The world would be a healthier place if everybody followed their doctor’s advice. People would get more exercise and eat healthier foods. They’d get regular checkups. And they’d even take their medicine as prescribed.
In the real world, though, all sorts of things can get in the way of good self-care. Many people have trouble finding the time or the money to see a doctor or buy medicines. In some neighborhoods, access to the tools for good self-care is scarce. Many low-income urban residents are hard pressed to find fresh fruits and vegetables in their corner markets or even a safe place to exercise outdoors. People in far-flung suburbs often find themselves without public transportation to health care: A recent California study found that families in one low-income suburb near San Francisco had no access to public transportation to a hospital — and only 1 percent had such access to get to a clinic.
Even when a treatment plan fits into both your schedule and your budget, you may not understand exactly what you need to do to get healthy. In a recent interview with the Center for the Advancement of Health, Dean Schillinger, MD, an assistant clinical professor of medicine at University of California, San Francisco, and San Francisco General Hospital, summed up the feelings of many patients: “My doctor is asking me to do all of these things, but she or he doesn’t understand all of the challenges I face during the day.”
Indeed, it helps for physicians to put themselves in their patients’ shoes. William Wishner, an endocrinologist who taught for some years at the Indiana University School of Medicine, used to conduct an experiment with medical residents who complained about diabetic patients not following advice. In an interview with Hippocrates magazine, he said he told the residents that for a week they had to prick themselves with a needle, check their blood sugar repeatedly, follow a strict diet, and exercise at least every other day. “Every time these young doctors said to me, ‘We can’t do that. It’s too time consuming,” says Wishner. And I said, ‘Excuse me, what do you expect a patient to do?’ “
When it comes down to it, only one person really understands the challenges in your life: you. It’s your job to overcome each of these obstacles as best you can, one by one. No matter what your situation in life, your health deserves your best effort.
A two-way talk
Learning to communicate with your doctor is an important step toward taking control of your health. Good communication can help clear up any uncertainties or concerns you have about your treatment. Lingering doubts make it easy to quit your therapy before it has really had a chance to work. Your doctor is also the ideal person to answer any questions about the best, safest ways to take your pills, perform your exercises, or do whatever you need to do to get better.
But talking to a doctor isn’t always easy. Many doctors have only 15 minutes per patient visit, which doesn’t leave much room for conversation. In fact, a doctor might have 160,000 conversations with patients during his or her career — it’s no wonder so many seem rushed or distracted. Many doctors also suffer from a condition known as “doctor speak.” If your doctor starts talking about, say, “sequelae such as pruritus” (“problems such as itching”), ask him or her to use real language.
Let your doctor know that you want to work together as a team. It’s important to establish trust and rapport from the beginning. When your doctor is talking, try to be a good listener. Repeat instructions back in your own words, and don’t pretend to understand more than you do. There’s no shame in being confused about medicines and diseases.
There’s also no shame in being confused by the instructions that come with medicines. The words and symbols on prescription bottles just aren’t very clear, and the package inserts won’t necessarily help. According to a report from the American College of Physicians, about half of the people in a recent study had trouble understanding health information, including crucial details on their prescriptions. If you don’t understand how to take your medicine or the instructions on the label don’t seem to make sense, get the real scoop from your pharmacist or doctor.
Besides asking questions, be as honest as you can. Perhaps your family has taught you to agree politely with people in authority, even if you have no intention of following their advice. Maybe you secretly think your disease isn’t such a big deal, or you’re afraid the treatment plan won’t work. Maybe you don’t have any symptoms right now, so you don’t see why you should keep taking the medicine. You may be depressed and feel as if you have no control over your illness, or — just the opposite — you may feel that you can keep it under control without any medical help. Be honest with your doctor about your thoughts and attitude.
In an atmosphere of trust and respect, your doctor should be able to help you work through these issues. If, however, after several visits you feel that you’re not communicating well, bring that up in a neutral manner (i.e. “I’m not sure communications are working”) and ask how you could work together to improve it. If you continue to feel uncomfortable, you might want to look for another doctor.
Taking the right pills at the right times in the right doses can be a difficult task. Here are some guidelines:
- Be direct with your doctor. If you aren’t taking your medicine, say so. Some very honest people stretch the truth in the doctor’s office. They may say they’re taking a medicine when they really aren’t. Then the doctor wonders why the patient isn’t getting better. He or she might even prescribe more and more drugs, ones you wouldn’t need if you had taken the drugs originally prescribed.
- Tell your doctor about side effects that are bothering you. If your medicines are causing problems, you may be tempted to stop taking them, but there’s almost always a better solution. If your medicines bother your stomach, for example, your doctor might suggest taking them with meals. In some cases, you may need other medicine to prevent side effects. For instance, people taking narcotic pain relievers like morphine may need a laxative to prevent constipation. Your doctor may also be able to find a different medicine that doesn’t have the unwanted side effects.
- You don’t have to wait for your next appointment to tell your doctor these things — most doctors want to know if you are having medication problems at the time they occur, so that they can respond in a timely way and help you get better sooner. Some drugs could even be dangerous to stop suddenly or to take intermittently, so it is always a good idea to discuss these issues with your doctor right away, as soon as you notice them.
- Get organized. A pill organizer can be a handy way to keep track of medicines, especially if you have to take many different medicines. You can find one in almost any grocery or drug store. You can also print out a copy of our Personal Medication Inventory, which can help you keep track of the time and date you take each medicine.
When talking to your doctor or pharmacist, you may also have to bring up the sticky subject of money. Nearly 46 million Americans lack any type of health insurance, and everything from pills to x-rays seem to get more expensive every day. If you don’t have good health insurance or a pile of money in the bank, costs will be a very real concern.
But even if you’re low-income, good health care may — and should — be within your reach. For starters, find out if you’re eligible for Medicaid, a federal program that helps low-income people pay for medicine, medical tests, childbirth, nursing homes, and other types of medical care. Each state has its own rules for eligibility. Low-income people are more likely to qualify if they’re also disabled, elderly, or pregnant.
Children and infants in low-income families can also receive Medicaid, and all states offer some type of children’s health insurance for working families whose children are not covered (www.insurekidsnow.gov, or 1-877-KIDS NOW). This program, called Healthy Families, ensures that kids can get doctor visits, prescriptions, and hospitalization at little or no charge, even if the families have an income above the federal poverty level; it also serves families regardless of immigration status, which the program doesn’t require you to reveal. In most states, you can qualify if you earn up to $34,100 for a family of four.
Some doctors and hospitals go the extra mile to bring health care to low-income people. Mobile health clinics — think of an RV packed with medical equipment — provide free or low-cost care to many poor neighborhoods in cities across the country, from Louisiana swamp country to farm worker homes in Yuba City, California. For more information, visit www.mobilehealthclinicsnetwork.org.
As nurse practitioner Suzy Yost explained to a reporter, “We don’t turn anyone away, whether or not they have insurance or the ability to pay.”
Hospitals that accept federal dollars are also required to offer financial aid or free care to low-income patients. Advocates recommend that hospitals should offer you an aid form as soon as you reach the intake window. (California, in fact, has recently passed legislation that requires that uninsured and underinsured families be given notice about their consumer rights and financial options when seeking care.) Beware: The forms for getting the aid can be just as confusing as the prescription bottles. Ask if there’s someone at the hospital who can help you apply.
If you’re not covered by any insurance and medical costs are making it hard to make ends meet, check your phone book under “public health department” to find the public clinics available in your area (just be prepared to wait a whole afternoon or more for service in some places). If you have a regular doctor and dentist, try working out a payment program with them. Many medical providers accept credit cards, and many will also let you pay off your bill month by month. Some dental societies sponsor free teeth cleanings and checkups, and dental schools offer free or low-cost services.
You can cut the cost of your medicines by asking your doctor or pharmacist to use less expensive generic drugs instead of brand names whenever possible. Many drug companies also offer drugs for free or at reduced cost for people in need. To see if you qualify, contact the Partnership for Prescription Assistance at https://www.pparx.org/Intro.php or 1-888-477-2669. And remember: Taking your medicines now can help prevent even costlier problems in the future.
Making the time, finding the motivation
Staying healthy takes time as well as money. Even if your days are already jam-packed and hectic, you can find a way to fit your health care into your schedule. Your doctor may be urging you to get some exercise, but you usually don’t and you just don’t see where the time will come from. There’s no need to spend hours at the gym: You can get healthier by staying active for 30 minutes five days a week by taking “exercise breaks” whenever you can — using the stairs instead of the elevator, dancing to an exercise video, walking the dog, stretching before you go to bed. It’s also important to add muscle strengthening exercises to your regular routine at least two days a week, such as heavy gardening or yoga.
Any kind of lifestyle change takes commitment and motivation. For some people — especially people who suffer from depression — this can be the biggest obstacle of all. Depressed people often have trouble seeing the point of medical treatments. After all, it takes at least a little optimism to believe that a pill or a daily jog can actually improve your health. A study published in the Archives of Internal Medicine found that people who are depressed are three times as likely as nondepressed patients to stray from their treatment plans.
They don’t just skimp on their antidepressants, either. People who are depressed are less likely to take potentially life-saving medicines for heart disease, diabetes, and other serious illnesses. Your doctor should discuss options for depression treatment, including medicine, counseling, and even exercise.
Good teamwork for good health
Ideally, your doctors and nurses should work with each other. A study published in the Journal of General Internal Medicine found that low-income women were more likely to follow important medical advice (in this case, getting tested for breast cancer) if their health care providers communicated well with one another.
The study also found that women had an easier time following advice if they saw the same doctor or doctors on a regular basis. In other words, you’ll have a hard time keeping with the program if you bounce from one doctor to another without a referral or lose touch with your current doctor. It’s very important to keep your doctor appointments. If you do miss an appointment, schedule another one, even if nobody from the office calls to check on you.
Other tips for good teamwork: If you have more than one doctor, make sure all of them know about each other. Keep a personal medical record and take it with you to each visit; also, keep track of all the medicines you’re taking and give each doctor a list of them at every visit. (If you have trouble writing down the names of the medicines, just bring them all to each visit in a bag.) Finally, doctors’ offices often rely on patients to know when they need to be seen. So if you think you need to be seen or are not sure when your next appointment should be, don’t assume the doctor will call you to tell you — take the initiative and find out.
As the Journal of General Internal Medicine report concludes, many women in the study manage to watch out for their health “despite numerous barriers.” With some planning and getting help when you need it, you can too.
Haynes RB et al. Helping patients follow prescribed treatments. Journal of the American Medical Association. December 11, 2002. 288(2): 2880-2883.
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American Academy of Family Physicians. How to get the most from your medication. February 2003.
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O’Malley A.S. et al. Adherence of low-income women to cancer screening recommendations. Journal of General Internal Medicine. February 2002. 17: 144-154.
Center for the Advancement of Health. Talking the talk: improving patient-provider communications. March 2003.
The Mobile Health Clinics Network. Going out to the community.Mobile clinics bring health care to families of migrant farm workers. July 2005.
Study links lack of transportation options for Bay Area residents to decreased access to care. Kaisernetwork.org. The Henry J. Kaiser Family Foundation. October 25, 2002.
American Medical Association. Making the most of an office visit. 2001.
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Centers for Medicare and Medicaid Services. Medicaid program: General information. April 2006.