vendredi 19 septembre 2014

PHYSICIAN PATIENT RELATIONSHIP AND COMMUNICATION

COMMUNICATION BARRIERS BETWEEN DOCTORS AND PATIENTS
This morning, I received the following text message from an Indian friend of mine, who lives in a remote reservation. She had consulted me about her Thyroid Dysfunction years earlier. When her glucose fluctuations began worrying her she consulted her primary care physician who immediately prescribed medications that made her sick and she discontinued taking them. She wrote to me at that time and we decided to follow a path of a change in lifestyle, searching for better food, and becoming more active.
She kept her appointments with her primary care physician, and the text message this morning was prompted by her last visit to the doctor.
I copy the text message in full:
Dear Dr, I just recently went for my check up with my FP. I still manage everything by nutrition and exercise. However I just found out she has ordered me a medication called “simvastatin 20 mg”. She had not called me regarding this but is this something I should take? I am not on any medication and don't want to be. I do take omega 3 krill oil, could this be causing my cholesterol to be high?
(Rick Two Dogs, a Lakota Medicine Man with a Jewish Medical Anthropologist)
The questions are:
Does she need Simvastatin therapy to lower her cholesterol? How high is her cholesterol? Are there other non-pharmacological methods of lowering her cholesterol? What is the significance of higher cholesterol in this lady who is nutritionally competent and is not sedentary?
The above are strictly biomedical questions. For an anthropologist, something far more serious that gives rise to the erosion of confidence in the medical care is taking place.
The patient was not told during the encounter that she would be prescribed a new medication. This patient is extremely health conscious and a good explanation and discussion would have been welcome. Her last foray into medications was a disaster for her with gastrointestinal complaints and also symptoms of low blood sugar. It caused enough anxiety in her to send me a text message, and I live 4000 miles away!
It is well known that in the developed world, 50% of the times patients do not take the medications prescribed and in some chronic conditions this level may rise as high as 80%. When worming with marginalized people with other social issues, it is all the more important to have communication open and non judgemental.
In the hierarchy of medical care in the western world, with its predominant biomedical ways of thinking, the blame has always been directed at the patient. Even the word, compliance is a guilt laden, accusatory term.
So, when a few years ago, we suggested that the “doctors may be non compliant”, they were indignant. No, they protested, we do the best for the patient; it is up to them to take the medications.

One of the earliest observations I made with the Indians that I work with, which I could translate anthropologically into practice, was this. When they go to their traditional healers or attend healing ceremonies, there was no problem of “non compliance”!
I recognized the following “reasons” for this “success”.
Respect
Healer and the Patient share the same culture
There is no hierarchy
No orders, only suggestions
A strong belief in the outcome
No remuneration of any kind
Gratitude for the outcome
In my opinion, if an Indian knows that you respect her or him, you can be sure that medical outcome is helped by that fact!
Indians in America are some of the poorest people in the country but they do have access to primary care and medications and investigations. So many of the patient related structural factors are absent. The other patient related factors are mostly remediable, if the provider takes the time to find out and it would need a little bit of analytic investigation.
Explanatory models of why the chronic condition is not well controlled, I have had traditional Indians tell me:
There have been too many deaths in the tribe recently.
My children play after school sports in the nearest town.
I will devote another blog for deciphering this among many other explanatory models of Indian patients.
Even if the provider feels that he or she is unable to confront the social aspects of medical care, they can pay attention to Physician-related Factors, as enumerated below in a review from Mayo Clinic.

Physician-Related Factors
Not only do physicians often fail to recognize medication nonadherence in their patients, they may also contribute to it by prescribing complex drug regimens, failing to explain the benefits and adverse effects of a medication effectively, and inadequately considering the financial burden to the patient.3,55 Ineffective communication between the primary care physician and the patient with a chronic disease such as CVD further compromises the patient's understanding of his or her disease, its potential complications, and the importance of medication adherence.5 Failing to elicit a history of alternative, herbal, or supplemental therapies from patients is another source of ineffective communication.
Communication among physicians is often insufficient and may contribute to medication nonadherence. Direct communication between hospitalists and primary care physicians occurs in less than 20% of hospitalizations, and discharge summaries are available at less than 34% of first post discharge visits.64 Inadequate communication between physicians, hospitalists, primary care physicians, and consultants also contributes to medication errors and potentially avoidable hospital readmissions.64,
I shall reply to the text from my friend from the isolated part of the USA:
Please do not begin the medication.
You can find out the absolute numbers of Cholesterol either from the FP or from the Clinic. You can also ask the FP, WHY he/she decided to put you on this medications? Also ask him/her the various side effects of the medication.
We can talk on the phone and figure out why the cholesterol has risen. And try to make changes accordingly.



It feels good to be of service to the native people of this Turtle Island. Please be assured that what has failed our patients is the SYSTEM rather than the Servants of that System..