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Who's Responsible? The Patient or the Physician?

Posted Sep 07 2012 3:00am
This is isn't a typical post whereby I review the latest study or answer some question posted on www.avvo.com or www.healthtap.com .  Instead, I'm taking a moment to ventilate my frustration.

I saw a brand new patient the other day who'd been hospitalized for shortness of breath.  And why had he become short of breath?  Because he'd run out of his medications!  Apparently, this wasn't the first time he'd landed in the hospital with similar symptoms.

But when I met him for the first time, he readily admitted that he couldn't afford his medications.  Granted, he had the usual litany of chronic conditions that required 8 medications.  However, I noted that his sulfonylurea could cause hypoglycemic complications if he didn't eat regularly (which he didn't do) and his biguanide wasn't maximized. So in one fell swoop, I decreased his chance of passing out and saved him some money, about $4 per month.

It turns out that 7 out of his original 8 medications were generic and available for $4 per month.  However, it was the brand name anticoagulant that threw a wrench in the picture at $245 per month.  When informed by his pharmacy that his monthly total was close to $280, he had elected to stop all his medications, thus leading to his nth readmission.  Of course, upon this most recent discharge, he was sent home on the exact same regimen and admonished to take his medications as directed.

So I offered to trade his expensive but easy to take anticoagulant for an inexpensive alternative that required monitoring.  Guess what?  He didn't like that option either!  I warned him that by choosing neither, he risked suffering a stroke and losing his current level of independence & function.  And here I'd been rather proud of myself just a few moments prior for dropping his monthly total by close to $240.

Want to hear the really bad news?  I'm going to have to shoulder the blame when he has a stroke.  Worse, my taxes (and yours) are going to pay for his care & institutionalization.  And that's after his attorneys sue me for not making more of an effort to explain the consequences of his (in)action and encourage him to take his (in)expensive medications as directed (as my hospital colleagues have repeatedly done).

I guess that old saying is still true:  You can lead a horse to water but you can't make him drink.  PS  I've asked to have a social worker to step in & help him get his medications.  PPS  I've been letting this diatribe sit & stew for a while.  Ironically, a meta-analysis was published this month in the American Journal of Medicine suggesting that financial reinforcements increase medication adherence.  What has this world come to such that not is it not enough for a patient to get his/her medication for free but s/he has to be financially incentivized to take it as directed?  When did we abdicate personal responsibility?

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