"Mr. Lee" is a 35-year old Asian male with HTN, HLP and DMII
who had s/p stent placement in his LAD two years ago. He has stopped taking
simvastatin, lisinopril, Metformin and aspirin, does not exercise, continues to
smoke, and does not check his blood glucose at home. Despite adequate amounts
of patient education (and a psych evaluation), Mr. Lee refuses to adhere to
medications or to implement any lifestyle changes to reduce his risk factors.
His reason: "I'm tired of popping pills. This is America. I can do whatever I
want. If God wants me to live, he'll save me. I don't need your divine
intervention. You're not God." Needless to say, this patient encounter did not
go well. We did nothing for him...how disappointing.
"Ms. Smith" is a 44-year old female with relapsing remitting
multiple sclerosis (RRMS). She stopped taking her medications one month ago.
Her reason: "I want to be medication-free. My relapses are rare and the
side-effects are terrible. My quality of life is good and I want to keep it
that way without being dependent on any medications for it." She is
knowledgeable about MS and about its potential to progress and cause
disability. Despite this knowledge, however, she has chosen to stop treatment.
This patient encounter did not go well either. We did nothing for her...how
In clinical practice, we often label Mr. Lee and Ms. Smith
as "non-compliant" or "non-adherent." In all honesty, I find these patients to
be challenging because they do not let me "fix "or help them. As students, we're taught to always come up
with a plan... a solution of some sort. Patients expect this from us as well. Most
do not want to leave their office visit empty-handed. They need something. When patients refuse to follow recommendations,
it can be quite frustrating. Sometimes, we're not prepared to handle this. At
least, I wasn't.
Are Mr. Lee and Ms. Smith right? Or as my preceptor bluntly
put it, "Is it our role/duty to save patients from themselves?" What I've come
to understand is that medical-decision making is complex. Patients' illnesses,
their reactions and understanding about it change throughout their lives.
Chronic disease is, after all, a dynamic process. What is right for one patient
may not be right for a different patient. What is right now may not be right
ten years from now for the same patient.
Each patient's illness needs to be viewed in the context of
his/her life, values and beliefs. This is no easy task, however, because it can
challenge evidence-based recommendations. It helps to remember that these
recommendations are just that-recommendations or guidelines. After
that, the ball is in the patient's court.