Your Medical Mind_ How to Decide What Is Right for You - Jerome Groopman [11]
“I’ll work even harder on my diet,” she replied.
“Keep working on it. But you know I’m not going to give up,” Carter said.
Susan nodded. “And neither am I,” she responded.
Shortly after their meeting, we spoke with Dr. Carter. “So often a patient’s preference has nothing to do with education,” he told us. “You are continuously surprised by people like Susan Powell. She works as a nurse’s assistant and sees every possible complication of atherosclerosis and still won’t take a statin.”
When Susan had repeatedly declined to take a statin, her previous primary care doctor told her flatly that if patients don’t follow her instructions, she can’t care for them. When we spoke with Jacques Carter, he said he was familiar with this story and shook his head.
“That’s just wrong. It’s the old, paternalistic way of dealing with patients. Ultimately, you know, patients have final control of what goes on. And once a doctor realizes that—that patients don’t have to take what you prescribe—then you realize that if you want them to do things you think will benefit them, you have to sit down and talk and come to an understanding. Caring for people is all about negotiation.”
Jacques Carter grew up in North Carolina, the son of a plumber’s assistant who couldn’t advance in the trade because he was African American. Before going to medical school, Carter worked in Washington, D.C., for that city’s Department of Health. His job was to improve sanitation, monitoring the sewer system, trash collection, and other community needs. In that job, “you had to learn how to talk to people,” he explained. “You can’t just tell them what to do. That’s where I first became so aware of the importance of negotiation. People want to discuss why they do what they do.”
The first time Carter meets with a patient, he doesn’t expect him or her to immediately follow his advice. “You are putting a lot of stuff out there, lots of numbers about benefit and risk. But often people will say, ‘No, I don’t want to take that medicine. I just don’t want that.’ Or they say they’re worried if it really is best for them. So, you bring them back in a month or two months, and then bring it up again. And still they say no. And then the third time when you raise the issue, you see that they are thinking about it more deeply.
“As a doctor, you are jockeying for position. It’s not an efficient process. It’s not like you just go, ‘Boom, boom, boom, here is the prescription.’ Because too often I’ve found a patient at that point will smile at you, take the prescription, put it in her pocket, and never take the medication.”
When Susan Powell first met with Dr. Carter to discuss her cholesterol, she told him, “It’s my body, and whatever I put in it, it’s going to affect me. It’s fine for you to advise me differently, to tell me that by not taking the statin pill this is what could happen over the short term or the long term, and how much damage might be done. That’s fine. But remember that there are side effects. Everything from stomach pains to muscle damage. None of those things has ever happened to me.”
As Susan found in her Web search, national guidelines recommend statin treatment for women like her if diet and exercise are not enough to lower her cholesterol. However, some experts question this recommendation and believe the benefits for any single patient do not clearly outweigh the risks. Dr. Carter, who has a master’s degree in public health from Harvard University in addition to his MD from Georgetown University, is especially alert to the contrast between guidelines for groups and advice for individuals. “Taking care of individual patients requires you to think differently than when you are talking about entire populations,” Carter said. It is much easier to grasp the impact of a pill that changes the risk of a heart attack from 1 percent to 0.7 percent