CW: A hand surgeon’s view of non-adherent patients…

Tonight, in the true spirit of cycling blogs, I will tell you a story. (We definitely need to lighten things up a bit.)

Consider yourself warned.

It is a saga of a cat-like mountain biker, who is also a heart specialist and perhaps a less than ideal patient.

But first, you may be wondering why I am using the funny word ‘non-adherent.’ It’s because the older word, ‘non-compliant,’ has fallen out of favor. Doctors used to say patients that did not follow a prescribed plan were not compliant. But this kind of harsh language implies a paternalistic condescending attitude towards the patient. Saying that a patient does not adhere indicates that doctor and patient are partners on equal terms. That sounds funny, doesn’t it?

Don’t worry, the story gets better. (Is it normal to laugh as you type?)

Being as we heart doctors are mindful and nurturing souls, we often describe patients that refuse to exercise, stop eating potato chips or fail to take medicines as directed as non-adherent. We don’t take non-adherence personally, rather, we press on with upbeat positive reinforcement. “Keep fighting; you can do it; it’s ok; I know it’s really hard, and, of course you don’t eat very much,” are all things we say.

It turns out that not all doctors employ the cardiology approach to ‘challenging’ non-adherent patients.

Take my hand surgeon as an example…

Wait, what did you say, “your hand surgeon?”

Yes, it’s true. The ulnar collateral ligament and extensor pollicis longus tendon do not have infinite stretching properties. A brief side note: It was a nothing thing. A rock garden that I have ridden a thousand times. Sure it was a little wet. The front wheel turned on a wet rock. No problem; it wasn’t at high-speed. But those rocks were so jagged, so uneven, so hard. I felt the tear. Dang it. My thumb was as we ‘like to say’ in KY, severely caddywompus.

The shared decision-making went well. For me, surgery was the easy part. I just laid there and the doctors did the work. I read my own op note: “In essence, it was torn open like a book.” Ouch.

Back to non-adherence, and that story I promised.

After the repair, the surgeon put my hand in a hard splint and sent me home. The splint looked perfect; it was nicely wrapped, white and comfy. For the record, nowhere did it say I couldn’t ride. I mean, who doesn’t ride the trainer the nanosecond anesthesia wears off?

One thing easily taken for granted in non-casted, non-sutured folk is how easy it is to deal with sweat. You get in the shower and change the sweaty clothes. To me, and I’m sure to you, a partial splint implies that it’s okay to change dressings and re-wrap. Come on, if you can ablate AF, surely you can change a splint.

Another mistake; don’t just ‘stop by’ the surgeon’s office and ask the nurse to help re-wrap a splint that wasn’t meant to be unwrapped.

“You took it off?” the nurse asks.

“Yes.” Not said, just thought…“I’m a heart specialist, and a bike racer!”

“Why did you take it off”? she asks.

“It got and hot and sweaty.” Again, not said, just thought…“Don’t y’all have moisture-wicking technical wrap?”

She did not call me non-compliant, but I knew she thought it. I got a new bandage and all seemed well. As I left, I planned my next trainer session. I’ll do repeat 5’s. That’s what you would do on post-op day 3, right?

As I was seeing patients in the office the next day my iPhone buzzed an unfamiliar number. I answered–you never know, it might be the newspaper wanting an interview on medial blogging. “Dr. (hand surgeon) wants you to come over to the office,” said the friendly but serious voice.

“My incision check appointment isn’t for a week,” I answered. “Wait, crap, I missed another appointment.”

Ever serious, the voice says, “No, the doctor wants to see you this morning.”

Gulp.

“Okay. I’m coming over.”

Sure I had patients. But my patients are used to waiting. Many of my cycling/AF patients have a blog to write anyways; they don’t mind the peace and quiet of the exam room, as long as the Wi-Fi is working.

“It’s me, DrJohnM,” I said as I entered the office. Just kidding, I don’t call myself that. Well only when I whisper sweetly to my wife. (I’m laughing again.)

There was a chill in the office when I arrived. It was as if their faces could talk. He’s here; you know, the guy who took his splint off. Wait, let me see what he looks like. OMG. That’s the guy. He was here yesterday. You should have seen it. The splint was a mess—sweaty and all. The wrap was so bad. He said he’s a doctor, but geez, don’t heart doctors know anything?

It’s funny how guilt messes with your imagination.

Now, I’ve never been in the presence of a hand surgeon before this week. I had only heard rumors. Supposedly they consider themselves apex-predator doctors too.

“Trying to heal thyself; I see,” the surgeon says as he looks down at my disheveled splint.

Before I could counter with a something witty, he shakes his head and walks out. Counting to ten, I suppose.

A shy office staff person then directs me to a large cast room. There were two toddlers with casts. They kept talking while I tried to read a review article in the Journal of the American College of Cardiology. It was hard to concentrate. My thumb throbbed. I waited. I read. I listened to the toddlers. My medical assistant texted me, “ETA?.. the two cyclist/AF patients have finished their posts for today.”

I responded, “dunno, I think they are mad here…not sure they know what electrophysiology is.”

I get up and looked around.

Then it happened.

“What do you need?” asks the very mom-like woman. Flash-back to junior student OB-GYN rotation. A run of atrial tachycardia thumps my chest.

In cardiology mode, I say, “Well, should I tell my patients that are waiting for me to go home?”

“You need to sit down and let him put a cast on your arm.”

Vagal surge. Dizzy. Hot flash.

Ah…

Well…

“He won’t tell you that, but I will.”

I thought, “How many joules was that shock?”

An amazing thing happened. I sat down, shut up and waited. When he came over and started with the casting, I managed to eek out something about getting another (removable) splint.

“Don’t take this the wrong way, but I am going to idiot-proof this situation. I am going to protect you from yourself.”

You ever see a dog with those collars over their noses? They keep shaking their head about and scratching at the thing with their paws. That’s me with this damn cast. I keep wanting to shake it off. Not only can’t I ride, or sweat; the worst part is not being able to hit the space bar. I am back to pecking out blogs.

The take home:

Of course the greater message here is more than a dumb doctor’s non-compliance adherence.

What poofs in my mind is the fact that hand surgeons use casts to protect people from themselves.

Imagine if heart doctors could do that for heart disease. Or, are we already trying?

JMM