Taking medication and why Jerry Kill won’t

Sunday, November 1, 2015

Jerry Kill walked away from head coach at the University of Minnesota football team because he could no longer balance the demands of the job with the treatments required for controlling his seizures. The side effects of his medications made it difficult for him to function. He changed the way he took his pills, even against medical advice, but still was unable to find the balance that he needed in his life and football had to go.

The patient doctor relationship is supposed to be a partnership, but too often it fails. With face-to-face time decreasing, a doctor’s visit has become more about filling out forms and writing prescriptions than about actually visiting with the patient, talking together and learning about the patient’s wants and needs. For that reason, a big hole has developed in medical care, which costs hundreds of thousands of lives every year.

Compliance describes a patient passively following their doctor’s advice to manage a chromic health condition. Adherence is the term used by the World Health, where doctors and patients team up to help the patient actively engage in maintaining their health. Pick a term! Patients tend not to take their medications as prescribed and the price can be deadly. Up to 40% of nursing home admissions are a result of poor compliance and 125,000 deaths per year are attributed to people not taking their medications as directed.

Surveys repeatedly reveal that up to 75% of people who are prescribed medication for high blood pressure or high cholesterol, admit to not always taking their pills as directed. People have a hard time taking drugs when it might take decades to see the positive results of not having a heart attack or stroke from high blood pressure, or not going blind and needing dialysis from diabetes.

There are plenty of reasons that patients give when asked about their compliance/adherence. Too often though, the doctor doesn’t know, because the question wasn’t asked or because the patient doesn’t tell. Either way, the opportunity to impact the health of the patient is lost. Think about a few barriers:

  • The prescription’s price or its co-pay is too expensive. Often there are alternative options. Most doctors don’t know the price of the prescriptions they write, but many drugs cost less than $10 for a month’s supply. However, that may not be the solution. Studies show that compliance increases only by about 5% when patients are given their medications for free.
  • The side effects interfere with life. Diuretics, or water pills, are one of the mainstays of high blood pressure (hypertension) treatment and they make people need to go to the bathroom. It’s inconvenient and most people take the pills in the morning because who wants to get up in the middle of the night? Some medications cause nausea and indigestion; some headaches and others weight gain. Blood thinners make you bruise, have nosebleeds or worse. Nothing comes without a potential cost, but again, there are potential alternatives and the goal of a medication is to maximize benefit and minimize side effect.
  • The directions are too confusing. Drugs dare not one-size fits all. Some need to be taken with food; some on an empty stomach. One a day, twice a day, more often? There may need to be routine blood tests to check the medications level in the body. But there are people out there to help. If it’s too inconvenient to talk to the doctor or the nurse, a local pharmacist may be a useful resource. But most providers presume that if questions aren’t asked, that the patient understands what’s going on. Often the patient does not but also does not feel comfortable asking.

There are myriad other obstacles that get in the way of the chain of events that should happen. The prescription is written: the patient gets the medications; the patient takes it as directed. But perhaps the most important barrier is that the patient questions their doctor’s advice or does not believe that the medications will work.

Studies show that patients rely on their doctor’s advice only a little more than half the time. Instead they seek to validate that advice with friends and family, or from the internet (If it’s on the internet, it must be true). Patients want more knowledge but they want it in a form that they can understand. Almost half the time, they do not understand the information provided by their doctor about their illness or medication…and the average time spent discussing that medication? 49 seconds.

It should come as no surprise that Jerry Kill decided to adjust his seizure medication regimen. He could not tolerate the side effects; it affected his family life and ultimately his ability to do the job that he loved. His story is not an isolated one; it is just the public face of what happens every day in medicine. In our attempts to streamline the practice of medicine, we have forgotten that the key to success in providing care is having the doctor and patient sit and visit, to talk and learn from each other. But who has time for that.

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shoulders and elbows

Tuesday, January 20, 2015

Medical advice can only work in two given situations: if the patient chooses to seek that care and if the patient chooses to follow that given advice. It comes as no surprise that those two situations were ignored by two Seahawks in their playoff game. Earl Thomas dislocates his shoulder, reluctantly runs to the locker room and is back on the field minutes later. Richard Sherman sprains his elbow and refuses to come near a trainer or doctor, but instead, stays on the field grimacing in pain. NFL players and other driven athletes tend to ignore damage to their body because the will to play and win is stronger than the pain that they experience. But a warning should appear on the video screen: “Trained professionals. Do not try this at home.”

The shoulders is the most common dislocated joint of the body. The mechanism of injury can be a fall on an outstretched arm or from a blow that occurs when the arm is abducted (moved away from the body) and externally rotated it (forearm turned palm side up). The shoulder is a ball and socket joint and when dislocated, the humeral head or the ball of the joint, is ripped out of the socket, the glenoid fossa. The structures that hold the shoulder together are torn, including the labrum, the joint capsule, the cartilage and the ligaments of the rotator cuff. If a player is lucky, the shoulder can be popped back into place immediately on the field before the surrounding muscles start to spasm. That can make it tough to provide the traction needed to reduce the dislocation and return the bones to their normal position. For many patients, mild sedation may be needed to help with reduction, often because there is a significant delay getting to medical care.

 

shouledr norm

Normal

shoulder dislo

Dislocated

Once the shoulder is reduced, the goal is to allow the shoulder to heal and remain stable, meaning that it will not dislocate again. There is a balance between that healing and allowing range of motion to occur. It takes weeks for all the damaged tissue, from muscles and ligament to joint capsules to become strong and stable. If one waited until that happened to move the shoulder, it would stiffen and require weeks of rehab to help return range of motion. It is safe to say that Mr. Thomas did not heal in the few minutes that he was in the locker. Instead, he was fitted with a brace that prevented the shoulder from abducting or rotating, the movements that likely occur with reaching for a football or stretching to make a tackle. It is likely that this was not the first treatment option for the medical staff, but when a patient refuses to consider option one, negotiations likely occur to try to minimize future risk and damage. In general, a shoulder dislocation will require six weeks of treatment before return to play.

It is easier to speculate about the Thomas shoulder dislocation than Mr. Sherman’s elbow sprain. Practically, there are only two types of shoulder dislocation, anterior and posterior, and posterior is rare. The elbow is a much more complicated joint. Three bones come together, the humerus, the radius and the ulna, to allow both flexion and extension (bending and straightening) as well as supination and pronation, turning the palm upwards or toward the ground. The medical collateral and the lateral ligaments hold the elbow stable but they have different bundles that protect the elbow depending upon the position of each bone within the joint and the movement that is trying to be accomplished. As well, the biceps and triceps muscles of the upper arm and the muscles of the forearm also work to promote joint stability. Sprains of the elbow, like any other ligament injury are graded by severity of the damage. In grade 1 sprains, the ligament fibers are stretched, in grade 2, they are partially torn and grade 3 sprains denote a completely torn ligament but even a grade 1 elbow ligament sprain can allow the elbow joint to dislocate completely or partially dislocate (subluxate). Injuries to the area can cause bleeding within the elbow joint and a little blood goes a long way to cause significant pain, even with small movements. Mr. Sherman’s cradling his arm and wincing is a testament to the amount of pain a pro athlete can endure. And while his teammate saw visited the trainer and negotiated his care, Sherman refused to come off the field and when he did, tried his best to avoid being evaluated. Treatment of this injury depends upon what is damaged but the time to recovery is measured in weeks.

elbowligament

 

Playing through injury is the stuff legends are made of, but should not be considered the stuff of role model. The potential for long term damage is real when joints are damaged and not allowed to properly heal. There is a real risk that other injuries might occur because the player cannot react instinctively while still protecting the injured body part, but the invincibility of youth and the athlete often take precedence over common sense.

In the real world, patient compliance in following advice and instruction is somewhat lacking. Moderating diets, alcohol use and smoking are the big three but others follow close behind. Studies show that patients who take blood thinners because of blood clots or atrial fibrillation, often missed taking their medications 30% of the time. Patients do not complete a course of antibiotics, stopping when they begin to feel better. Post op physical therapy sessions get missed when they are not a patient’s priority. At the end of the day, the doctor’s advice has to be practical and apply to that specific patient’s situation and hopefully the patient will buy into that advice…hopefully, because the doc and the patient, just like in football, require teamwork to make the miracle of modern medicine happen.

 

Figure attribution: American academy of Orthopedic Surgery

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