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Compliance

Compliance - noun 1 compliance with international law: obedience to, observance of,adherence to, conformity to, respect for. ANTONYMS violation.

he mistook her silence for compliance: acquiescence, agreement, assent,consent, acceptance; docility, complaisance, pliability, meekness,submission. ANTONYMS defiance.

(New Oxford American Dictionary 3rd edition © 2010 by Oxford University Press, Inc.)

"Why aren't you taking your cholesterol medication?"  I asked the woman.  With the coronary disease I diagnosed a year ago, my discovery that she had not taken her medication was very troubling.

"It made me tired," she replied matter-of-factly.  "And besides, the cardiologist said the stress test was negative, so my heart is fine!"

I ordered the stress test after her heart calcium score was significantly elevated, revealing significant atherosclerosis.  She totally misunderstood the results, and I needed to fix that problem.  So I pulled out my secret weapon: a good analogy.

"The purpose of the calcium score test was to see if you had termites in your home"  I explained.  "I found them.  The negative stress test just said that the termites hadn't eaten through your walls.  It's good news that your walls aren't falling down, but they will if we don't stop the termites."

Her eyes opened wide comprehension: the termites were eating her walls.  She was living on borrowed time.

"Would you take a medication if it didn't have side effects?" I asked.

She quickly nodded.  Of course she would.  From now on she would be a compliant patient.

Compliance is good.  Noncompliance is bad.  It's something I learned very early in my training: patients who do what their doctors say are compliant (good), and those who don't follow instructions are noncompliant (bad).  If you are lucky as a doctor, you have compliant patients.  They are the best kind.   They obey their doctors.  They are submissive.  Noncompliant patients are bad; they are a bunch of deadbeats.

Please hold your nasty comments; I don't really believe my patients should obey or submit to me.*

Sadly, however, many doctors wouldn't flinch at that description of noncompliance, heaping all the blame of noncompliance on the patient's shoulders. But this woman's story (true, albeit changed for anonymity) illustrates one of the most common cause of noncompliance: misunderstanding. She was thrilled when her stress test was negative, grasping at the opportunity to be out from under the diagnosis of heart disease.  The cardiologist told her that her "heart was fine," and that was all she needed to hear to be excused from taking her cholesterol medication.  She didn't understand, and the blame of that misunderstanding can be shared between me, who didn't adequately explain the test before sending her to it, the cardiologist, who gave her "good news" that didn't tell the whole story, and the patient herself, who didn't ask questions when she should have.  It wasn't until I gave the termite analogy that she really understood.

Source

I love good analogies.

In the "good old days" of medicine, doctors were not obligated to explain things like they are today.  Patients didn't have access to medical information and so would have to take the doctors at their word about what they should do.  Today, however, patients have far more knowledge at their disposal than the doctor has in his/her head.  Contrary to what some doctors think, this is (usually) a good thing.  The doctor is forced to defend and explain medical decisions, making truly bad decisions less likely.  True, some questions come from untrustworthy medical sources (websites selling "miracle" cures, those relying on anecdotal data, conspiracy theorists, and Dr. Oz), but if I can't give a convincing enough argument to counter these foes, one of two things is true:

  1. I am not on solid scientific ground.
  2. The patient doesn't trust me.

Either one of these is valuable for me to know.

So I have come to see compliance not as a monicker of disdain, but as a challenge to overcome.  I will never get  near 100% compliance, but I don't get this from my kids, my car, or my dog, so why should I expect it from my patients?  Besides, I get paid the same amount if the people ignore what I say; my job is simply to give them the best advice I have.

Once I get that taken care of I can turn my attention to more important things: compliance with "meaningful use," "medical home," and other fun stuff.  I need to make sure I am obeying and submitting to those wonderful Washington bureaucrats.  I never question them because they know what's best for me.

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*I'm using the crazy language tool called hyperbole.  It's good clean fun.  You should try it some time.

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Buckle Up

Lipitor can destroy your liver.

Back surgery can leave you paralyzed.

People who take Chantix might kill themselves.

You may never wake up from a simple surgery.

These statements are all true.  They also are very confusing to many of my patients when I am prescribing drugs or recommending surgery.  What should they do when they hear such bad things about drugs, surgeries, or procedures?  How much do they risk when they follow my advice?

It's a hard world out there, with the attorneys advertising on TV about drugs my patients have taken, with the websites devoted to the harms brought on by a drug or an immunization, with Dr. Oz and other seemingly smart people telling them things that are contrary to my advice, and with friends and neighbors who give dire warnings about the dangers of following my advice.  There are so many voices out there competing with mine, that I sometimes spend more time reassuring than I do anything else.  A doctor in our practice believes that Dr. Oz ought to issue a statement to doctors whenever he voices another controversial opinion as gospel fact so that we can be ready with our counter-arguments.

What can doctors do?  We can't quiet the other voices that speak against us.  In truth, those voices have an important role in preventing us from becoming comfortable and dogmatic in our beliefs.  So how do I combat such a heavy current against our advice?

By talking about seat belts.

Seat belts can kill you, you know.  You can be trapped inside your car by your seat belt and not be able to get out before your car explodes.  It's not a fable; it can really happen.  You may be sealing your fate to die terribly every time you buckle your seat belt.

When I say this to my patients they instantly get what I am saying.  Sure, there is risk putting on a seat belt, but that is overwhelmed with the risk of not wearing it.  EMT's will tell you that they rarely unbuckle a dead person.

I love using illustrations like this.  I can, with a good illustration, explain a highly complex subject in very little time.  They give the patient something they understand as a basis on which to consider their options.  In the case of the seat belt, the analogy gives them perspective.  It shows them that the people who talk about the bad stuff aren't lying (seat belts really can kill), but they aren't considering the risk of not having the surgery, taking the medicine, or getting the procedure done (seat belts save lives).

There is the risk of over-simplifying something, or leading patients to believe something is lower risk than it really is.  That's why I always follow this by talking about how I feel the risk of taking the medicine compares with that of not taking it.  I don't argue against those who say Lipitor can destroy your liver, doing so would undermine my credibility because Lipitor can kill your liver; I just simply put that risk in perspective.  Analogies alone don't explain things, but they do take difficult to understand concepts and bring them into a world the patient understands.  From that point on, the explanation is much easier.

I used the analogy this morning explaining to a mother who was worried about the risk of ear tubes in her baby.  I explained that the risk of surgery (wearing the seat belt) was much less than the risk of antibiotic over-use (not wearing the seat belt).  She visibly relaxed when I said this.  I am not belittling her fear, I am just putting it in perspective.

I use seat belt analogies in other ways too.  Today someone told me that they never get flu shots and haven't ever gotten sick.  I told them that I could have never worn a seat belt in my life (which is almost 50 years) and I would still be alive talking to them.  I've never gotten into a serious accident, so seat belts have been a complete waste of time, right?  The patient smiled when I said this.  No, I told him, I think it was a good idea to wear them and will continue to do so.  People who wear seat belts are more likely to be alive in a year than those who don't.  The exact same thing is true for high-risk people and flu shots.

He still didn't get one.

I also talk about the warning labels that seat belts would have if they had to list all of the ways you could be harmed by them.  Imagine a seat belt commercial done like a pharmaceutical ad: "Seat belts could choke young children, could trap you in the car and kill you, could cause bruising to the shoulder, pinching to the fingers, lacerations, and abrasions.  Seat belts also could be used maliciously by older brothers to torture their younger sister.  Call your mechanic if you cannot unfasten your seat belt for more than four hours."

You get the picture.  So do my patients.

Buckle up.

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Catching Some Z's

“I’ve got bronchitis and my doctor gave me a Z-Pak.”

I hear this from friends, from family members, and from my patient who went to the urgent care over the weekend.  I smile and don’t say what I am really thinking:

Bronchitis:  noun  -  inflammation of the mucous membrane in the bronchial tubes. It typically causes bronchospasm and coughing Translation: a loose cough.

This is one of the most common tricks we use as doctors: stating the obvious using a Latin or Greek word to describe the symptoms and call it the diagnosis.  The suffix -itis refers to inflammation. Dermatitis is one I frequently use: someone comes with a rash (skin inflammation) and I tell them it’s dermatitis, which simply means...drum roll please... it’s a rash.  If you have sore throat, we call it pharyngitis, which means inflammation of the back of the throat. The suffix -algia, which which means “painful” is also quite useful.  Headaches can be called cephalgia, joint pain, arthralgia, and proctalgia is a pain...where the sun don’t shine.

In all of these circumstances, of course, the person is quite aware of their cough, rash, sore throat, headache, joint pains, and pain in the butt.  Why call it by it’s fancy name?  Two reasons: 1.  it sounds better when we tell the patient, and 2. we can bill for it.  It does not, however, say anything about prognosis, treatment, or expected course; it simply states what is obvious.

Which brings me back to the Z-Pak.  Zithromax (Azithromycin) is truly a great drug, and the friend of many doctors.  It treats strep throat, skin infections, sexually transmitted disease, whooping cough, and certain kinds of, yes, bronchitis.  It is very easy to take, requiring a total of 5 doses over 5 days, and it comes in a handy-dandy pack with a catchy name.  When a patient tells their friends and family, "I got a Z-Pak," they are much more impressed than if they say, "I got an antibiotic."

The problem with Zithromax, however, is that it spends very little time in the blood stream, going directly inside the cells of the body and spending a very long time there, often away from the infection itself.  This is OK for certain types of infections, but not so good for ones that involve infected extra-cellular fluid, such as infected mucous (AKA sputum, green snappers, loogies, whatever you want to call them).  This means that it’s a fairly weak drug for middle-ear infections or sinusitis, and only marginally good against many forms of bacterial bronchitis.  These, of course, are the main things for which the drug is prescribed.

Why?  Why do people get a medication for conditions that are not well-treated by that medication?  For most of these conditions, bronchitis included, the real cure for them is simple: breathing.  You just have to keep breathing long enough while your body fights off the infection like it was designed to do and the infection will go away.  Skeptics out there who want to try not breathing will soon find out that this approach is not successful.  Trust me.

So what difference does it make to take a Z-Pak while you breathe?  In many, if not most cases, it has no benefit.  It does, however, makes the patient feel like the doctor is doing something for the patient, who paid the co-pay and waited 2 hours in the office.  There are still a good number of people who are dissatisfied when they spend their tie and money only to be told to breathe. Plus, modern medicine has indoctrinated doctors and patients with the belief that doing something is always better than just breathing for a little longer.  This untrue, but highly profitable belief is hard to dispel.  The patient got a Z-Pak and they got better!  Both doctor and patient make this causal connection, and both are happier for it, but breathing gets the shaft because the Z-Pak gets all the credit for what it did.

I once cynically said that Zithromax is the antibiotic you prescribe when you don’t think the person needs an antibiotic.  While that’s not completely true (I think it’s a good choice for strep, and for a chronic cough), I do think it’s the reality seen in primary care offices, urgent cares, and emergency rooms across this great land.  In fact, my PA told me on the week leading up to Christmas that she had joked with a colleague that they call this week “Zithromax Week,” as many prescriptions are written “just in case,” or “to make sure they are healthy for the holiday.”  I’m sometimes guilty for that one.  I do run a business, you know.

Of course, there is definite risk in taking an antibiotic when it’s not needed.  I’ve read (but am to lazy to find the citation) that overuse of macrolide antibiotics (of which Zithromax is the dominant drug) is one of the main sources of antibiotic resistance.  People can have side effects from the medication as well.  But as is the case with donuts, not exercising, spending time reading blogs when you should be otherwise productive, or watching reality TV, the inertia of the bad choice in the moment totally overwhelms any desire to do the right thing.  "Come on," the doctor says to himself, "The world won't fall apart if I give a Z-Pak to this one patient!"  Krispy Kreme donuts is depending on you to make a similar argument.

So, when you have a cough and go to the doctor, get the diagnosis of bronchitis, and get a Z-Pak think of me.  You may want to ask if you really need the antibiotic, or if you can wait to see if it will go away without it.  In many, if not most cases, you might just as well meditate with the word “Zithromax” as your mantra, or burn the pills in a sacrifice to the Greek god Z-pacchus.

God bless America, land of the Z.

*Obligatory disclaimer: This is not meant to convince people to not take prescribed medications.  I don’t know about your own personal medical conditions.  It is just meant to make you appropriately skeptical, and perhaps ask your doctor, “can I wait to take this?” or “do I really need this?”  If they say “yes, you do need it,” take the dang Z-Pak!

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