The Patient vs The Illness

by Danielle Ofri
The Los Angeles Times                                                                  200/110. The blood pressure reading was printed at the top of Bernice Ruger’s chart in blaring red ink, with three exclamation points added for emphasis. This was my first time meeting Mrs. Ruger (not her real name), but I could tell that we’d be spending a lot of time talking about hypertension, and how it causes strokes and heart attacks, and the urgency of treating such dangerously high numbers. Her chart listed at least three blood pressure pills, which—from the numbers—I assumed she wasn’t taking, so I steeled myself for a talk about medication compliance.

Ms. Ruger strode into my room, carrying a cane that didn’t touch the ground once. She sat in the chair and leaned in so close to me that I could see the crackles in her pink lipstick where it fell outside the lines of her lips. The red plastic frames of her glasses dominated vast swathes of her face, leaving little that wasn’t refracted by the powerful corrective lenses.  Her teased blonde hair and the bottled smell of her make-up seemed to expand in the room, defying the petite, grandmotherly body that exuded them.

“I can’t take any of your pills,” she rasped at me, before I could even introduce myself, her voice mottled by decades of cigarettes. “They make me sick. Sick!”

I eyed Ms. Ruger, trying to figure out the best approach to her forceful complaint, but she didn’t give me a chance to talk.

“That fosinopril? It made me sick! That water pill? It made me sick! That amlodipine? Sick! They all made me sick! I can’t take a single one of them.” Mrs. Ruger listed six more medications that made her sick, then she sat back in her chair and clamped her hands over her cane.

Medication side effects are certainly common, but patients usually have a specific reaction to a particular pill. It seemed to be stretching medical plausibility to have reactions to nine different medications, all with unique biological and chemical properties.

I asked her to tell me what happened when she took her medicines, trying not to let my skepticism show.

Mrs. Ruger rattled off a diverse list of symptoms—muscle spasms, nausea, headache, skin irritation, blurry vision—none of which suggested a uniform biological explanation.

I nodded slowly, asking her again if she was sure that it was the pills that were making her sick.

“Of course,” she said, indignantly. “As soon as I start taking them, I get sick. Sick! When I stop, I feel better.” She pursed her lips, drawing them up into a lasso of spackled pink.

Every single pill made her sick?”

She seemed surprised that I might have been surprised. “I have a very sensitive constitution,” she added, almost defensively.

My gut told me that this didn’t make sense.  I asked her if there was any medicine she was able to tolerate.

Mrs. Ruger brightened immediately and said that she had no trouble with the prednisone pill she took every day for her asthma.

Prednisone? Of all the pills in her regimen, of all the pills available on the market, of all the pills in the world, prednisone has some of the worst, and most commonly occurring, side effects. A steroid, prednisone causes diabetes and osteoporosis, it makes people loopy and sometimes psychotic, it leads to swollen faces and buffalo-hump shoulders, it causes adrenal insufficiency and electrolyte imbalances, it depresses the immune system allowing infections to occur more frequently and more seriously. The list is endless, and is drilled into the brain of every physician.

The irony of it startled me: The blood pressure pills that are dispensed so freely, and generally with so few ramifications, Mrs. Ruger could not tolerate. But the one medicine that is so gingerly prescribed, and with such reluctance and concern, Mrs. Ruger seemed to have no problem with.

As I pondered this paradox, Mrs. Ruger suddenly softened her tone. “I’m sorry, doctor,” she said. “I know I am a bad patient.”

I was puzzled about what she meant, and asked her to explain.

Mrs. Ruger’s lips began to quiver, and a tear crept out from the corner of one eye. “I’m really a terrible patient. I can’t take any of the medicines you doctors give me, and I know you are angry with me.”

The abrupt shift from voluble annoyance to tearful contrition was unsettling. Before I knew it, she was crying outright, saying how sorry she was that she couldn’t follow her “doctors’ orders.”  How she was going to die from heart attack or stroke because she couldn’t take her blood pressure pills.

I leaned forward to take Mrs. Ruger’s hand, wondering what I could say to comfort her. Sharing my honest thoughts, that I thought her medication intolerance wasn’t “real” was unlikely to be helpful. Telling her that it seemed odd to be able to take something as problematic as prednisone, but not eight other, far more benign medications, would not be constructive.  And of course I did think she ran a significant risk of a heart attack or stroke if she lived life with a blood pressure of 200/110.

As I looked at her, eye make-up running, dripping past the edges of her red glasses, it dawned on me that we were focusing on Mrs. Ruger’s hypertension, and not Mrs. Ruger. And that these were not at all the same thing.

So often in medicine we speak in terms that make it sound like the patient is responsible for the clinical outcomes. If a patient’s cancer returns, we often say the patient has “failed” chemotherapy, as though she or he were taking a standardized test and simply didn’t study hard enough. But it is really the chemotherapy that has failed the patient.

While I still didn’t quite believe that Mrs. Ruger truly couldn’t take every single pill, maybe it was just that we hadn’t come up with a medical regimen that agreed with her.

I told Mrs. Ruger that her blood pressure was a separate thing from her as a person. Just because her pressure was 200/110 and the pills made her sick, didn’t make her a bad person or, frankly, any kind of person. If we happened to find the right pills for her and make those numbers come down, she’d wouldn’t suddenly be a good person; she’d still be Bernice Ruger, just with better numbers on her blood pressure readings.

Mrs. Ruger sniffed and started rubbing the handle of her cane like talisman.  She wiped her nose with a tissue. “I…I like that,” she said. And then she repeated, like a mantra: “I am not my blood pressure.”

I probed gently, wondering if there were any stresses at home?

Mrs. Ruger was quiet for a long time. And then she started talking about how she was struggling to make ends meet. That since her Irving had died, she was trying to make do with a tiny Social Security check, and that even with Medicare, her medical bills came to almost half of her monthly check.

We talked for a little while longer, then agreed to focus on three distinct issues: her financial concerns, the stress she was experiencing, and lastly, her blood pressure. We made an appointment for her to talk with our social worker about her Medicare. I tentatively raised the issue of antidepressant treatment and she surprised me by saying that she’d taken a pill for depression a few years ago, and didn’t have any problem with it. She’d actually felt good while taking it.

And then we examined the list of blood pressure pills, selecting the least problematic of all the ones she had tried. She agreed to try it again, at a low dose, taking it only every other day. I warned her not to expect perfection with it, that maybe she would have to tolerate some side effects.

 I was surprised at how easily a difficult patient encounter shifted into a relatively satisfactory one. It was a simple lesson that Mrs. Ruger had reminded me of, but one that I should probably keep posted above my desk: the patient is not the same as the illness.    (from The Los Angeles Times  )