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READERS RESPOND
A 63-Year-Old Man with Multiple Cardiovascular Risk Factors and Poor Adherence to Treatment Plans
Thomas Delbanco, MD
JAMA. 2007;298:(doi:10.1001/jama.298.16.jrr70000).
The patient described and interviewed below faces a crossroads in medical care. Consider the patient's history and the patient's perspective, expressed in his/her own words. Then review the questions posed and imagine you are caring for this patient. How would you approach this crossroads? Using evidence from the literature and your own experience, respond by using the link to the right. Responses will be selected for posting online based on their timeliness and quality including use of the available evidence, weighing the issues, and addressing the patient's concerns. The discussion of this Clinical Crossroads case, authored by Dr Thomas Bodenheimer, will be published in the November 7, 2007, issue of JAMA; responses must be submitted by October 31, 2007, to be considered for online posting.
CASE PRESENTATION
Mr P is a 63-year-old retired businessman who has been obese for much of his life, has had hypertension and hyperlipidemia for at least 20 years, and was diagnosed with diabetes about 10 years ago. He is happily married, with several children and grandchildren. He has commercial health insurance and has sought care at hospital-based primary care practices in Boston.
He and his family note that he has been poorly adherent to various suggested medical regimens for more than 20 years. In 1988, a stroke felt to be hypertensive in origin, left him without deficits. In 1996, he was hospitalized for cellulitis of his foot. In 1998, he came to the hospital with crescendo angina, leading to coronary artery bypass graft surgery. He has not had chest pain since that time. The same year, Mr P had a pulmonary embolism, recovering uneventfully. He has had intermittent back pain. He currently has disabling hip pain, associated with degenerative joint disease, and plans hip replacement surgery in the next few weeks. He has had severe erectile dysfunction for about 8 years. Changes in his medications and a trial of sildenafil did not improve sexual function.
Mr P was formerly a heavy user of tobacco, but stopped in 1982. He now smokes an occasional cigar. He drinks little alcohol, maximum 2 beers daily. Over the years he has had little exercise but, as he notes below, had been more active physically in the past 2 years. There is a strong family history of obesity, arteriosclerotic cardiovascular disease, and hypertension. He has been prescribed many medications, including allopurinol, aspirin, atenolol, atorvastatin, amlodipine, furosemide, glyburide, insulin, ibuprofen, lisinopril, and metformin.
On recent examination his blood pressure was 162/94 supine at rest, with a large cuff. His pulse was 60 and regular; he was not tachypneic. With a height of 70 inches, he weighed 267 pounds; over the past 10 years his weight has varied from 245 to 280 pounds. He has mild, non-proliferative diabetic retinopathy but not hypertensive retinopathy.
No cardiac abnormalities or signs of congestive heart failure were present. The lungs were clear, and examination of the abdomen revealed only abdominal obesity. Ankles demonstrated 2-plus pitting edema; peripheral pulses were full. He had hip tenderness and an antalgic gait while using a cane. Neurologic examination was normal with no evidence of residual deficit following his stroke.
In recent laboratory evaluations, his glucose control has been good with a HbA1C level of 5.7%. Creatinine and BUN levels were normal but he did have microalbuminuria and frequent glycosuria. His calculated low density lipoprotein (LDL) level was 46 mg/dl and his uric acid was 6.4 mg/dl. Thyroid function was normal, as were liver function tests, serum calcium levels, and complete blood count.
MR P: HIS VIEW
Most doctors, they make 5 appointments for one o'clock. You can't see 5 people, so you are sitting and waiting and waiting all the time. And that bugs me. And I know there's a lot of people that are always late. I'm just the opposite. You don't mind waiting a few minutes, but when it is getting into the hour waiting for doctors, my blood pressure goes up. So then, when he takes it, it is sky high. And I just blame it on the doctor. But I guess that is just the nature of the beast, being a doctor.
Well, it's hard for me to do the right thing. And I try the best I can. My favorite thing to do is eat. I don't drink. I don't smoke. But I do eat. And it seems like I'm going to a banquet 5 nights a week. That is what it feels like. And I was taught from my family that when you've got 13 mouths to feed, you eat everything on your plate. And that's wrong now. I got to push the plate back.
I started the gym because my doctor told me I had to lose weight. And the gym turned out to be a good thing. I met people there, and it became an everyday habit, a good habit. I went for a whole year. I was down 60 pounds, and the pills were going. And then, in January, a year ago, my hip started bothering me. And I couldn't do the exercise. I couldn't walk. I couldn't go to the gym. And if you don't go to the gym, you start eating more and not losing the weight. And then I was just back to where I was. So I hope after the operation I'm having that I will be back to the gym. That was a big deal, the gym.
MRS P: HER VIEW
He's had many doctors throughout our married life. I think that doctors just need, for one thing, to look at the patients, look them in the eye when they talk to them. A lot of times doctors are so busy, and I understand that they are. You wait sometimes for 45 minutes, and you are in the office for 10 minutes. You like them to look at you and take a moment to say, "Is everything okay with you?"
DR Z: HIS VIEW
He usually comes to see me alone, and we have a few minutes together. And it's pretty hard to get him to really talk, particularly since I'm busy trying to figure out what's been going on since I last saw him. He misses appointments once in a while. I'm never quite convinced he is taking his medicine, although now that his wife has gotten more involved in his care, I'm more confident about that. And I really don't know how much he understands about his illness. His responses to me are 1 sentence, or just 1 syllable. And I'm never quite sure what's going on in his head.
I had been saying it for a long time, "You've got to exercise. You've got to eat less. You've got to do this. You've got to do that." I went through the nutrition business and the behavioral modification business, the usual patter song of an internist, and it never really took. And then suddenly he began going to the gym. And his weight melted away. His blood pressure came down. His glycemic control was better. His lipid control was better, and I became a convert. It is very rare that we see these people do that.
He hates waiting for me. He's figured out to come early in the morning, because that is the first appointment. But he doesn't really take me on about it. I just kind of see it in his face. I apologize and he kind of says, "It's fine." And I hear the "It's fine," and I know it is really not fine.
He is not a patient that pushes back and says, "Why should I do this?" or "Do I have to do this?" When he is pushing back, I think he does it without talking to me. It's kind of a quiet resistance, and he's probably saying, "I think my doc is crazy to have me swallow all these things. And I'm not sure I need them. I feel okay." But in the end, I think he takes quite a lot of the stuff I throw at him and probably gets sick from some of it, periodically. Right now his blood pressure is up, and I'm sure it's because he is taking too much NSAID. He just jacked that way up when he was away from me, couldn't talk to me, or felt he shouldn't talk to me.
It's awful hard to juggle a lot of medicines. It's maybe harder to juggle a lot, rather than just a few, because you have to develop a system. His wife is clearly the system by now. I don't think he has a real clue about what numbers he is carrying medically in the results column, but he has a sense of when things are awry and when things are okay. If I asked him to list his medicines, he would turn to his wife for help.
For a while he would see a nurse on our team, and that helped. But it never really took. He wanted to see the doctor. That was the way I think he was socialized, and that was the way he wants to behave. I never could make team care work very well. But we will see what happens in the future.
AT THE CROSSROADS: QUESTIONS FOR READERS
Has Mr P's care followed principles of "evidence-based" medicine? How do such principles relate to his course? If patients are not benefiting sufficiently from such care, who is responsible? How can primary care help patients incorporate evidence-based medicine into their lives? How can primary care practices improve the care of patients with cardiovascular risk factors? How can we help Mr P do better?
AUTHOR INFORMATION
We thank the patient, his wife, and his physician for sharing their stories.
Author Affiliation: Dr Delbanco is Richard and Florence Koplow - James Tullis Professor of General Medicine and Primary Care, Harvard Medical School, Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Mass.
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RAPID RESPONSES TO THIS ARTICLE
Helping Mr. P
Michael Pignone
JAMA Online, 6 Nov 2007.
TEXT
The "polypill" for "polyproblems"!
Elsayed Z. Soliman
JAMA Online, 6 Nov 2007.
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Reader’s Response to A 63-Year-Old Man with Multiple Cardiovascular Risk Factors and Poor Adherence
David M Paton
JAMA Online, 6 Nov 2007.
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