Patient compliance

Lorna appeared in my office yesterday suffering from another bout of asthmatic bronchitis. “How long have you had this?” I asked.

“About five days,” she replied.

“Why didn't you come in sooner?” I asked.

“I thought I would get better.”

If I had a dollar invested in Amazon. com for every time I've heard that from my patients, I would now be in a position to retire wealthy.

Lorna wasn't sick enough to hospitalize, and she balked when I recommended a shot of Decadron, so we agreed to a course of oral prednisone and Zithromax. This morning, I received a call from Gary, the ER doc. At midnight, Lorna had come in tight and wheezy, and he had kept her overnight. She was better, but not dischargeable. “By the way,” Gary said, “I don't think she took that prednisone you prescribed for her.”

When I rounded on her this morning, she admitted she hadn't taken the prednisone because she felt she was hypersensitive to medicines and was afraid of a drug reaction. She had opted for just the antibiotics and, of course, had gotten worse. In the hospital, she had already received two doses of steroids — without any ill effects — and was improving. And so my lecture began: “You know, Lorna, when you don't follow medical advice without telling me, you're not being fair to me or to yourself. If you had taken the prednisone as I had prescribed it, there's a good chance neither of us would be here right now.”

She readily agreed. Feeling like that was enough of a scolding for a sick patient, I went about the business of taking care of her, all the while wondering why patients abridge our recommendations to suit themselves. Is everyone an expert when it comes to their own health?

A picture is worth …

Looking for a way to justify my purchase of a digital camera, I hit upon the idea of sending pictures to my dermatological colleague, Dick, whenever I became stumped by a skin lesion. For years I'd been trying to describe lumps and bumps, but now I could save 1,000 words by simply emailing him a magnified view.

The first day I brought my digital camera to the office, I shot a small nasal tumor that looked like a basal cell and the hands of a patient with chronic exfoliative dermatitis. I had a response from Dick that night, commending the picture quality, asking to see the first patient for a biopsy and suggesting that the second patient could have psoriasis, a keratoderma or a fungal infection.

I appreciate the curbside; Dick appreciates the referrals; and my patients are agog over it all. “I'm not sure what you've got,” I say, “but watch this.” Then I whip out the camera, take a picture, put the floppy in the computer, show it to the patient on screen and send it off to Dick. Now, not only can we bring our patients better living through chemistry (by prescribing) but through the technology of the Internet as well!

The doctor-patient relationship

My beloved KLX 300 motorcycle refused to turn over several months ago due to a frozen kick starter. Not wanting to go out of town to an authorized Kawasaki dealer, I brought the bike into a local shop owned by one of my patients, Steve. His mechanic, Ray, also a patient, said I had damaged three gears and needed not only to replace the parts but to split the case as well, to make sure there were no gear teeth floating in the engine and transmission.

About $800 and three weeks later, I had my bike back — but it lasted only two months before the kick starter locked up again. This time I had broken the countershaft, a problem Ray said he had never seen before. Another $550 later I brought the bike home only to have it fail and the shaft break again on the tenth kick. This time Steve said he would fix the bike at no charge; the only problem was that I no longer wanted him to. But how could I tell that to Steve or Ray, my friends and patients?

I called Ray up and proposed that we hand over the bike to an authorized Kawasaki repair shop. “You'd probably be relieved to get it out of there anyway,” I said.

“Yeah, you're right,” he said, thinking for a moment. “I can't blame you.”

Later that day Steve called to say he had contacted Kawasaki headquarters and they weren't going to charge me for parts, even though the bike was no longer under warranty! I asked Steve how he pulled it off. “Just kept bugging them,” he said. “They'll give you what you needed to make it right.”

I thanked Steve for his efforts and savored the lesson I had just been handed: When our patients don't improve despite our best ministrations, it's important that we swallow our pride and refer them in a timely fashion. That shows our patients that, even if we are unable to help them, we care enough about them to do the right thing. In so doing, we preserve our doctor-patient relationships. That's worth infinitely more than a fixed motorcycle.