Friday, September 21, 2012

Trials and errors.

I was talking to a patient the recently. The conversation was easy and fluid, just like doctors like discussions with patients to be. A blood pressure was too high so we needed to do something about it. Two medicines needed to become three. Because even though she was taking the two, her blood pressure was still uncontrolled.

I listened to the amazingly competent resident physician as he unfolded her medical history in front of me like a linen napkin. Stage two essential hypertension. Currently on a thiazide diuretic. Next came a calcium channel blocker. Now he wanted to add another medication because the pressure was still too high.

He gave me a clear explanation for his choices of medications. That resident cited all sorts of clinical trials with funny acronyms that spell out words like ACCOMPLISH and MERIT-hf and provided evidence for why each potential drug combination was or was not the best for this patient. I marveled at how well he knew the fine points of so many intricate medical studies and how effortlessly he applied them to his practice.

Honestly? He was all over that plan. So much so that I had nothing much to add. Who could argue with clinical trials?

"Is she taking all of her medicines?" I had to ask at least a couple of questions.

"Yes. She's very motivated and is taking them all. She brought her bottles in and everything."

Then he assured me that she was taking her medications, exercising, and watching her salt intake. So a third medicine it would be.

Admittedly, this resident had memorized more medical evidence than I had. I knew the rules and what to do, but when it came to calling out the names of each study and those fine details like, "3100 adult white males were randomized to this medicine versus placebo." Me? I tend to mostly know the impact of the study and what it means to patient care.

But I'm always super impressed by others who can recite the details.

So after my less-than-probing queries, we went to see the patient.

I exchanged pleasantries and explained that we were concerned about her blood pressure. That's when we launched into that easy-like-Sunday-morning chat about her hypertension and she seemed quite amenable to all of the things we were saying. I then thanked her for bringing in her pill bottles and asked if she'd minded showing them to me again.

"That's no problem," she answered and pulled out her medications as prescribed during our last visit and also during a recent  ER visit.

He was right. This lady seemed to have it together. Greying hair in a tight chignon. A careful application of lipstick. And a fancy blouse with ruffles along the front. All accessorized with a warm demeanor--the very best kind of "together."

My resident launched into a discussion about our plan to add another medicine. How she should take it. What side effects to look out for. All of that.

I kind of zoned out while he was talking. I read the labels on her bottles and made sure they matched the amounts recorded in her chart. Everything was spot on and the resident was nearly done with the encounter.

That's when I let my eyes do what they habitually do. Check the fill date and estimate the number of pills remaining in the bottle.

Fill date: July 20, 2012.
Quantity dispensed: Thirty pills for each prescription.
Amount in each bottle: Easily twenty.

Rut roh.

"Is this the last bottle you had filled?" I asked her.

"Yes ma'am."

I twirled the bottle over in my hand and pressed my lips together. My brow knitted and then unknitted; I didn't want to alarm her. "Do you ever . . . .sometimes. . . forget pills?"

"No, ma'am. I take my pills every day." She kept her eyes carefully fixed on my own.

"Okay. I was just wondering because this bottle should have run out at last month around the eighteenth of August. Are you sure you always remember?"

She dropped her head and sighed. "I be forgetting. A lot."

I looked up at the resident and then back at the patient.

"You do? Did you take them today?"

And she shrugged.

We probed some more and found out that this "really together" patient with the stage 2 hypertension mostly took her medicines on a "as needed" basis. Because on the other days she often forgot. The day her head hurt, yes. If her urine was dark yellow, definitely. And in those next moments we uncovered a surprising amount of things that she didn't understand about her medical problems and couldn't remember in her life. It became clear that she had some pretty significant cognitive impairment.

"I live by myself. I don't be wanting to bother nobody and don't want nobody thinking something wrong with me."

"Something like what?" I asked.

"Like the old-timers setting in. You know. My daddy, he got the old-timers disease real bad before he passed on. It started with him forgetting stuff."

Aaah. She was afraid that she, too, might be developing some Alzheimer's dementia.

So we talked some more and arranged for her to see our neurologists in the "Memory Clinic" -- a session devoted to early cognitive impairment. The resident doctor spoke to her son on the phone who agreed to regularly check in on her and to get other family members to help him. Lastly, we spoke with our social worker and pharmacist to arrange some other interventions to assist her in managing her health.

It wasn't clear what this all meant. Was she on her way to developing severe dementia? Had those daily crossword puzzles and sudoku grids betrayed her? We didn't exactly know. All of this had been masked so well.

Finally we discharged her home with the same exact medications with which she'd arrived. Two medications instead of three.

"I'm going to worry about her," the resident told me. "I know I am."

"Me, too," I whispered.

He shook his head and stared out of a nearby window. "You do all this reading, you know? But for some things there's just no textbook."

And I got what he meant by that. He was right. Sometimes medicine isn't about knowing the clinical trials  off the top of your head. Sometimes it's just about trials and errors.


But the other part that isn't in the books is that it also involves worrying. . .  long after the patient has left your sight and just before your head hits the pillow.



  1. Hmm, feeling like "Old Timers" is stalking you is enough to drive anybody's pressure up. Why do we have to come apart as we age? Who signed off on that? Ugh!

  2. This was a really interesting story! I always like hearing things from an attendings point of view. That's a good tip about checking the dates on the meds. It's a good thing she brought them, or else all the context behind her cognitive impairment might never have come to light.

  3. Smart move Dr M! So many times I find my patients "taking the medicine" - but not the right dose, or at the right time or not at all- it's something we need to assess beyond the textbooks. Loved the post about Gunners as well in which Parul did the pill-count. These small clues help in unraveling the bigger puzzle.

    -- Tara

  4. My often-forgetful mom has hypertension and my dad stalks her about taking her medicine. It annoys her but Daddy is so diligent... and I thank God for his diligence, and her pacifying him by taking her medicine every day.


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