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Good Doc - Bad Cop
Written by Jeffrey R. Waggoner, MD   
Dr. Jeff Wagonner
Dr. Jeff Wagonner
 
When I left medical school, I was part of a new wave of physicians who were not only armed with knowledge but also with the belief that medicine needed to be organized like any other discipline. I had been trained in the “Problem Oriented Method.” All my progress notes were SOAP, and all my charts had a detailed problem list. I doubt that many of today’s medical school graduates have ever even seen a chart without a problem list. It has become the skeletal structure upon which all else is hung.

It took me a while to discover that my ability to make people better required more than organization and knowledge. I had to learn that patients are people.

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Editor's note: We are pleased to welcome Dr. Jeff Waggoner as a regular contributor to the NetDoc.com Community. Dr. Waggoner practiced family medicine for 30 years, and brings a wealth of experience and humor to his twice-monthly column. We're sure you'll enjoy his commentary as much as we have.

I’m sure there are those of you who are rolling your eyes and yawning, just about to turn to something that has relevance—like a discussion of whether or not you need to take your diabetics off Avandia. But the “patients are people” issue is more than a concern about warm fuzzies. As a matter of fact, I suggest that it’s significantly more important than Avandia’s side effects.

For example, consider compliance. I believe that most physicians have no idea what many of their patients are taking, how they are taking it, and if they are taking anything at all. If you doubt that statement, try grilling some of your patients the way you would if you were a police detective.

“Exactly what are you taking?”

“I’m taking ...you know ...the pills I’m supposed to.”

“How many? What color?”

“Five ...no six... two blues and a white ...no three blues, two whites ...and a pink. I think.”

“When?”

“In the morning. No, the blues are in the morning. I take the others ...at ...other times ...usually.”

If you were a police detective, you’d book your patient on the spot. But who grills their patients? Nobody. We ask them if they’re taking their meds, they say “yes” and we continue with the rest of the office visit.

But how can we do that? There is no more important information than whether or not a patient is being compliant. Forget side effects. If a patient isn’t taking a medication, he won’t have any side effects. He won’t have any medication effect at all.

Not until we double the medication’s dose because our patient’s Hb1AC hasn’t budged. He then becomes frightened because we’re concerned. He starts taking his new dose of medication and has horrible problems with hypoglycemia. At this point, real confusion begins because our patient once again stops the medication but is embarrassed to tell us. He doesn’t want to hurt our feelings. We institute a rigorous glucose monitoring system and two weeks later try to make sense out of its pattern. Unfortunately, we’re missing a key piece of information—our patient is taking the medication sometimes, but still mum about admitting so.

Patients are people. They forget. They become frightened and lose their sense of perspective. They succumb to pressures applied by well-meaning family members and add massive amounts of “natural” remedies to their diets. They play with dosage schedules depending upon how they feel.

These are the implications of that simplistic observation about patients having human frailties. We ignore those implications because paying attention is time consuming and involves the stickiest of human frailties—emotions. But the truth is, if we don’t wade into that difficult, muddy area of humanism, we run the risk of playing the fool in a most dangerous way.

It’s rather like an airline pilot taking off without looking at a fuel gauge. 

“How could he have not known his plane had no fuel?”

“How could he not have known his patient wasn’t taking his medication?”

About the Author

J.R. Waggoner, M.D. practiced family medicine for thirty years in Aurora, Colorado. He also worked as a consultant and herded cats as the managing general partner of a general partnership of physicians. Three years ago, he left his practice to study health care policy and write. During his time away from clinical work, he has written two books and worked as a Senior Clinical Content Specialist and freelance writer.

His current book Medical Metamorphosis: The three step cure for America's health care crisis is available at Lulu.com.

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