Monday, August 18, 2014

What Happens When Patients Won't Take Meds?

You're here reading Shrink Rap, so you may think this is a post about patients who refuse to take psychiatric medications, and non-compliance with psychiatric medications gets to be it's own issue.  So it caught my attention when Dr. Albert Fuchs tweeted that he was interviewed by NPR about "What happens when patients won't take medicines."  Dr. Fuchs is a primary care doc with a concierge practice in Beverly Hills, so I wanted to hear what he had to say, and I invested 6 minutes of my life in listening to his NPR talk -- you may want to go to the website and listen as well.  He makes a good point about being cautious when an addictive medication is prescribe, and he notes that in Los Angeles people are pro-health, anti-medication and perhaps that skews who he sees, but that medication refusal is common.  I'm thinking that by the time you're paying an outrageous concierge fee to your primary care doc that either you're ill and  feel you need extra attention or money's not an issue in your life -- after all it's Beverly Hills.  But my other thought is why would someone invest in this type of care if they are not going to follow the doctor's suggestions?  If you're going to blow your doc off, do it when there's a $20 co-pay.  

That said, I'm not exactly the best of patients, and I've had a doctor who has wanted me to take calcium supplements for years.  She is insistent.  One look at me and one thing is clear: I'm well nourished.  I don't think I need supplements, I think I get plenty of everything in my diet, and a close friend started taking calcium on the advise of her doctor and promptly got a kidney stone, and the literature suggests that dietary calcium is better than supplements, at least for people in some demographics .  I assure my doctor that I ingest enough calcium. She's asked me what I eat, to which I've replied milk, yogurt, cheese, and ice cream.  "Do you eat ice cream everyday?"  Isn't that harassment?  Of course I don't eat ice cream every day, but I wish I did.  I surrendered, I bought a bottle of Tums and a few times a year, I eat one.  This way, when I see this doc, I can say with impunity that I sometimes take Tums and this seems to stop the conversation.  Maybe I'm wrong and someday I'll have brittle bones and wish I had listened and taken calcium supplements.  So I have mixed feelings about whether one always needs to follow doctors' orders exactly and under what circumstances.  Certainly the issue in psychiatry gets very complex if the patient is psychotic and  repeatedly decides not to take medications and keeps ending up in the hospital or puts himself or others at risk.  

 In the meantime, my favorite flavor, for anyone who wishes to buy me ice cream, is praline pecan. 


Simple Citizen said...

Going to a doctor isn't paying for medication - it's paying for educated advice and access.

When you go to your car mechanic do you make every single repair they recommend every time?
No, you choose which repairs get done - based on cost, need, and personal preference. You also base your decision on the mechanic - do you trust their opinion, their motives, etc...

Doctors are the same way - instead of your car's health, it's your health, but the same decisions apply.

You pay for expert advice and access to medication. If you just wanted to buy meds, there are plenty of websites where you can diagnose yourself and order whatever meds you want. (Fairly cheaply too)

elbee said...

I like chocolate peanut butter.

Anonymous said...

It's so refreshing to hear this discussed as a patient issue, rather than as a psychiatric patient issue.


Sarebear said...

I have some stories about this. Most recently, I had reuppedd taking the latuda in May, and a bunch of stomach problems started within days of that, but I didn't think much of that, at first.

The doc had told me to rely it when I felt circumstances warranted so I did. I didn't tell her though, my psychologist kept urging me to as he felt I should be supervised on the med. I wanted my options open to stop it if necessary and I felt informing her I'd started it back up would tie my hands on that.

A few months later she was told about the few weeks I took the latuda but she didn't seem to mind that I didn't tell her nor that I stopped. She said to this that she had told me to use my discretion.

I became a little uncomfortable at how much she seemed to not care about what had gone on, I would have felt better about informing her, or rather a psychiatrist I can actually trust, at the time, about it, and feel like my doctor knew I was back on the med should something happen. I feel like she was having me play doctor, but I guess my reluctance to tell her I was back on the latuda means I was mind of playing doctor myself, before I really knew I had permission, so to speak.

Ok, so the reasons I stopped the Latuda were that it was messing with my swallowing and it was going to make me choke on my food, and I was having several gastroenterologist appointments during this period and before the next one I needed to know if the latuda was causing the stomach problems, so I stopped it five days before, and the problems went almost entirely away.

The rest of it was due to what showed on the cat scan, no ulcer, they checked, but extensive gallstones, we had not even been looking for that, my gall bladder hadn't been sick except a twinge or two in March when the latuda made it sick then. I had a nuclear hideascan then and it was fine.

So the cat scan showed problems, the doctors said it needs to come out, I pretty much think the latuda ruined my gall bladder but can't really prove that. I did have them take it even though I didn't feel sick, the doc kept saying it should go.

So that's my story. A little more to it, is, since I've had a mood stabilizer cause my over active bladder even though lamictal doesn't affect the kidneys/bladder, and at one point I was feeling discomfort and pain in the kidneys for months from it and the docs didn't believe me because "lamictal doesn't do that", well I knew this time I needed to act quicker, before the next appointment, to see if the med was causing the problems.

Anonymous said...

One scenario is an accurate diagnosis. After being diagnosed with high blood pressure, I read that patients need to ask for a 24 hour monitor to confirm it. Many times, the diagnosis in the office can be wrong due to white coat hypertension or simply the blood pressure being taken at the wrong time or inaccurately. Good thing I did because mine was completely normal.


EastCoaster said...

FWIW on the calcium: my PCP, who does research at a major teaching hospital and is no slouch when it comes to evaluating evidence, is against supplemental calcium.

There was a Swedish study which showed that women taking calcium supplements had higher rates of heart attacks and strokes. I asked her about it, and she said "What I like about that study is that we've known for a long time that at higher levels calcium hardens arteries. We've really been over calcifying women for a long time. Just have a couple of servings of skim dairy and eat your vegetables. You'll be fine."

The Alienist said...

It is unfortunate that more clinicians aren't trained in Motivational Interviewing. Not only does this process allow the physician to explain the diagnosis to the patient, it elicits feedback from the patient that indicates what measures they are willing to consider for its treatment or monitoring.

(Man, do I sound like a geek talking this way in your living room.)

The Alienist said...

It is unfortunate that more clinicians aren't trained in Motivational Interviewing. Not only does this process allow the physician to explain the diagnosis to the patient, it elicits feedback from the patient that indicates what measures they are willing to consider for its treatment or monitoring.

(Man, do I sound like a geek talking this way in your living room.)