When It's the Patient's Fault

These days, more and more patients are forced to take some responsibility for their own illnesses. The obese adolescent who won't lose weight, the osteoporotic woman who won't exercise or take calcium, the patient suffering with lower-back pain who won't consider a stretching routine - there is only so much a physician and pharmaceuticals can do in the face of addiction, advertising, and the culture at large. The rest is up to the patient. And that is frustrating for physicians.

You probably haven't been trained in the psychological tricks needed to move a kid from daily McDonald's to an apple a day. Major lifestyle changes are not easy to make, and the subject is uncomfortable for physicians to discuss.

But it's crucial.

Consider chronic obstructive pulmonary disorder (COPD). How many patients have COPD yet have gone undiagnosed - or have been misdiagnosed as asthmatic? It's impossible to be sure, but there are plenty. These patients are losing lung function yet aren't being properly treated or counseled to stop smoking. Instead they're being treated for asthma if they're being treated at all.

While both diseases can include coughing, wheezing, and difficulty breathing, most of the time it is not difficult to distinguish between asthma and COPD. Asthma, after all, is mostly episodic. It appears in all age groups, is usually associated with an allergic history, and is not necessarily connected to smoking. Asthmatics cough mostly at night with minimal sputum. COPD patients usually have a history of progressive respiratory problems, are mainly adults over age 45, and cough most severely in the morning, producing purulent sputum.

The treatment is different, too: asthma patients almost always respond to inhaled corticosteroids. Only a small percentage of COPD patients do.

Why are COPD patients being misdiagnosed? There are many reasons, but one is that working with a COPD patient can be emotional and frustrating.

COPD patients have to be confronted about smoking cessation. This is not easy; smoking is both a physical and emotional addiction. But it's tough for physicians with a strong desire to heal to face a patient who just doesn't seem to want to do his part. Or to help a patient whose addiction is nearly out of his control, seemingly engineered by cigarette manufacturers. And the damage from smoking cannot be reversed, only controlled, once the smoking is stopped - a conversation stopper for a physician on a mission to heal.

Asthma patients, meanwhile, get an inhaler and a pat on the head. It's relatively simple - a tempting diagnosis relative to COPD.

Even so, patients who have contributed to their own problems can and must be aided, difficult as that is for doctors. Luckily, even minimal physician involvement can help. According to researcher Robert Mallin, "The advice of a physician alone can improve the smoking cessation rate to 10.2 percent. The combined use of nicotine replacement, bupropion (Zyban), and social or behavioral support can increase the quit rate to 35 percent."(American Family Physician, March 15, 2002.) In addition, most states are now offering free programs to smokers through the telephone and Internet to help in this process of quitting.

Still, it's likely that physicians will face more and more uncomfortable conversations as "lifestyle" disease increases. Brace yourself for less prescribing and more time spent treating the emotional part of these medical problems. Almost as important, be aware of reasons that you may not consider a diagnosis because of the difficulties it presents in managing the patient in the future.

This article originally appeared in the June 2005 issue of Physicians Practice.