A good doctor prescribes medication and helps a patient get better, but a better option is to discontinue medication if it is causing the patient’s problems. Although that scenario is generally gratifying for both the doctor and the patient, it’s not always as easy as it sounds.
Consider a 75-year-old woman whom I saw recently. She had lots of complaints but topping her list of sorrows were alopecia and xerostomia. Her hair loss had gradually gotten worse over the last 5 to 6 years.
Her dermatologist had suggested that she use topical minoxidil, but she wasn’t happy with this advice. Another rheumatologist had her use pilocarpine for her dry mouth, but it didn’t help, and cevimeline was too expensive. I had seen her once a few years earlier for unrelated problems, and she decided to return to see me regarding a positive ANA (antinuclear antibody) her primary physician had drawn.
Her past medical history included diagnoses of fibromyalgia, osteoarthritis, osteoporosis, multiple sclerosis, and depression. She was anxious and, given her ever-lengthening list of diagnoses, doctors, and medications, she had good reason to feel anxious.
She might have Sjögren’s syndrome, but citalopram was on her medication list, and I thought her problems might be drug related. She had been on citalopram for years. An on-line drug reference listed alopecia and xerostomia as possible side effects of this medication. I told her that I couldn’t be sure that citalopram was the cause of her woes, but it was a possibility. Before labeling her with Sjögren’s syndrome and prescribing medication for that diagnosis, I wanted to know if she got better by stopping citalopram rather than by adding a medication to her already long list of pills.
She gladly accepted this proposal, but she was definitely a nervous individual. Watching her fidget, the best adjective that popped into my charitable mind was "squirrelly." Although there isn’t an official billing code for this diagnosis, there should be. What might happen if I took away her nerve medication? Would her family doctor think I had lost my mind? Could her family cope with her undiluted personality once she was off her medication? These questions all bothered me, but we went ahead with the program. She came back a month later with a new set of gripes.
I asked her if she had any problem getting off the citalopram. She said she was unhappy because I didn’t give her instructions about tapering off her medication. I had been on vacation in the interim, and she accused me of "going off to Disney World!" Her husband was there in the exam room with us as was a family practice resident, so there were two spectators to this small clinical melee.
Before responding to her complaint regarding her medication instructions, I felt that I had to clear myself of the heinous accusation of abandoning her while I cavorted in Disney World! I have pleaded with my staff previously, to avoid using the "V word" (vacation) with my patients. It really gets under my skin when I come back to the office after a vacation and patients ask me how my vacation was or where I went. With most patients, those questions are just casual chitchat, but other patients have a cold sneering edge to their voice. Their implication is "I was suffering while you were playing." I guess it is invariable that patients find out about my outings when they can’t get appointments or the staff has to change their appointments, but I still don’t like it. I had made a short pilgrimage home to visit family and friends whom I hadn’t seen in a long time. Even though I knew the notion that I had gone to Disney was just a manifestation of this patient’s intrinsic goofiness, I could feel her burrowing under my calm clinical defense perimeter, and pushing my buttons in a big way. Her squirrelly personality was rubbing off on me.
I looked through her chart, and found her instructions. "At your last visit, you couldn’t remember your dose of citalopram, so you had to call back and let us know that you were taking 40 mg a day. I wrote instructions for tapering off that dosage, and the nurse left a message on your answering machine that afternoon."
She said she never got the message, and she again accused me of fleeing to Disney World. By this time, Disney World was starting to sound increasingly attractive. I wasn’t quite sure why she looked different, but I had noticed that she looked better as soon as I opened the exam room door. She told me her hair loss was a little better, and she had her hair professionally colored for the first time in many months. Her hairdresser really did know for sure!