Tuesday, 15 Oct 2019

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FEAR: A Perception of Fact In Spite of the Fiction

Choice words can make a difference in convincing patients to follow a medical plan. The practice of medicine is now a shared decision-making process between patients and physicians. Paternalism has fallen out of favor as patients are able to access medical information online and want more autonomy in their healthcare. 

So how do you help your patients who are resistant to your medical recommendations when they are receiving biased information from friends, family, and the internet?  I wanted to share with you two cases and my approach. 

My octogenarian patient with rheumatoid arthritis, chronic obstructive pulmonary disease on continuous home oxygen, has a history of lung cancer and lymphoma and is a current smoker of 2 packs a day. She  told me she was “deathly” afraid of starting any medicine to treat her osteoporosis.

“Are you kidding me, Doctor, that stuff can cause your jaw to fall off!” I explained that her tobacco use is more likely to cause her to have more health issues than the miniscule chance of the side effects listed on the TV ads. 

I informed her that women who sustain an osteoporotic fracture are more likely to lose their independence and have higher mortality rates. I cited statistics, proclaimed metaphors (your bones are fragile like a house of cards; topple one, the rest falls), and bargained with her (“I won’t nag you about your tobacco use for the next 2 visits, if you start osteoporosis therapy”).

She did not blink. I finally pulled out my last trick; it was a manipulative one but true. “You do understand that if you develop a fracture, you may need surgery; they do not allow smoking in rehab.” Her eyes opened wide, “You mean I can’t smoke?” The conversation flowed more readily, and she was willing to start therapy.

My second example was a retired orthopedic surgeon with rheumatoid arthritis (RA) and right hip osteoarthritis who hobbled into my exam room, insistent that surgery was the only solution. He did not want to consider my recommendation for physical therapy to optimize his muscle strength and improve his function before deciding whether or not to proceed with surgery. 

He was a pessimist; he did not want the conservative approach because he had already decided it would not help. I stood in front of him, stared straight into his eyes and said, “The hip is not that bad.”

He was shocked, incredulously asking if I’d looked at his X-rays. I informed him that I did, and that I had seen cases far worse where patients were able to delay surgery and did well with physical therapy. 

He laughed, admitting that he also had seen more severe OA that did not require surgery, and those patients are still walking. He had anchored to the thought that surgery is the cure all and that his life would end if he did not undergo hip arthroplasty. He left my office walking straighter with a prescription for physical therapy in his hand. 

In the first case, the patient was more afraid of losing one of her last pleasures in life than she was about developing a fracture. I was able to find out that her fear stemmed from the TV and newspaper ads that mentioned osteonecrosis of the jaw in association with the drug.  Then she heard stories from friends who knew someone who had the rare complication. Her fear grew because she associated the drug with ONJ, a condition that would not allow her to smoke again (because her “jaw would fall off.”)     

In the second case, the retired orthopedist had convinced himself surgery was the only way to fix his hip because of his experience and livelihood.  He anchored on surgery as the cure for everything, including his fear of rheumatoid arthritis and possible damages from the disease, and the only thing that would allow him to maintain independence.  He focused only on his X-rays showing some loss of the chondral surface and eburnation of the femoral head. I shocked him when confronting him with the fact that the hip was not as bad as he believed. It jarred him from his fixed thought processes and opened the opportunity for me to present him with other possibilities.  He had forgotten that patients who arrived on his surgical table had to first fail conservative therapy, including physical therapy, with their referring doctor.  

The common thread in cases of patients who resist sound medical advice is fear.  If fear is confronted, treatment adherence becomes less of a struggle. Many healthcare providers do not have time to conduct a proper history and exam while documenting meaningful use measures. How can they be expected to have time to dissect and address the fears of their patients?  

Rheumatology is a mystical specialty; we are viewed as the one who can make the diagnosis where others have failed. A Twitter feed extolled rheumatologists: “Before you call the priest, consult the rheumatologist.”

I truly believe the only reason we are in this position is because of the time we spend with patients and truly listen.  Many doctors fear the loss of quality time with patients due to poor reimbursements, burdening reporting requirements, and the need to see more patients to cover costs; this likely contributes to the shortage of rheumatologists and why doctors are leaving practice. 

These concerns have angered physicians who just want to see and treat patients; physicians view these requirements as a loss of their autonomy.  Maybe these fears are unfounded and that detailed documentation and outcome measures will not interrupt patient care but rather enhance quality of healthcare delivered. 

Maybe someone needs to address physician fears so that attrition rates will not be so high.  

 

 

 

 

Disclosures: 
The author has no conflicts of interest to disclose related to this subject

Kathryn Dao, MD, FACP, FACR, is the Associate Director of Clinical Rheumatology at Baylor Research Institute in Dallas. She is in clinical practice at the Arthritis Care and Research Center in Dallas, TX and is actively involved in patient care, medical education, and clinical research.  Her interests include Rheumatoid Arthritis, Systemic Lupus Erythematosus, Gout, Infections with Biologics, Osteoporosis, and Drug Safety. She has served as the co-editor for the American College of Rheumatology “Drug Safety Quarterly” 2010-2013.   

 

Rheumatologists' Comments

No surprise with the orthopedic surgeon....When you are a carpenter, everything looks like a nail!