Family medicine, 2012

One of the Jones sisters has died. We heard that a live wire had fallen on her car and she was electrocuted while trying to get out of it, after refusing to wait another few hours for the Hydro crew to come from the city. Susan or Linda? No one seems to know. One of our least faithful patients or one of our most — which will be deleted from the active database?

According to the Clinical Practice Guidelines for Treatment of Diabetes Mellitus, published in 2008, Susan has classic diabetes mellitus type 2X. The diabetes society recommends an implanted glucose sensor, regular checkups and multiple medications for sugar and obesity control. Susan will have none of it. “I'm too busy,” she always says. “Maybe later.”

Her computer registration screens are often carelessly (some of my partners allege falsely) completed and she declines the extra preventive services we offer at our new Wellness Centre. I have wasted a lot of time trying to explain that these are evidence-based screening interventions, that her chances of dying of colon or breast cancer or heart disease would be lower if she had the virtual colonoscopy, mammoMRI or 𝛅-homocysteine/methionine levels done regularly. “They're not covered,” she'd say. “I have other things to spend my money on.” However, she also applied to have her name removed from the government waiting lists for manual colonoscopy and radiation mammography.

It is difficult not to be angry with her when she also refuses to enroll in any drug trial. Like most group practices, ours has recently become part of the Ministry of Health Trial Initiative. The drug company has an office next to mine to recruit patients for a study of gremlinizide. Of course, the MoH gave them access to our patient database and they sent Susan regular invitations to participate. She defaced them with rude comments and mailed them back.

When my partners got wind of her intransigence, they reminded me that the initiative helped with the overhead and provided us all with extra income when we enrolled patients. In combination with the Wellness Centre (set up last year with the Canadian Laboratories Collaboration) we have become much less dependent on our salaries, which have steadily declined since the Canadian Reform United Democratic (CRUD) Party achieved its majority. “Can't complain about CRUD,” the partners say. “Without them, these opportunities for direct billing wouldn't exist.”

If you ignore her obvious obesity, Susan is attractive in a rumpled sort of way. She retired early to raise dogs just outside our medium-sized rural town and quickly joined volunteer organizations. Her dog float won best of the Rotary parade 3 years running, and the residents at the Manor love her canine visiting program. She has the rare ability to make waves without drowning people.

But she is such a difficult patient. She misses follow-up appointments. She shows up and demands to see me on days I'm not on intake, and of course she refuses to follow suggestions generated by the computer. I reminded her once (perhaps unethically) that since 2005 our remuneration has been dependent on achieving certain goals in screening and treatment of common conditions. Not only was she depriving the practice of the extra billing income, but the basic government transfers were also affected. “I'm sorry,” she'd replied calmly, “but I'm saving not only my money but the government's. If I followed all these guidelines, I would be like Linda, spending all my time having tests and taking pills. I'm just fine as I am.”

“You might go blind,” I warn. “You could have renal failure. If you don't lose weight, your knees will give out.” Her response is to fail to check her sugars and miss her next appointment. But, perhaps months later, she'll be back, carrying some high-calorie baking for the staff. “How are you?” she asks. “Are the partners being nice to you?”

The partners love Linda, who is attractive, thin and well groomed. She exercises regularly and fills in the Wellness forms with obsessive attention to detail. Her Palm XVII has been programmed so that she undergoes all the screening tests just as soon as she can. She has enrolled in every drug trial for which she is eligible. I have her on oral iron for the anemia from the frequent venipunctures required by the study protocols. That, of course, was a diagnosis of exclusion.

Linda takes her cholesterol-lowering agent regularly (her cholesterol is 4.8, but she insisted), her hormone replacement, her ACE inhibitor (no known heart disease but a great-uncle died of an MI), registered herbal supplements 4 through 7 and, I am sure, others from the naturopath and chiropractor. Linda never misses a follow-up appointment and will suggest one if I don't. She is always sending emails, posing questions about the latest treatments.

Linda doesn't have time for much other than taking care of herself, although since her husband died she has spearheaded the local Implanted Defibrillators for all Seniors group. She often worries aloud about her sister. “I do all I can to keep myself healthy,” she says. “Why won't she?”

Which one has been killed? Why, when Linda is the more faithful patient, is it the possibility of Susan's death that upsets me most?