Patience with Patients: A Medical Student’s Perspective on Helping Patients Be Adherent
Not following the course of prescribed medicine (medication nonadherence) is a well-known and costly problem in the United States and worldwide. Retrospective studies have found that in many subpopulations, more than 50% of patients may be nonadherent; this is estimated to cost between $100 billion and $300 billion annually in the United States alone.1-3 In our clinic, many third-year medical students come for their clinical clerkship; the following is one of the student’s perspective and observations on medication nonadherence.
I had spent 5 years in undergraduate training, 2 years in medical school, and so many hours studying alone in my bedroom that I could not even bother trying to keep track of the time any more. All of the medical jargon that once had seemed like a foreign language was now second nature to me; my mind had a tentative grasp on disease processes. I was finally ready to start helping patients.
Not long into my third year, as I was still flexing my newly acquired ability to treat patients, I had an encounter with a patient that was fairly standard for the family practice clinic where I was doing my clerkship. He was an older middle-aged man who presented with polyuria. We were discussing the advantages, costs, and possible adverse outcomes of having a prostate-specific antigen (PSA) test drawn and a digital rectal examination (DRE) performed, as the current guidelines4 recommended for a man of his age. He decided that he wanted to have both performed.
His PSA levels were shown to be markedly elevated, and the DRE showed an enlarged, firm prostate, at which point my attending physician and I agreed that the patient needed prostate ultrasonography to determine the cause of his symptoms. From there, we would be able to figure out the treatment options. I quickly recited the newly formed plan to the patient and gave him a referral to the urologist before going on with the rest of my day. There were plenty of other patients to see and notes to write up. I didn’t think about the patient again until weeks had passed, and he was back in the office for a follow-up visit.
Early in this second visit, the patient sheepishly admitted that he had never gone to see the urologist. Before he could even complete his sentence, I was reflexively furrowing my eyebrows, unintentionally expressing my frustration. Did he not know he could be wasting precious time? Did he not care that he might be causing further problems for himself by not taking care of this as soon as possible?
The patient must have read that I was judging him, because he felt the need to defend himself with his very next sentence.
“You see,” he said, looking at the floor, “I work with electronics, and I have a very logical mind.”
He went on to explain that he had spent hours poring over the different treatment options for prostate cancer and their possible complications. After all of his research, he simply did not think that the benefits of treatment outweighed the risks. He was afraid of the fecal and urinary incontinence that are common adverse effects after the procedure. He also was very concerned about the possibility of erectile dysfunction. Yet, he said, the thing that really scared him was the bleeding. If the surgeon were going to be cutting into him far enough to cause bleeding, he did not understand how they could remove the tumor without exposing it to the blood—and therefore giving it a means of spreading.
This whole experience was incredibly surreal for me. I had studied computer engineering before medicine, and I had even worked in the industry for several years. I prided myself on my ability to think logically. I always did research and weighed the pros and cons before making a decision. With this patient, I was looking into a mirror of who I was, and who I could have been. I realized, I would not disregard my health, and neither was he disregarding his. On the contrary, he was trying to make the best decision for himself. He just was not convinced from our first meeting that getting the ultrasound scan was the best next step.
I sat down with the patient, addressed his concern about surgery, and asked him what other worries he had. He perked up a little and, seemingly empowered, told me that he had a list of questions about prostate cancer and his current state. From his backpack, he pulled out a piece of paper filled with carefully jotted inquiries, and I went through these questions with him, one at a time. He seemed to be eagerly soaking up my responses.
After a few minutes, he was out of written questions. He put the paper away, looked me in the eye, and asked, “What do you think I should do?”
I rehashed what I had said to him at the first visit; I explained that he might not have cancer, and that we first needed to find out what we were dealing with. I explained that, in the worst-case scenario—late-stage cancer—surgery might be the best option, but we cannot know that until we know his current state. I repeated everything that I had said before, but this time, something was different: He was listening.
As medical students and physicians, we spend so much of our time learning. There is an endless stream of new guidelines, research studies, and treatment options; if we stop learning even for a week, we are behind. Yet all of this effort is completely worthless if we can’t connect this with our patients. Some patients need only a course of action from the doctor, some need to be consoled, and some have questions that need to be answered. We cannot know what our patients need unless we are sitting with them, listening to them. And sometimes—not always, but sometimes—this simple act of listening is all that it takes to turn a nonadherent patient into an adherent one.
Timothy Holley, BS, is currently a fourth year MD student at the Herbert Wertheim College of Medicine, Florida International University in Miami, FL.
Syed A. A. Rizvi, PhD, is a professor of pharmacy in the College of Pharmacy at Nova Southeastern University, in Fort Lauderdale, FL.
Sultan Ahmed, MD, is the medical director at JAS Medical Management LLC, in Miramar, FL.
References:
- Iuga AO, McGuire MJ. Adherence and health care costs. Risk Manag Healthc Policy. 2014;7:35-44.
- Osterberg L, Blaschke T. Adherence to medication. N Engl J Med. 2005;353(5):487-497.
- Marcum ZA, Sevick MA, Handler SM. Medication nonadherence: a diagnosable and treatable medical condition. JAMA. 2013;309(20):2105-2106.
- Carter HB, Albertsen PC, Barry MJ, et al. Early detection of prostate cancer: AUA guideline. J Urol. 2013;190(2):419-426.