Wednesday, December 13, 2017
Health

Are you following doctor's orders? Your health depends on it

One afternoon, when I was seeing patients in the office, an emergency room doctor called.

"Your patient Mr. Larry H is here, looks like he is developing a stroke. You know his blood pressure is quite high."

That was a surprise to me since during a recent visit his blood pressure was well-controlled with two medications. He looked very healthy and fit.

I went to the hospital and met his wife. "You know, Larry felt good for the last several days and he decided to stop those pills you gave for his pressure. You know he doesn't like to take medicines," she told me.

So, that's what happened. He quit his pills without telling me and his blood pressure shot up, something physicians worry about all the time.

Many studies have clearly shown that failure to take blood pressure-lowering medicines as directed greatly increases the risk of stroke and death in patients with hypertension. Yet an estimated 20 percent to 50 percent of patients do not take their medications as prescribed.

It's dangerous to patients, frustrating for physicians and costly for the entire health care system.

"The cost of patient noncompliance is easily in the tens of billions of dollars a year because of the needless complications and hospitalizations," says Dr. David B. Nash, chairman of the Department of Health Policy at Jefferson Medical College in Philadelphia.

As former U.S. Surgeon General C. Everett Koop once lamented, "Drugs don't work in patients who don't take them."

This brings up the question about how we can improve the situation. Lack of health literacy is one major issue. Many patients simply do not understand how and why they got sick in the first place. That makes it more likely they won't understand why the treatment is so important, or what could happen if they don't do their part.

Physicians and their assistants need to spend time to educate patients, who also must be willing to listen, take notes and ask questions.

Another problem is the cost of medication. In my community free clinic, I meet patients who are ashamed to admit they can't pay for their prescriptions. Those who have lost their jobs and their health insurance are going to skimp on their drugs. Doctors can help by giving cheaper substitutes when possible, and enrolling patients in the pharmaceutical companies' drug assistance program, but these options aren't always possible.

Some of my older patients are overwhelmed by the sheer number of pills they must take every day. Someone with diabetes, hypertension, high cholesterol and heart disease — a common scenario in the older population— can easily wind up by taking six or eight drugs spread throughout the day. They may need some supervision from a relative or caretaker.

As one older patient joked, "The tape recorder in my brain has not been working for some time, doc. So explain to me one more time how to take these pills."

The fear of side effects is universal and often it's genuine. A traveling salesman once told me, "I can't take those water pills doc. Give me something else." I have difficulty coaxing many patients to take statin drugs that reduce their cholesterol — the common complaint being muscle aches and pains. With proper education and switching to drugs they can tolerate, the problem can be solved.

Recent studies show that up to 11 percent of hospital admissions and about 125,000 deaths a year can be attributed to medication noncompliance. A case in point was an older patient of mine whose diabetes appeared to be way out of control. Asked why, he said: "Oh, the cost of the new medicine you prescribed was over $300 a month. I can't afford that kind of price."

But he didn't tell me that until his deteriorating condition told me something was wrong. Doctors, nurses, pharmacists and all professionals involved in patient care must be aware of their patients' needs and look for red flags of noncompliance. And they must invite patients to participate in their care.

"Be compassionate," says Dr. John Steiner, author and a researcher at Kaiser Permanente in Colorado. "Improving adherence is a team sport.''

M. P. Ravindra Nathan is a Hernando County cardiologist and author of "Stories From My Heart: A Cardiologist's Reflections on the Gift of Life."

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