“This is the first admission for this 60 y/o male who has been non-compliant and is admitted with…..”
If I was admitted to the hospital, that could be the first sentence in the HPI, History of Present Illness, of my hospital admission. The HPI is where physicians write about the history of the current problem as told to us by the patient and from the information that we find in the patient’s medical record. It is the meat of the history and, as we were told in medical school, “90% of your diagnoses will be made by the history. The physical examination will mostly confirm your impressions from the history you obtained. Take a good history!” This is the way that all physicians begin their HPI for their admission History & Physical. As I said, that 60 year old man could be me. But what does non-compliant mean? Is this a defiant patient? A lazy patient? A stupid patient?
What it actually means is that the patient has not followed the advice of his physicians and yes, the judgmental tone is there. As a physician, and I speak now for the whole profession, we don’t like it when we prescribe medications and our patients don’t take them. When we make lifestyle recommendations and the patients don’t follow them. When we instruct patients on dietary restrictions for their particular medical problem, and they don’t change their diet. When we ask a patient to come back for a three-month follow up appointment, but they come back in six months. Or they just miss scheduled appointments altogether. These are non-compliant patients. How hard can it be to be a patient? What about when the foot is on the other shoe?
In 1999, I went to see my physician for one of my rare checkups. As a doctor, I usually know when something is wrong with me. To quote a giant in the history of medicine, William Osler, “A doctor who treats himself has a fool for a patient.” But I felt good and was still relatively young, so I didn’t go for physicals as often as I instructed my patients to do so. “John, your cholesterol is still pretty high. Have you been following your low fat, low cholesterol diet? “ my physician inquired. With as much sincerity as I could muster, I replied, “Doctor, I have done everything I possibly can do to reduce the fat and cholesterol in my diet.” While this was technically true, I really hadn’t tried very hard to change my diet. But it was everything I personally was capable of doing to reduce the fat and cholesterol from my diet. I don’t know… is that splitting hairs a bit too finely?? I like eating, and I have strong food preferences. I didn’t want to change my diet then, and I still don’t want to now. For someone who likes food, which is just about everyone, I have found that changing dietary patterns is difficult, if not impossible. Some people are better at doing this than others. Almost everyone can change their diet for short periods of time, but lifelong changes are hard. Really, really hard. The bright spot was that I was still considered a compliant patient to my doctor because he thought I had really tried. I was a good patient. Since those days, I have had several minor orthopedic procedures, and I always did exactly what the physical therapist and orthopedist recommended. A perfect patient!
Well, as the years piled on, I, like most everyone, developed some medical problems that require me to take medication. I don’t take enough to count for a morning meal, but I take more than I did when I was 40. Fortunately all of my medications are taken once a day in the morning. How hard can it be to take a few pills once a day? I used to think nothing of giving patients multiple medications, some that needed to be taken once a day, or twice a day, even three times a day. I was the doctor and they were the patient! Did they want to be labeled the non-compliant patient? Why come to see me if you’re not going to do what I tell you to do? I expected them to comply, including religiously taking those prescribed medications on time, every day. So what about me, the combo doctor-patient… How often did I miss my daily medications? Not that often, certainly not more than once a week. Well… maybe occasionally more than once a week, but some weeks I didn’t miss any at all. Now I was starting to feel a bit guilty about slapping my patients with the dreaded “noncompliant” label. Perhaps I’d been a little hasty? Being a patient and taking medications regularly, exactly as prescribed, is actually harder to do than I used to think it was. But I do my best, and I wasn’t yet labeled a non-compliant patient. (I hope Nancy, my physician, is not reading this.) There should be a label difference between being forgetful and being willful, between being preoccupied and being noncompliant, but there isn’t. I know there isn’t because I write those chart labels! But you should know, I no longer ask patients, “Are you taking your medications?” But rather, “How many doses of your medication do you miss a week?” I think I get more truthful answers now than I ever did before and, when they confess, I’m not so quick to label them as noncompliant, probably because I don’t want to be labeled that way!
With a couple of new medical diagnoses added to the chart of this (gracefully) aging physician, it was suggested to me that I continue my low fat diet and, additionally, to significantly reduce my intake of phosphates. How hard could that be? I can change from Diet Coke (high phosphate) to Diet Sprite (low phosphate.) I am becoming a patient Rock Star! Giving up chocolate, regardless of my doctor’s admonitions, was off the table or, I might rephrase that and say, “staying on the table.” I am not giving up chocolate, no matter what. Ok, so maybe I’m a Patient Rock Star, but not exactly a Patient Saint. I can live with that. What’s next on the low phosphates list? Bring it on! Avoid dairy and bran cereals. Rice milk to replace skim milk—oops, well, that’s not going to happen. I love breakfast cereal, and Raisin Bran Crunch is my favorite. Lots of phosphates there. The low phosphate cereals are Apple Jacks and Fruit Loops. Not exactly health foods, but they might hit the spot, taste-wise. I make a note to look up Sugar Pops and Frosted Flakes. I’m just following my doctor’s orders! This could be fun… Now for lunch. Avoid whole grain breads and eat white bread for my sandwiches. Whoo-hoo! I wish my doctor had “prescribed” that a while ago! I love pillow-y, puffy, marshmallow-like Wonder Bread, but my wife buys me whole wheat “white” bread—as if I didn’t know better! But now Wonder Bread it is. I am a child of the 50’s and 60’s, and I do believe Wonder Bread “Builds Strong Bodies 12 Ways!” Guiltless am I, the Rock Star Patient! I am just following doctor’s orders! What’s next? Butter is low phosphate, but high fat, so I will put that in the win-some, lose-some category. Fruits and vegetables are in, but nuts and seeds are out. Ok, I can snack on popcorn. Life is good. On to dinner. Beans are out, too high in phosphates, no loss there for me. I’d make a terrible vegan. Liver is out, and I do like liver. Fish, beef, and chicken are okay phosphate-wise, but only in small quantities. I confess, there are not very many foods I eat in “small quantities” — only the ones I don’t like! As I go down the list of foods that are low in fat, low in phosphates, I am very thankful that I am not a believer in the low-carb or gluten-free fad diets. (While I don’t reject outright that someday some of those kinds of diets might become scientifically-based health recommendations, they certainly aren’t that today. ) No Paleo for me, and please pass over to me any extra portions of the processed gluten (low phos) that you’re giving up. News Flash: Following a very specific diet that is given to you by your doctor is very hard. We should all do this, but it is very, very difficult. How much cheating is allowed and still avoid the dreaded “noncompliant patient” label? I don’t know, but now I do know why patients lie to their doctors. Who wants to be judged?
So I am neither a Patient Rock Star nor even a very good patient. I don’t take my medication as I am supposed to — but I try — and I don’t follow my prescribed diet as well as I should — I don’t try that hard. I manipulate and justify the trade-offs in what I should eat in order to get what I want to eat. Being a doctor is difficult. I’ve already talked about that in many previous posts. But I’m now discovering that being a patient is difficult, too. I am beyond grateful that I can’t even imagine what it must be like to have a serious medical illness, to be in a situation where it is a matter of life and death to follow your physician’s orders. As a physician, I really do know how important it is to follow the advice of my own physician, and yet I don’t even come close to being a great patient.
My new motto: There are no noncompliant patients. There are only patients doing the best they can do with doctors recommending more than is reasonably possible to expect. But don’t quote me on that to your physician!
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