When patients have concerns that trump their disease

How often does this occur?  A patient comes into the hospital with a chronic disease, or two or three.  The patient has worsening of their disease(s) because they have not taken their medicines.  They say that the medications are too expensive, but they have been smoking and/or drinking and/or using cocaine.  Usually they also have a DSM-IV diagnosis or two.

You can fill in more information about the patient, unstable social situation, often homeless, often estranged, and much sicker than they should be.

So we perform great rescues in the hospital, stabilize the patient, restart the appropriate medications, institute physical therapy.

Then we start discharge planning and everyone – physicians, nurses, case managers – deals with the frustration of the social situation.  Actually the problem is the lack of a social situation.  The patient usually has no, or minimal social support.

As I often tell patients, I cannot treat them after they leave the hospital.  Only the patient can manage their disease in the long term. The patient must own the disease and the treatment.

But when the patient has other concerns that trump their disease, then their disease management suffers.

We get frustrated with these patients, but this frustration really reflects our frustration with the social confounders of disease.

Each day we must remind ourselves that we can only do the best we can do.  Not every patient will succeed because not every patient will own their disease and its treatment.

We do the best we can.  We try to help.

And sometimes we really do make a difference for these patients.  Batting averages really do not matter, what matters is that we continue to try, and hope that we do sometimes succeed.

We are not magicians.  We are not able to achieve perfection.   But we continue to try.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • Fred Ickenham

    An ESSENTIAL component of the ACA-ObamaCare is to make YOU the “provider” financially liable for the adverse results of that patient’s choices, such as cocaine, smoking, inertness, gluttony, etc. Such preventable disease is 40% or so of healthcare costs. No matter what how they destroy their health, you still must fix them regardless of costs. Their own insurance premiums rise as a result, but since many/most of them for whom the ACA is intended, pay nothing now, that penalty will be meaningless, since they just won’t pay it, and will still get the same care. Tort reform is needed to prevent that major driver of healthcare costs – defensive medicine, which the plaintiff’s bar seeks to deny exists.

  • http://twitter.com/PortiaChalifoux portia chalifoux

    We all of us live within our immediate, local, regional and greater societies. Physicians used to play a large role in community and social life and influence. Extended families, visiting neighbors, and private organizations often provided the fabric of advocacy and survival for the vulnerable among the community.

    People who are without safe, reliable shelter, without dependable sources of nutritious food, without the means to acquire both over the counter and prescribed medications, and without access to green and safe recreational spaces for activity and socializing spend their waking hours focused on satisfying immediate needs: hunger, safety, exposure, dread and anxiety.

    Because they don’t have the resources to assure themselves of basic essentials beyond the next meal, the next night, beyond their line of vision, they focus on the immediate instead of long term.

    Much of substance abuse (including passivity) behaviors are essentially self-soothing/calming attempts in the face of constant threat and high levels of prolonged stress.

    When societies no longer provide adequately for the vulnerable among them, then it’s put on the front line workers in the helping professions to do society’s dirty work: discharge to the street, knowingly place people back into unsafe and often untenable living situations, and dealing with the fallout.

    Add to that all which was mentioned in the post (excellent synopsis), and you have a recipe for continued misery, preventable suffering and high ongoing costs and use of scarce resources from this population.

    It seems to me that the only people who should be allowed to deny vulnerable people safe shelter, decent food and an equal opportunity for life, liberty and the pursuit of happiness should be mandated to be the people responsible for taking patients from their hospital beds and delivering them to the curb. Now, THAT would be some education.

    Thank you for this critical post, Dr. Centor.

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