Thursday, April 11, 2013

Teachable Moments III: Harm Reduction

I happily trotted through the front door of the clinic and planted myself in front of the elevator waiting to go up.  Although many students complained that their preceptors didn't know their names or didn't acknowledge them my experience was completely the opposite.

Dr. Parker was fantastic.  Not only was I clinically useless but mostly incompetent but he never made me feel that way.  He was kind, he was warm and he had this way of being reassuring that not only gave you confidence in him but in yourself, just for under his guidance.

A long time patient of Dr. Parker's, we'll call her Maria, came into the office for the 3rd time to finally be given a clinical diagnosis of hypertension.  Her BP was off the charts (in retrospect probably it wasn't that off the charts because if it was it would have been malignant hypertension--see me dropping that M2 knowledge--and we would have called and ambulance to take her to the hospital).  The obvious answer here was to start her on some pharmacotherapy and then make sure we could assure some compliance to keep her within a healthy range.

Much to my surprised Dr. Parker turned to her and asked what she thought.

Maria responded, "You know doctor, I really don't want to take a pill.  I know its really high.  I see that, but that is just not something that I want to do.  What are my options?"

"Well if we can get you a little bit more active and check in for another BP reading and see if its declined maybe we can hold off on taking a medication," said Dr. Parker.

For the next ten minutes Maria shared that some ladies at work had been walking a few times around the block at lunch time and doing yoga after work two days a week.  Dr. Parker and her decided she would try to get on this regimen with them and if the next time she came in it was still elevated she would choose to take the medication.

In my head I was screaming.  She had high blood pressure! She needed to take medicine to bring that down otherwise . . . and that was when I figured it out.  Otherwise what? She had been walking around  with this pressure for a while another week or two wasn't going to kill her, but giving her the opportunity to make a lifestyle change could alter the course of her life, could save her.

Too many of us, medical students I mean, are the type of people that see a problem, synthesize a solution and implement it in rapid succession.  Slowing that down, breaking the solution down into incremental chunks is a challenge for me.  I had the opportunity to witness a harm reduction principle in motion, before my very eyes.  For those of you who aren't familiar with the term it is essentially the idea that when you're wresting with a very severe outcome from an adverse event, any small decrease in the adverse event is a great.  Allowing free needle exchanges for IV drug users in order to reduce the transmission of HIV and Hepatitis C by infected needles is a direct correlate of this public health principle.

Dr. Parker met her where she was.  She wasn't ready to take a medication but she was ready to discuss adding some physical activity to her life.  If that didn't work or she wasn't happy with that outcome he would be there to guide her down another path.

At the time I left the clinic that day I was still baffled as to why the so obvious solution was not implemented immediately--but after some reflection I realized that making the conscious choice to delay use of that solution exemplified far higher level thinking.

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