By Lim Chee Kong
When you say you agree to a thing in principle you mean that you have not the slightest intention of carrying it out in practice.
——Otto von Bismarck, German Chancellor
Your Time, My Time
How much time do I have with you, doctor? The fifty-year-old woman, seeing me for the first time, shouted across the table in my consultation room. I caught myself and replied that she could have as much time as she needed for her condition.
She had long-standing poorly controlled diabetes and was also seeing a psychiatrist for co-dependent personality disorder. She came from a single-parent family with two younger siblings, and she was not on speaking terms with her family. She wasn’t taking her diabetic medications as prescribed because she didn’t see the need to do so.
From her body language, I could see that the patient was taken aback by my response. Fortunately, the rest of the consultation, and our subsequent relationship, went more smoothly than expected. My offer of a listening ear somehow provided her with the impetus towards medication adherence. Her glycosylated haemoglobin went from 11.5 to 7.9 percent over the next year and a half.
Sometimes we are blessed with unexpected partnerships.
Commentary
Gaining insight to why our patients do not do what we tell them to do is the first step toward helping them. Have they been properly educated about the disease? Do they understand what is at stake? Is there a learning barrier?
At the same time, more information may not translate into improved compliance. Studies have shown no change in compliance irrespective of knowledge levels, including understanding of the consequences of non-compliance.
Neither has compliance been definitively linked to severity of condition, despite extensive research. As with much of life, patients’ reasons for not doing something are multi-faceted. The reality of living with an illness, the burden of the treatment regimen, and the emotional distress and stigmatisation, are among many factors that strongly affect what our patients do, irrespective of disease severity.
The drawing shows a woman with poorly controlled diabetes, living life on her own terms, discarding her medications and enjoying all the goodies she loves.
There are many reasons for her defiance. She may be in denial despite her non-healing ulcer. She may be apathetic from previous bad experiences. Lack of trust in her doctor, a complicated drug regimen, unpleasant side-effects, or even cost of her medicine may play a role. Or she may have decided that life on her own terms, now, is simply what she wants.
Lim Chee Kong is a senior consultant family physician in a polyclinic.
The commentary and vignette were reproduced with permission from the book “Being Human, Stories from Family Medicine” edited by Cheong Pak Yean and Ong Chooi Peng and published in 2021 by the College of Family Physicians Singapore.
Pictures of illness experiences were drawn by NUS medical students in workshops conducted from 2012-2017 by A/Prof Cheong Pak Yean. Senior family physicians subsequently shared vignettes and commentaries based on the pictures.
