The importance of being curious

June 7, 2002

The author had grown exasperated with her delightful but severely noncompliant patient. Then she discovered the key to motivating this charming challenge.

 

The importance of being curious

The author had grown exasperated with her delightful but severely noncompliant patient. Then she discovered the key to motivating this charming challenge.

By Ann E. Dominguez, MD
Family Physician/Chicago

I met Betty when she had her first heart attack. She had just turned 60, and I was the intern who admitted her. I figured out quickly that Betty was going to be a challenge. She wore a T-shirt that said "Jesus or Bust" over her gown and had twice kicked the cardiologist out of her room because she didn't want to hear what he had to say about the severity of her heart disease. When I told her she might need dialysis after her angiogram, she retorted, "I won't have none o' that. That dialysis done killed my mamma."

Thus began our three-year relationship—one that survived the angiogram, dialysis, multiple graft surgeries, and much noncompliance.

Betty had uncontrolled hypertension, diabetes, renal failure, and a history of cancer. Before she left the hospital, she and I had a long talk about how she was to check her blood sugar four times a day, take her insulin, and begin cardiac rehabilitation. But one week later, she returned with no record of her blood sugars, no prescriptions filled, and a fasting blood sugar of 345.

Betty's downward course was predictable: creatinine rising, blood sugars out of control, not a single day spent at rehab, and several admissions for uremic symptoms. The only good news was a 100-point drop in her LDL.

After one of her many visits to my office—her attendance there was 100 percent—I asked my preceptor what to do about Betty's noncompliance. "What does Betty want?" she asked me. I knew she wanted to see her grandson graduate from college in two years. So I tried using that on her.

"Betty, you need to stay healthy if you hope to attend his graduation." But at her next visit, her hemoglobin A1c was over 12 and her potassium was 6.5. "Must ha' been those ribs and the sweet tea," she told me candidly. "They're not on my diet."

"If you can remember what's on the diet, why don't you follow it?" I asked, trying to hide my exasperation. Clearly, attending the graduation wasn't motivation enough for Betty to control her diabetes. Let me try the mother angle, I thought.

"Tell me more about your mother," I said. "How long was she on dialysis?" With much sadness, Betty related how sick her mother felt from the renal failure and the long hours she spent on dialysis. Betty's mother, a diabetic, also had had both feet amputated, which Betty was terrified of experiencing herself. So I said, "Betty, you're looking at your own amputations and another heart attack if you don't get your diabetes under control."

Three months and six visits later, there was no change in behavior for either of us. I was still pulling out my hair, and Betty was still ignoring me completely. I told her not to come back for a month, since I didn't know what I could do for her. Puzzled, she told me to take care when she left.

A few days later I admitted her for pneumonia. While in the hospital, she told me about the three grandchildren she was raising, and I talked about my garden. The problem, I thought, is that I simply like Betty too much. She hadn't finished high school, but she had a great sense of humor and liked to tease me. But our laughing together had to stop; it was time to get tough.

Sounding more resolute than I felt, I told her, "If you can't follow my directions, I don't see much point in you coming back. Maybe it's time you found a different doctor."

"But I like you for my doctor," she said.

"Betty, you don't do anything I say. You don't let me help you." There, I've said it. Now what if she actually does find another doctor, I thought with dismay.

"I'll try," she said sadly. "For you."

For weeks it bothered me that Betty would try to be compliant for me. What kind of doctor was I if my patients were only trying to make me happy? When I saw Betty's name on my schedule again, I felt my stomach knot. My palm was moist on the doorknob when I went in the exam room.

"There you are!" she said, clearly pleased to see me.

"How are you, Betty?"

"Fine, fine," she said.

I looked at the chart: her blood sugar was 297. At least it's under 300, I thought, defeated. I loved Betty, and, as incompetent as I felt, I was glad to see her. "What can I do for you, Betty?"

"You mean, what do I want?" she asked. I nodded, recalling my preceptor. "Oh, a million dollars, a vacation to Hawaii . . . and to get off those dang shots."

I laughed. "I wish I had a million dollars, too." Suddenly her words sunk in. "Did you say you wanted to get off the shots?"

"Yeah. I don't mind th' pills, even if there's so many of 'em. But I can't stand the shots. I'd do anything to get off them shots." Betty was giving herself insulin shots only a couple times a week instead of daily as she was supposed to. And when she did take the shots, she'd go off her diet to reward herself.

I felt like such a fool. Although she loved her grandchildren, attending the graduation didn't motivate her. She had a paralyzing fear of amputation, but even that didn't motivate her. Insulin was the key to motivating Betty, and I had missed it.

Betty left the office with a new prescription and a promise that we would decrease her insulin in four days when she called in with her home blood sugars. She called first thing Tuesday morning, and I cut back her insulin. A week later, we eliminated one of the shots, and in a month, she was off insulin completely.

I wish I could say her hemoglobin A1c is seven, but I can live with 8.5 since Betty is checking her sugars twice a day, taking her blood pressure twice a week, and walking at the mall every day. She has even given up ribs and is using an artificial sweetener in her tea, which she keeps track of as part of her fluid restriction. She and I both know that she will eventually need insulin again, but for now, she is making plans for her grandson's graduation.

When I finished my residency, Betty was one of the patients I was most sad to leave. "You take care, and don't ever forget what's really important," she said as we said goodbye.

Betty meant faith and love of course. But she also taught me to ask my patients what they really want—instead of assuming I know the answer.

 

Ann Dominguez. The importance of being curious. Medical Economics 2002;11:65.