The uncertain art: Hippocrates redux.

Author:Nuland, Sherwin B.

Patient responsibility


On June 24, 1889, a youth of twenty--forever after to be memorialized in the literature of medicine by his initials, G. H.--was punitively discharged from The Johns Hopkins Hospital eight days after an operation. Only the second patient to have undergone a newly devised method of hernia repair, he had been found guilty of "insubordination." His offense? In the words by which he is fated to be remembered for as long as medical historians study the origins of modern surgical techniques, "Patient got out of bed several times and took cathartic pills without permission." The punishment decreed by the surgeon, William Halsted, was nothing compared with that meted out by the young man's seemingly taxed tissues. Three years later, the repentant G. H. returned to the hospital with a palpable loop of squishy bowel in his scrotum, signifying "a complete return of the hernia." Of the first ten patients followed for a period sufficient to test the effectiveness of the new technique, G. H. was the only one to develop a recurrence; he was also the only one to get out of bed before the prescribed three weeks. To the surgeons of the time, it was Q.E.D.: Get out of bed too early and your stitches will not hold.

Young G. H. was one of the astonishingly high number of patients who don't follow doctors' orders. In Halsted's time, their sin was called "insubordination"; fifty years later, it was "recalcitrance"; today the preferred term is "noncompliance" or, if one is striving to avoid any connotation of medical paternalism, "nonadherence." No one is sure just how many noncompliant patients there are, but in the studies of prescribed medications that serve as a rough index of such things, the figure averages 50 percent; in one survey, of cases in which children depended on a parent to administer oral penicillin, the rate was 92 percent. At least one-third of hospital admissions for heart failure are necessitated by neglect of dietary or pharmacologic instructions. Many of these patients are elderly, and their noncompliance is caused by such factors as forgetfulness, confusion, cost, intolerance of minor side effects, lack of a social support system, and, finally, complacency after having been relieved of their symptoms by the very therapy that they therefore abandon.

Not all patients end up in the kind of jam in which G. H. found himself. The reasons why some (though not many) get away with medical self-neglect are uncertain, but one of them is surely that in some cases the treatment was not necessary in the first place. We physicians have been taught to categorize our patients and deal with their illnesses by following the algorithm that certain findings should necessarily lead to certain treatments. In the vast majority of cases this approach is appropriate and effective, but sometimes it is found wanting because we have not considered individual variations. The same disease may have different manifestations in different ways in different patients, and therapy should be modified accordingly.

And even a non-complier's relapse or therapeutic unresponsiveness cannot necessarily be ascribed to his failure to follow instructions; there may be other reasons for the poor result. G. H., in fact, is the perfect example. With today's knowledge of wound healing, we can be sure that he could not have done...

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