing, “Blah, blah, Ginger. Blah, blah, blah… .” I can totally identify with this cartoon, as I am sure most physicians do also.

All of us have sat in front of patients and spoken at length to them about their medical condition. We have explained the treatment program and rationale for its recommendation, provided advice for how to correct or prevent problems in the future, and tried our best to communicate intelligibly for their benefit only to wonder how our words were being received or even if we were being understood at all. gibly ur f edical issue n n medications alone. This does clude le such as diet, exercise, oughly not medications properly or ir ts their p mpromise for nt of ens with reduced oads or ver, in actual of b, fewer t. be ompliance with ysicians

Medical compliance is a huge issue with an estimated annual cost of $150 billion per year because of the adverse effects of non-compliance with medical care in taking medications alone. This does not include the cost of non-compliance with lifestyle changes such as diet, exercise, etc. Roughly 125,000 people die each year due to not taking medications properly or at all. About 21 percent of patients never fill their prescriptions. Sixty percent of patients do not know all their medications, and up to 50 percent of patients ignore or compromise instructions for taking their medications. In the laboratory, 85 percent of patients on new anti-AIDS drug regimens have responded with reduced virus loads to low or undetectable levels. However, in actual practice outside of the lab, fewer than 50 percent of patients benefit. The main reason appears to be non-compliance with the regimen.

PATIENT

I thought aspirin was good for me?

PATIENT

What is the best food to eat with it?

PATIENT lain ts theless, have a n and with their care. If o not understand their doctor’s ctions, should ask and satisfied until know t ctions in and take the time to hem. Medicine is serious l procedures, medications, and ions have the for harm, as s

How long do I wait before I can drink?

Physicians have a responsibility to explain their treatment plan for patients clearly and in understandable terms. Anything less is poor medicine. Nevertheless, patients have a responsibility to listen and comply with their care. If they do not understand their doctor’s instructions, they should ask questions and not be satisfied until they know exactly what it is they need to do. If necessary, get instructions in writing and take the time to read them. Medicine is serious business, and all procedures, medications, and operations have the potential for harm, as well as benefit.

M.D. , & first to full-time cosmetic and reconstructive 1989

PATIENT

How long do I wait?

PATIENT

My mom can’t take one?