Trusting Your Doctor

“Concordance.”  That means doctor and patient wanting the same thing.  In psychiatry we call it a “therapeutic alliance.”  We work for it — assuming we have the time.  But if the time is not there, on some level we all know that nothing will happen.

Leave it to the pharmacists to at least touch on a reason for “lack of concordance” that nobody seems to discuss. “With increasing numbers of medications shown to do more good than harm when taken as prescribed, low compliance is a major problem in health care,” reads an unpretentious sentence in the abstract.

And people wonder why there is no “trust” between patient and doctor.

Other countries publish studies that absolutely chill me because they hit the nail on the head.  They say there are things a clinician might see but cannot prove without having the time or means to research.

I remember sitting in a doctors’ lounge in medical school in France with a senior endocrinologist who told me — then still a student — that people who are diabetic long enough start having memory problems.  This is especially if they are not compliant.

Years later, I heard pretty much the same thing in a doctor’s lounge stateside.

It is people in other countries, most frequently, who author the research that demonstrates it.

We have lots of non-compliant diabetics.  I am unaware of anyone checking them for dementia.  I am even more unaware of anyone who discusses with patients advantages and risks of treatments — telling them that years of non compliance could lead to cognitive loss.

There are lots of people like my uncle – the most non-compliant diabetic I’ve ever known.  He eats sweet cookies or cakes on a daily basis and never misses a piece of a Bar mitzvah cake at the synagogue where the activities he does are the cornerstone of his life.  His wife – my aunt — told me not to confront him about this because she had many times.  She said he always came up with something like “I’m going to die anyway so I might as well eat things I like.”  I agreed it was useless to confront him.

Then there are people like the mental health professional who once spent hours telling me how horrible her life was.  How at the advanced age of 57 — which I had obviously not yet experienced yet – she had made the decision that her contribution was over and she could exit the profession.  Her memory loss was evident; she never told me the same thing two meetings in a row.  I tried real hard to work with her, but she covered her inconsistencies with the belief she was always right — which she was not.  She had stopped taking her insulin and had gained 6 dress sizes, but did not hear my offers to help her by using my 30 years of experience to help her health or her failing institution.

There is a lot written about increasing rates of dementia in the population – but little about its consequences, and even less about how to fix it.

No knowledgeable or complete discussions seem to be given by anybody about the advantages and risks of treatments, although I really try to do this with psychotropic drugs.  I do not think anybody – ever — has obtained an adequate informed consent for diabetes medication.

It would include telling medication risks, non-compliance risks, and making the patient an adequate partner in treatment.

If my retired uncle has an unknown blood sugar and eats everything sweet he can find, nobody is very much worse for this situation.

If an alleged mental health professional gives confused directions and alienates both staff and patients, there are endless possible problems.  Most institutions are run on inertia, with people staying in their corridors of influence.  If things move at all, it is only when something horrible happens.

Me?  I keep moving.  This, I think, is my nature and my destiny.  For the past several years I have identified “honeymoon periods” when they exist and I try — with all I have — to do the best job I can.

But sooner or later, with even the most loving attempts to extend myself, I find myself moving on to other things.  I have done work in every sector of my profession I can imagine — as well as some I may not have been able to imagine.

When looking for spirit and inspiration to give my patients, I find so many things wrong with the system and I cannot begin to describe them.  I can describe this one.

America is “stupiding up” and I cannot begin to cite all the reasons.  However, our failure to treat chronic illness appropriately is one of them.  Without treatment, people do worse and lose the ability to function, something nobody ever wants to admit.  Obesity, lowering of memory, problem solving, and intelligence functions — lots of things we call “lifestyle” problems may be the fault of many things.

One of these problems seems to be excessive and inappropriate medication.  A sort of “medicalization” of problems with negative effects that leave chronic illnesses — such as diabetes — inadequately treated.

So – “concordance”.  Because poor use of a doctor-patient relationship — or failure to build one — can lead to noncompliance, morbidity, and a cascade of denial that benefits nobody and can hurt many.  Very many.