American College of Physicians: Internal Medicine — Doctors for Adults ®

Friday, September 25, 2015

The youth code

“We think it's a really good idea for us to go ahead and get you on blood pressure medicine. As a matter of fact, this particular medication gives you an added bang for your buck since it protects your kidneys and lowers your blood pressure.” Our patient raised his eyebrows gently and tried not to look as reluctant as I know he felt.

My resident chimed in. “Since you have diabetes, this particular medication is shown to help keep your kidneys from becoming weaker. You know that can be a big issue with diabetes.”

Mr. Amos (name changed) shifted in his chair nervously. “I hear you,” he said. But from what I could see, hearing definitely didn't mean he was feeling this plan.


If you saw Mr. Amos walking down an Atlanta street, he's the last person you'd expect to be carrying with him diagnoses of diabetes and high blood pressure. He was, by our standards, young. Just shy of his fourth decade and with boyish looks that suggested he was far younger. Lean in build and tall in stature, no spare tire in sight. “Amos,” as he told his to call him, had been athletic all of his life and examining him quickly let any physician know that he still maintained that lifestyle.


But Amos was a victim of genetics. His mama and his daddy had been affected by diabetes. Two sisters were diabetic and grandparents, aunties and uncles all up the family tree had equally representative medical histories. Diabetes and hypertension simply ran in his family. It wasn't a “you gained too much weight” thing or a “you smoke/drink/use thing” either. But nonetheless, for whatever reason, that high blood pressure dog didn't hunt with him.


Now when it came to the diabetes? Amos was awesome. He took his insulin and counted carbs. He did the things we asked of him and, though he occasionally had a few dietary indiscretions, he mostly adhered to our recommended meal suggestions. His number always looked great which made seeing this young, fit man a joy.


Somehow he always managed to shake his providers off when it came to starting something for his blood pressure. He'd come up with some compelling gameplan to increase his physical activity and watch his salt. And since he was generally such a motivated and great patient, it wasn't unreasonable for someone to give that a shot. That is, the first 2 times.

Mmm hmmm.

On this day, though, from the chart review it was clear. Amos' genes were just too stubborn. For us to do right by him, he'd need blood pressure medication. And you know? This wasn't personal. It was just the standard of care.

So in the hallway before we'd gone back together to see Amos, my resident told me that he was pretty adamant about not taking blood pressure pills. I asked my resident if he knew why our patient was so against taking something for his hypertension and he admitted that he honestly didn't know. And so. That was one of the first things I explored when I encountered him.

“So, Mr. Amos. What is it about blood pressure pills that gives you such a bad taste in your mouth?”

He squinted his eyes and seemed to be thinking. I could tell that my question caught him off guard. “I guess I just feel like I can control it, you know? Without an extra pill.”

That was reasonable. I thought for a bit about who he was, young and male. I imagined him having some trepidation about the potential for erectile dysfunction, a very real concern in many men who take antihypertensives. So I asked.

“Do you feel concerned that taking something for your blood pressure might affect your nature?”

And yes, I said “nature” because this is Georgia and I've been working at Grady for a while. Long enough to know that “nature” is a safe and all-encompassing way to discuss not only what is found in the nether region but its function as well.

Amos' eyes flung open at that question and then he chuckled. “Good Lord. I hadn't even thought of that.” He shook his head and shuddered.

So that wasn't it. And what's funny is that I felt sort of lost at that point because I was so sure that this was his issue that I'd already lined up my talk points to counter his concerns.

What was it, then? What had this compliant with appointments guy so gun shy with taking something for his blood pressure?

“You know what? I guess I just … it's weird … I just see myself as too healthy for all that. And too young.” Amos laughed again, this time at his admission to us. “I know it probably sounds crazy. But something about having high blood pressure just doesn't seem like it should be attached to me. It's like I just can't accept that, you know?”

“You don't feel that way about the diabetes, though?” I asked.

“Naw. Little kids get diabetes. Skinny folks and all sorts of folks, you know? Jay Cutler is a pro football player and he's got sugar. So I know that happens to people like me. But high blood pressure is something that just seem like it goes with smoking and eating bad and needing to lose weight. And even though I know it ain't personal, I always feel lightweight offended when folks come at me talking about my blood pressure. It's like I feel like they mixing me up with somebody else.”

“I guess it's crazy to think that somebody could run 13.1 miles and still have high blood pressure.”

“Exactly. Especially when they do all the right stuff along with it and they aren't that old. I just keep waiting for somebody to tell me they looking at the wrong chart.”


Now this? This was some real talk. Amos stuck a pin straight into the thing that stops so many youngish people from seeking a doctor's care. Hell, it's stopped me from getting care as regularly as I should, too.


It seems like there's this line in the sand where some of us feel it's reasonable for us to have certain diseases. Hypertension and high cholesterol? Those are for the older folks. So a lot of the young ones look at it as some kind of fluke when you tell them they have it. Like you aren't talking to them in real life. Just for pretend.

And this? This is a tough mountain to move. Our myopic view of our reflection and how that plays into the likelihood of anything being awry with our health. Amos gave me a lot to think about.

So you know what I did? I told him just what I'm telling you. That I understood how he felt and got it that it seemed like some kind of crazy betrayal to keep tacking this diagnosis of high blood pressure on to his chart. Then we discussed family history and how “essential hypertension,” that is, the kind that runs in families, works. And how people like him, despite their half marathons and burpees in the morning, needed some pharmocologic interventions in the morning, too.

This resonated with him. I mean, it did enough to get him to take that medication. And no, he didn't like the idea but he did get it that continuing to put this off was like him drinking poison but expecting someone else to die from it.


So what's my take away from this encounter? Hmmm. Well, first of all it's this idea that it really benefits me and my patients when I really push myself to think about the WHY of a patient's position instead of just my own agenda. I also was reminded to just slow down and listen instead of tracking ahead with my scripted comeback since real people improvise and canned/planned dialogues feel like exactly that. And lastly? I think I recognized the power of just being honest with my patients about what's going on in my head and giving them a platform to share what's happening in theirs.

I learn so much from my patients at Grady. And I'm glad.


Kimberly Manning, MD, FACP, FAAP is an associate professor of medicine at Emory University School of Medicine in Atlanta, Georgia where she teaches medical students and residents at Grady Hospital. This post is adapted from Reflections of a Grady Doctor, Dr. Manning’s blog about teaching, learning, caring and growing in medicine and life. It has been adapted and reprinted with permission. Identifying information has been changed to protect individuals’ privacy.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

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Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

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Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

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Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

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Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

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