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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