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dimanche 11 mars 2012

Homage to an Indian Patient of Ours: Patience does produce results


About ten years ago, when I had seen this patient, an Indian from the tribe with whom I have the longest continuous relationship, came to see me.
The appointment was for 3 pm and she informed me that she had just gotten out of bed, and that she really did not want to be there anyway. I knew her family well and knew that she had lived an outcast’s life because of other diagnoses she carried and she was on an array of medications prescribed by her Psychiatrist.
Her Blood Sugars were extremely elevated and reluctantly I chose to increase the medications to combat the high blood sugar knowing well that getting through to her and becoming a friend of hers would bring better results that more and more medications. With the other tribal members working in the clinic, we made the collective decision that I will see her, much more for a social visit rather than a Medical visit, each time I was in their territory.
No change in medications for Blood sugar did its trick. She kept about one in three appointments and when she came it was always, just after she had woken up and told me from the beginning that she did not wish to be there. Once our relationship became more in the joke pattern which is familiar to any one who works with indigenous peoples, I decided to write a letter to the Psychiatrist requesting whether he could find other medications which would not add to her Blood Pressure, Blood Sugar and Cholesterol Burdens. He agreed to do that.
About two years later, I noticed that she was keeping every appointment and was resisting, when I jokingly told her that I didn't wish to see her for another three months. She kept up coming and upon suggestion; she decided to enrol in one of the wellness classes run by Indians for other tribal members. The teachers who themselves are from the community talk about Nutrition with whatever they happen to have at their homes, learning to read the labels on food substances, plausible exercise patterns to follow.
Each November, we hold a three-day In-Hotel education, when we invite about 30 patients of ours for a combination of socialization, education and good cooking demonstrations and for a general good time. It is always held in a hotel in the nearby town, with a swimming pool and nice rooms facing the River Missouri.
I was surprised to see her there; this lady who had the habit of waking up only after the hour had struck three! More importantly, there was a glow in her face, she looked thinner and was more jovial than normal. She had been attending the classes and had made changes in her food habits and was doing a reasonable amount of physical activity. On my next visit in December 2011, she requested that I stop her medications as she felt that she was making such improvements. Sure enough, her biochemical profile was more than excellent!
BP 126/78
HgA1c 5.7%
Total Cholesterol 137 mg/dl
Random Blood Sugar 112 mg/dl
All these values are what a healthy person would have on his laboratory examinations. What all she had done, after years of our begging her and the appropriate forum and context of education, was to make no great changes but enough to normalize her metabolic abnormalities and with the loss of weight and wellness felt with regular exercise, her emotional situation also got better. She requested the Psychiatrist to take her off most of the medications, which he did as well.
Two months later, she was well, feeling much better than before, happy with her lifestyle and integrated well into her family and the tribe.
Ten years ago, if one of us had written: Non-Compliant Patient, see when necessary in the Clinic, what would have become of this patient?
Who is responsible for the “non compliance” (horrible word to use) among the patients? The Mid Level Providers such as PA, FNP or Primary Care Providers such as FP who do not have enough time for difficult patients who have been treated off handed for most of their time as patients in various facilities?
I know in my heart that whenever I see the term, Non Compliant in a Health Record, it is the Provider who is Non Compliant for the welfare of that patient… if he or he was compliant, she or he would have spent more time and effort… It does take time to get good results.

Perhaps that is why the Little Clinic catering for Indians in the northeastern corner of that state in the USA has good results with the OUTCOMES. It is not what is being done to the patient that matters (audits would show that measurements and education have been given) but what brings the results are: what actually did you sacrifice for that patient?