The Second Law of the Dinosaur states:
It is impossible to make an asymptomatic patient feel better.
Chapter 2 of my book, Declarations of a Dinosaur, discusses how I handle a patient who may be asymptomatic at present but who will not remain so for long without taking my advice. Essentially, I explain in as much detail as necessary to create just enough anxiety, which can be relieved by doing what I say, be it taking pills, quitting smoking; whatever.
Another way of looking at it is that although the patient may not feel there’s anything wrong with him, my anxiety spikes when I see things like a hemoglobin A1c of 14 %*. All I have to do is find a way to get my patient to feel the same level of alarm as I feel.
This is what I did a few months back when I saw an African American gentleman with a blood pressure of 210/130. He hadn’t been to see me in quite a while (I think his BP had been a little elevated then and he was afraid of what it was going to be now). It also turned out that his LDL was 180, and his A1c was 12%. I felt like I was on the verge of a cardiovascular event just sitting there in the room with him! With that collection of risk factors, he was literally a heart attack waiting to happen. And that’s what I told him.
He felt fine. No chest pain; no headache; no retinal changes. No symptoms at all (which was why he didn’t meet the criteria for a diagnosis of Hypertensive Urgency with its attendant trip to the ER). Still, as I explained to him, if I were to get a phone call the next day that he had dropped dead of a stroke, I wouldn’t be surprised.
He hated pills. That was another reason he hadn’t returned earlier. Carefully prioritizing the situations, I prescribed two antihypertensives (in a single combination pill) and a statin. Hardly optimal therapy, but I wanted to start him as slow as I felt was safe, explaining at length exactly how scared I was, and how important the pills were.
He said he understood, taught it all back to me to show he got it, and thanked me, setting up an appointment the following month to see how he was doing.
Job well done! Or so I thought.
Next month he comes back.
“How are you doing with the new medicines?” I ask.
“Well, I didn’t start them.”
“I don’t know.”
Blood pressure was still over 200. Another month closer to that stroke. How could I have failed so utterly to get through to him? No idea. I had to try something else; some other way to communicate to him the emotions these encounters had produced in me.
I had an idea:
“Listen,” I began, “Have you had the conversation with your sons about ‘driving while black’?”
“Oh yes,” he replied. “Of course I have.”
“Okay,” I continued. “Do me a favor. Think for a minute about how you would feel if, after you had this conversation with your son, knowing what you know about the world we live in, he came home one night and told you that a police car tried to pull him over, but he managed to ‘get away’? Or that he was stopped, and boy did he give that cop a piece of his mind. Somehow, he lucked out, and got off without serious consequences. But wouldn’t your heart be in your throat, aware of the risk he had taken? Even worse, that he didn’t even seem to recognize it?”
My patient was nodding.
“Well, that’s how I felt hearing that you’re not taking any of the meds I asked you to. Seeing how high your blood pressure still is gives me palpitations. Please, please, please…please start taking the pills.”
This time I got through to him, and I’m pleased to report that three months down the road, we’re on the right track at last.
*(corresponding to an average blood sugar of 355; poorly controlled diabetes, with increased risk for heart attack, stroke, blindness, kidney failure, impotence, etcetcetc.)