Brian Fishman, DO, Internal Medicine, 08:12AM Mar 25, 2013
I've always found it amazing that people can be in such denial about their health. Just this past week alone, I've seen three patients who put off getting a colonoscopy into their 70s and 80s who presented with recurrent rectal bleeding that turned out to be cancer. I know a pulmonologist who takes cigarette breaks. Even my own father, an oncologist who should know better, had chest pain radiating down his arm, knew he had had an MI, and only told someone three days later when a nurse asked him why he looked so terrible.
A few days ago, I saw a patient who was admitted for recurrent bilateral lower extremity cellulitis. She had multiple chronic non-healing ulcers on the dorsal surface of her feet, neuropathy, DVTs, and MRSA infections. She had a 40-pack-year history of smoking and an HbA1c of 12. When I asked her if she'd ever been diagnosed with diabetes, she scoffed and said of course not. Then I asked her if she was aware that her blood glucose that morning was 236, and her response was, "that's normal, isn't it?"
Later that day, I went to see her again with my attending to change the dressings on her legs. He started giving her the you-need-to-quit-smoking and the you-need-to-take-your-diabetes-medication talks. He told her that the majority of her issues - the chronic wounds, her COPD, bronchitis, neuropathy, and DVTs - were all because of her smoking and noncompliance with diabetes medications. Her response? "I don't believe you. Every doctor tells me that my problems are all because I smoke or because I'm fat." That's a direct quote.
There's only so much you can do to help people who aren't willing to at least try helping themselves. Noncompliance is one thing. There are tons of patients who are noncompliant with medications for one reason or another. Usually, it's because their medications cost too much or they can't get to their doctors' office. This was the first time I'd seen a patient who was just so obstinate that she refused to believe she even needed treatment.
What are we supposed to do now that we're moving to a system where physicians will be paid based on patient satisfaction? This woman is obviously going to complain about whatever treatment she receives. Then when she refuses to take her medications, she'll wind up back in the hospital, and the hospital will get docked because the patient was readmitted so quickly after she went home. No health care system is perfect, but sometimes I feel like ours is broken beyond repair.