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7. "What I believe matters a lot"


When clinicians talk with patients we bring our compassion and knowledge to the table.
Patients, our partners in achieving outcomes, bring their knowledge, their apprehensions, their belief systems and their beliefs to the table. We must share our knowledge in order to assure patient safety. Clinicians must listen to patients, and if patients seem reluctant to talk then we must ask probing questions.
Belief systems include both metaphysical perspectives and also confidence in complimentary approaches to treating illnesses. Complimentary approaches include herbal, homeopathic and vitamin supplements or “remedies”. The issue is not whether these approaches work but whether patients believe they work. Doctors need to understand patients’ beliefs and to utilize them to an advantage. Working with patients is about understanding and partnering.
Case Study:
A 35 year-old woman has been diagnosed with a clotting tendency secondary to deficiency of protein S. When blood clots form in the body protein S works to break these down as part of the normal healing process. A deficiency of protein S can lead to enlargement of clots and can be very dangerous. The patient had suffered a deep vein thrombosis, now resolved after anticoagulation therapy. She will require warfarin, a medicine that interferes with Vitamin K dependent synthesis of proteins that cause clots to occur in the first place.
The patient is a highly educated professional woman and believes in the merits of complimentary therapies, though she does not volunteer this information when her doctor discusses her diagnosis; and he never asks about this.
The risks of warfarin therapy are two fold. Under-treatment might result in additional serious clotting. Over-treatment might predispose to serious haemorrhaging. Warfarin therapy is an orchestrated balancing act, and vitamin K is often given to reverse the effects of over anticoagulation.
For the first three months the patient’s blood test, the INR level, is within the safe range. In the fifth month she suffers a moderate gastrointestinal haemorrhage, and her INR test is found to be way above the safe limit. On questioning, the patient admits to taking herbal remedies, “things my sister recommended” but is not sure just what they are. She is treated successfully with blood and plasma transfusions and vitamin K. She could have died!
Numerous herbal substances interfere with warfarin, either because they have warfarin-like activity, i.e., they prevent clotting, or because they interfere with the metabolism of warfarin and enhance its activity leading to over anticoagulation. This patient’s gastrointestinal haemorrhage was possibly preventable, had her doctor included the following as part of his initial conversation:
“Ms Smith, you have a serious clotting condition, a tendency to form clots related to a deficiency in a blood factor known as protein S. Everyone forms blood clots in response to cuts and trauma, and protein S prevents the growth of these clots by helping to break them down as part of the healing process. If clots do not break down they can grow and cause serious harm.
You will need to take warfarin daily to prevent clotting. Warfarin is a tricky medication to take as many other medicines and even some foods, herbal, homeopathic and vitamin supplements can interfere with its effectiveness, resulting either in a risk of severe bleeding, over-activity, or a risk of further clots, under-activity. I am giving you a list of medicines, foods and supplements that you must avoid when taking warfarin.
Your life could be endangered.
If you are inclined to take herbal, homeopathic or vitamin supplements, I would ask that before doing so, you discuss this with me. If I know that a supplement is safe then I will advise you so. If I know that a supplement is unsafe, or if there is insufficient information to assure its safety, then I would ask that you not take the supplement. We both want to achieve a safe outcome, for you to enjoy life free of concerns about haemorrhaging or clotting, and only by working together can we hope to achieve these goals. Please, please come to me with your thoughts before you begin taking anything.”
Always better to be inclusive and safe than exclusive and very, very sorry!
* Editorial comment:
Some of you may wonder why I included homeopathic supplements in my list of concerns, and the reason is that patients often confuse herbal and homeopathic preparations. I wanted to be as inclusive as possible in my recommendations.
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