How do you save people from themselves?

Or should you even try? If you are a physician, the answer to the second question is “yes”, to the first is, “I don’t know”. But we try like hell…

One of my favorite patients is a smoker. He’s tried like hell to quit. He’s tried every pill, patch, and gum, but it’s just not working for him. He has cut back quite a bit. Is that good enough?

His chronic cough is slightly better, but he has pain in his calf whenever he walks any distance. An ultrasound of his leg showed pretty bad arterial disease in that leg. Smoking is only going to make it worse. He could lose a toe, a foot, a leg, or worse.

A well-done study was published last year looked at the effect of cutting back on cigarettes vs. quitting. It doesn’t look good for the smokers. Cutting back by half did not lower the risk of dying prematurely, compared to quitting altogether.

Cutting back has been associated with higher rates of successful quitting, so perhaps he’s on his way to better health. Meanwhile, he’s in trouble.

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Addiction isn’t the only thing we try to save our patients from. Often, we are trying to save them from their tragically bad decisions, rather than an addiction.

A young man came into the office with a strange and shifting story. He had a blood clot in his leg (it came out that he had been diagnosed the other day at another hospital, but he walked away).  This condition (deep venous thrombosis) gets quite a bit of press as “economy class syndrome”. It’s a big killer. The clot in the leg can break off, travel to the heart and kill you. I explained this in every way I could, but for some reason, this guy did not want to go to the ER. It finally came out that he was afraid of losing his job (a VERY big deal in my part of the country). I of course explained that if he were dead, his job would be irrelevant. No luck. I offered to call his boss first thing in the morning, if he thought it would matter. Nope. Problems at home? Childcare issues? Substance abuse? Gornischt.  He seemed to clearly understand the issues–I laid it out starkly: Go to the ER or you have a high chance of being dead in the next few days.   He did not appear to have any cognitive problems.  He apparently understood.

Finally– maybe to get me to shut up– he went to the ER.  After a short time there, he took off without treatment.

As a physician, it’s my job to try to save people from themselves.  Most prevention and treatment of disease relies on the patient, so I can’t do it alone.  I can’t save them all, and sometimes my forehead gets bruised from banging it against the wall, but I’ll never stop trying.