Compliance

I am currently on rotation at a clinic for people on blood thinners (aka, warfarin clinic). My days are spent poking patient's fingers, running the blood through a machine, and hoping that the result (their INR) is within the desirable range.

When they are perfectly in range, the patient gets a high five and an appointment to come back and see me in 30 days. When they aren't, it could mean trouble. A INR that is too high means the patient's blood is thinner than we would like and puts them at a higher risk for a bleed. Conversely, a low INR can put the patient at risk for a blood clot. In clinic, we prefer a happy medium.

For some people, you can find an obvious reason for the discrepancy.

• Consuming alcoholic beverages
  
• Forgetting to take doses during the week
  
• Eating too many or too few vitamin K rich foods (spinach, brocolli, or greens for example)
• A new prescription added to the regimen
  

For other folks, it is more difficult to figure out what on earth is going on.

A patient came into clinic with an INR that was far higher than the previous results. I drilled the patient with questions:

Me: "Have you been drinking?"

Patient: "No. "

Me: "Have you taken your medications every day this week?"

Patient: "Yes."

Me: "Have you put on a clown suit and juggled kittens recently?"

Patient: "Not this week."

Me: "Have you done anything differently? Come on... ANYTHING?"

I actually ran out of questions to ask.

Then I had a light bulb moment. Maybe the patient wasn't doing anything wrong, perhaps he was actually doing everything right. I started a new line of questioning.

Me: "Do you usually take your medication everyday?"

Patient: "No, not usually. I made a special effort this week."

AH HA! The fact that the patient was now taking the medication as directed instead of at his own discretion made all the difference in the world. It's not often that you find compliance to be the problem.

I'm not a mind reader, people. Meet me half way. I'd even accept a quarter of the way. Anything.

At least it keeps me on my toes.