Last week I began my 8-week long pediatric externship, beginning first with pediatric infectious disease (PID) for 2 weeks. I've had the pleasure of working with Dr. H and his resident all of last week.

Today he left me with some parting words:

When a doctor or a student says, "The patient won't take his/her meds," change "won't" into "can't" in your mind. Think, "The patient can't take his/her meds."

Dr. H was of course referring to drug adherence or compliance. In general drug adherence is surprisingly low, though there is also a lot of variability. There have been studies looking at how often and how timely prescriptions are filled, and studies looking at the difference between drug adherence for "acute" illnesses (e.g. infections) and for "chronic" illnesses (e.g. hypertension, diabetes, HIV). And there have been studies looking at dosing. Unsurprisingly, taking few medications and taking them only once daily is associated with better adherence. Increase the number of medications and/or increase the dosing to twice daily or even thrice daily, and adherence drops like a rock.

We in the health field need to be cognizant of the struggles patients endure. No one is perfect, and no one should ever be expected to maintain near-perfect drug adherence. We in the health field should not assume an accusatory and antagonistic tone with patients. Let's not assume the all-too-easy tone of voice, "I see you didn't take your meds."

There are a plethora of reasons why patients are unable to adhere to drug regimens. It's not simply that they don't want to; as Dr. H states the obvious, "No one wants to die." So what gives? If you have to take 3 HIV meds twice a day approximately 12 hours apart, and you knew that if you didn't, you're risking your life, why wouldn't one adhere to that strictly? One's life certainly does depend on it.

Consider this: Mondays through Thursdays are pretty standard for most working people. Thus medications are easier to time to daily schedules. But Fridays through the weekend are a different story. If one were to go out somewhere and forgot his/her meds, one would have to return home to take the meds. It's very difficult to revolve one's life around one's medication schedule.

Furthermore, patients may simply not be ready to take their meds and/or don't know why they're taking them. Both are critical issues that must be addressed over a long period of time. At diagnosis, patients may be so overwhelmed by the disease and the implications on being on medication indefinitely that their minds are in a state of shock and disbelief. Imagine you were just diagnosed with HIV, and the person giving you the diagnosis then launches into this long talk about the different meds you have to take, when to take them, how many times a day, the importance of taking it, the disease progression, etc - all in the span of an hour or so. And then for it all to sink in that this will be for the rest of your life. Yeah . . .

There is a model of health behavior called the "transtheoretical model." It begins with "precontemplation" and progresses to "contemplation," to "preparation," to "action," and then finally to "maintenance." With precontemplation, the patient isn't even thinking of medication. Then in contemplation, the patient begins to consider the possibility of medication. With preparation, the patient readies him/herself to take medication. Action is where the patient is actively trying to remember and take the medication; and with maintenance, adherence becomes more or less routine.

It's a long process that requires a lot of counseling from the health provider. It may take months to years to progress from precontemplation to action. I believe I read somewhere that many patients don't even make it to maintenance, because it's so difficult.

So we should ask, "Why can't this patient take his/her meds?" instead of "Why won't this patient take his/her meds?" A patient may be in the precontemplation phase, a patient may be unable to afford his/her meds, a patient may not understand why he/she is taking the meds, a patient may react to an adverse side-effect, and there may be psychosocial factors at play. It is our job, our duty, to help patients work through such issues so "can't" changes to "can."

As with all things, easier said than done.

Today, I'm going to write about something that came up on my infectious diseases rotation this month.

The Infectious Diseases Society of America (IDSA) just published new guidelines for treating intra-abdominal infections. They came out at the beginning January. Apparently, there's been some debate in the ID world over whether these guidelines have too much industry influence. Several of the authors of the guidelines have connections with drug companies, and several of those drug companies happen to have recently come out with some very broad-spectrum, very expensive new antibiotics. These new antibiotics are part of the guidelines, and they are listed as options to treat intra-abdominal infections while some older, generic antibiotics were excluded because of concerns about resistance.

So there is debate and controversy over these new guidelines. The issue becomes a bit more complicated when you look at it from the hospital's perspective. We try to practice evidence-based medicine, as much as possible, and guidelines from major organizations like the IDSA are important tools in doing that, since they are essentially literature reviews. At a hospital like UM, the hospital's guidelines and policies might be based on the IDSA guidelines.

The question then becomes, if you are responsible for creating your hospital's antibiotic policies, what do you do with these guidelines? If you think there's too much industry bias, do you still base hospital policy on them? Do you ignore them? Do you just take the parts you think are unbiased and ignore the rest? And if you have to go through and figure out which parts are biased and which are not, how is that different than creating your own guidelines and ignoring the IDSA ones?

And if you have a patient with an intra-abdominal infection, and they die, and the patient's family thinks you should have used one of these newer, broad-spectrum antibiotics, then what? The patient's family/lawyers can point to the guidelines and say, look, here are national guidelines that say you could have used this drug. Why didn't you? Then you are left defending the tenuous position that national guidelines don't constitute standard of care.

And yet, if you really think that using the newer antibiotics will unnecessarily increase resistance and cost, you are ethically (and financially) obligated to restrict them.

It's a balance that each hospital has to find on its own. I think a big part of the answer is to look at resistance levels at your hospital, and to decide whether the older antibiotics will work in most cases or not. Cost, as always, is important as well.

In the end, guidelines are just that - guidelines. They shouldn't dictate policy on their own; there should be a significant amount of thought put into the value of the guidelines and of policy changes at a given hospital. That's why there are infectious disease specialty physicians and pharmacists.

I've had the pleasure of being paired with a pediatrician in private practice, Dr. D, as a part of the M1 Mentorship Program at my med school. He's already told me many things that one simply doesn't learn in the classroom - some of them are common sense but need to be said anyway. There are things he told me that I would do well to remember. Simple things that can make all the difference in the world:

- show proper respect to patients and colleagues (including doctors, nurses, PAs, etc)

- check up on your patients and call them back in a timely manner

- be conscientious and hard-working

- be good at what you do

If one meets the above criteria, word spreads and patients will come. It actually somewhat amazes me when he calls patients* 3-4 days after a visit just to check up on them, or make a call to let a patient know about the results of a lab test. Most patients don't expect him, as a doctor, to be taking the time to call them back.

But in the spirit of the holiday season, I will comment on the compassion that great physicians should ideally possess.

During my first visit to shadow Dr. D, he told me of instances where some of his patients lost their health insurance or were otherwise unable to pay. Yet he saw them and treated them anyway as their doctor by accepting what they could afford or even without repayment. He just reassured them to pay him next time when they get health insurance again. Most of the time patients respond in good conscience but a handful have "abused" his altruism. Often at the harping of colleagues and with great reluctance does Dr. D let these patients go. Alas, private practice medicine is ultimately a business and needs to be in the black, not in the red.

During my latest visit to shadow Dr. D, a patient came in with his mother. Dr. D instantly noticed that the mother didn't seem to be well either and inquired why. It seems the mother has had a rather severe headache for the past week, severe enough to be almost debilitating. So after treating the patient, Dr. D went to lengths to find a number for a neurologist at my med school's hospital. After spending almost half an hour (with some help from one of his nurses), he was able to locate the secretary for a neurologist and helped the mother schedule a visit for that same week.

This instance, that I had so fortuitously observed, demonstrated Dr. D's compassion as a physician. That he was willing to go to lengths at all to help out a patient outside his "jurisdiction" within medicine - this is a hallmark of a great physician. It had me in a momentary awe that after decades of practicing medicine he was still able to let his altruism and compassion guide his actions, rather than becoming jaded and burnt out as reported on so often nowadays in the news.

Perhaps this was part of his secret that has "second generation" parents (formerly kids that he once treated as patients) bring their own kids to see him. He even has some "third generation" families, where he used to treat not only the parents, but the grandparents as well. o_O

Happy holidays everyone and have a happy New Year! :-)

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* Note: For the purpose of this post, when I say "patients" it almost always means the parents of the patients, by the very nature of a pediatric population.

Hi again!

First, I have to whine that I constantly feel that I lack knowledge. And it's absolutely true. So if you know the answer to something I don't or disagree with something I say, don't hesitate to mention it (politely, if you can :)

It'd be great to learn more and fill the holes in my understanding.

Okay. That said...

I'll admit, at the time when I entered the School of Public Health as a first-year Masters student, I had no idea that I would be taking a total of 4 biostatistics classes within 3 semesters. All I had was a vague image that epidemiology was the process of taking data (numbers!) and translating that into information that the general public can understand.

In truth, epidemiologists seem to me to be enslaved by numbers. We have to read papers dating back to the 1980's about the correct way to interpret models and numbers. Well, it is important that we understand our data properly, and don't demand more answers out of them than they are equipped to offer. So in this sense, it's good to think a lot about the figures.

Until we get to the point where the concern is too much in the numbers themselves.

Here, I'll illustrate two examples that I find interesting. I know there are many more out there!

Cutoff points for p values (if you don't know what I'm talking about, feel free to comment as such) are hilariously arbitrary, in my opinion.

Cutoff values in clinical use--such as BMI cutoffs for who is 'obese' versus 'morbidly obese' or Hemoglobin counts > 13.5 being 'eligible to donate whole blood'--seem to be more thoroughly thought out and disputed in most cases...?

This is something that came up in my Global Health class last week. Those periodical ___ (fill in with the name of a health initiative of choice) Conferences like to set goals for how much work they want to get done before their next meeting. The funny thing is, some of those organizations get too caught up in the numbers and suggest crazy things to achieve them.

I think one example (I apologize for not remembering the exact organization, notes are somewhere else right now...UN?) was about HIV/AIDS goals.

The idea was that the participating countries wanted to get their AIDS prevalence lowered to a certain number. Sound normal enough?

But considering that AIDS is a life-long condition that can't go away, its prevalence in a population will inevitably keep increasing as long as the incidence of new cases never hits zero.

So someone suggested that they stop providing antiretroviral therapy (a.k.a. let the cases die off), otherwise the goals won't be reached. Plus that would be better economics.

I'd like to believe that our job as health care providers is to help all people live, and let them enjoy good quality of life while they're at it, rather than strive blindly for numeric goals set by higher-level policy......but that's just me.