QD 81 - Less Is Dangerous Save
QD Clinic - Lessons from the clinic
What to do when blinded by noncomplianc!
Features Dr. Jack Cush
YouTUbe link: https://youtu.be/AJKaQKe1So8
Transcription
Welcome to QD Clinic. I'm Jack Cush from roomnow.com. QD Clinic is brought to you by RheumNow live, where we will change minds and change practice. Our meeting begins in just two weeks. Go to rheumnow.live to check it out.
Today's case is called less is dangerous. So I saw a patient recently who is a non English speaking older woman who has rheumatoid arthritis and I almost blew a pupil over her non compliance. It's been a repeated issue every visit. It's really hard to tell what she is taking and what she is not taking. It's totally maddening because guess what?
At every visit, she's doing horrible, has a pain of, you know, six, seven, eight, nine, sometimes 10. You know, sometimes she has swollen joints. Today, had swollen joints. You know, what are you going to do with this? Noncompliance is a gigantic problem, and I think you need a strategy.
Lord knows I need a strategy on how to manage this. You have to recognize the problem. The problem is number one, age. Older patients really suffer from this issue more so than do younger. Language is a major problem here.
Polypharmacy just compounds the problem, and comorbidities just makes the problem scarier. So my solution in dealing with this is as follows. Number one, I have to impress upon the patient that I need to have certain things at every visit or else I can't do this, meaning take care of you. Number one, I need another person present. It's not enough just to have you.
I need a daughter, a spouse, a best friend. It's got to be the same person. It can't be a series of volunteers who are pitching in to help with translation and or transportation. It's got to be the same person who's going to get involved in that person's prescribing and taking of medicines and filling of medicines. Number two, I don't see the patient unless the medicines are in the clinic in a bag and we're gonna count them off.
We're gonna go over them. We're gonna throw away the ones we're not taking. We're gonna change the ones we need to change. We're going to accentuate the ones that need to be taken correctly. Number three, the goal has got to be reduced medicines.
If the patient is taking less medicine, they'll believe that they're safer and they'll be motivated to actually take the medicine. You've got to work real hard at reducing medicine, which means number one, get rid of all the vitamins, it's a bunch of crap, it ain't really going to change the story, unless it's folic acid for methotrexate, it's all crap, forget it, get rid of it. Number you also need to work with other doctors on this, you probably need to call a primary care doctor. If your clinic is lucky enough to have a clinical pharmacologist around, get them involved. And again, another prob you know, there are other doctors who are contributing to this problem as well.
Number four, rheumatology is easy. If they have advanced RA and they're on advanced therapies, go IV. Stop screwing around with pills that you hope they may or may not be taking. In this case, the patient stopped the medicine months ago when the surgeon stopped the medicine because he thinks he knows what he's doing. He's getting his education from the television.
He doesn't know what he's doing and the patient's been off of a DMARD for three and a half months and guess what? She's worse. So go IV. Go monthly infusion. Go whatever it is.
You know, you can control it and you can be sure that she's getting it, he's getting it and go IV. Number five, as frustrating as this is, you probably need to see the patient more frequently. See them every month until you get this right. Let them know that you're really concerned. And that's my last point.
Show your concern, either your frustration, your worry, your sense of urgency. You've got to back it up by seeing the patient more frequently, getting more frequent labs. And then lastly, you need to tell them less is dangerous. Less is not safer, less is dangerous because taking less medicine means that they're going to get worse. And worse means more pain, more disability, more damage, more hospitalizations, and ultimately just really poor RA care that's got your name all over it.
You as the physician need to take control of this less is dangerous situation, which is rooted in noncompliance, polypharmacy, etcetera. Tune in tomorrow for another good case of QD clinic.
Today's case is called less is dangerous. So I saw a patient recently who is a non English speaking older woman who has rheumatoid arthritis and I almost blew a pupil over her non compliance. It's been a repeated issue every visit. It's really hard to tell what she is taking and what she is not taking. It's totally maddening because guess what?
At every visit, she's doing horrible, has a pain of, you know, six, seven, eight, nine, sometimes 10. You know, sometimes she has swollen joints. Today, had swollen joints. You know, what are you going to do with this? Noncompliance is a gigantic problem, and I think you need a strategy.
Lord knows I need a strategy on how to manage this. You have to recognize the problem. The problem is number one, age. Older patients really suffer from this issue more so than do younger. Language is a major problem here.
Polypharmacy just compounds the problem, and comorbidities just makes the problem scarier. So my solution in dealing with this is as follows. Number one, I have to impress upon the patient that I need to have certain things at every visit or else I can't do this, meaning take care of you. Number one, I need another person present. It's not enough just to have you.
I need a daughter, a spouse, a best friend. It's got to be the same person. It can't be a series of volunteers who are pitching in to help with translation and or transportation. It's got to be the same person who's going to get involved in that person's prescribing and taking of medicines and filling of medicines. Number two, I don't see the patient unless the medicines are in the clinic in a bag and we're gonna count them off.
We're gonna go over them. We're gonna throw away the ones we're not taking. We're gonna change the ones we need to change. We're going to accentuate the ones that need to be taken correctly. Number three, the goal has got to be reduced medicines.
If the patient is taking less medicine, they'll believe that they're safer and they'll be motivated to actually take the medicine. You've got to work real hard at reducing medicine, which means number one, get rid of all the vitamins, it's a bunch of crap, it ain't really going to change the story, unless it's folic acid for methotrexate, it's all crap, forget it, get rid of it. Number you also need to work with other doctors on this, you probably need to call a primary care doctor. If your clinic is lucky enough to have a clinical pharmacologist around, get them involved. And again, another prob you know, there are other doctors who are contributing to this problem as well.
Number four, rheumatology is easy. If they have advanced RA and they're on advanced therapies, go IV. Stop screwing around with pills that you hope they may or may not be taking. In this case, the patient stopped the medicine months ago when the surgeon stopped the medicine because he thinks he knows what he's doing. He's getting his education from the television.
He doesn't know what he's doing and the patient's been off of a DMARD for three and a half months and guess what? She's worse. So go IV. Go monthly infusion. Go whatever it is.
You know, you can control it and you can be sure that she's getting it, he's getting it and go IV. Number five, as frustrating as this is, you probably need to see the patient more frequently. See them every month until you get this right. Let them know that you're really concerned. And that's my last point.
Show your concern, either your frustration, your worry, your sense of urgency. You've got to back it up by seeing the patient more frequently, getting more frequent labs. And then lastly, you need to tell them less is dangerous. Less is not safer, less is dangerous because taking less medicine means that they're going to get worse. And worse means more pain, more disability, more damage, more hospitalizations, and ultimately just really poor RA care that's got your name all over it.
You as the physician need to take control of this less is dangerous situation, which is rooted in noncompliance, polypharmacy, etcetera. Tune in tomorrow for another good case of QD clinic.
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