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Demystifying Medicine One Week at a Time

Inertia

I’m working in the hospital this month, managing a team that consists of a resident, an intern, and a sub-intern (a 4th year medical student on a job audition).

I do these in-hospital rotations two to three times per year.  I usually get pretty anxious beforehand, since the vastly different “rounding” schedule throws my normal patterns into disarray.  Also, the patients are much sicker. These folks are in the hospital, after all.

I always wind up enjoying my hospital rotations. Mostly because helping very sick people get better is emotionally satisfying. Also, I find that working with the residents, interns, and students is rejuvenating and keeps me on my toes intellectually. I learn a lot. Invariably, I see and experience things that I’ve never seen before.

The hospital is incredibly dynamic. So much goes on in such a short time for a hospitalized patient that it’s enough to make anyone’s head spin. That includes us doctor-types, who in theory are calling the shots.

That’s why when there’s a relative standstill, it’s very noticeable.

My dictionary defines inertia as “Resistance to action, motion, or change.”

Some of the patients that get admitted to our service typify this.  No matter how many adjustments we make in their management (medications, which specialists we consult, what IV fluid we provide), they just seem to stay in bed. That’s why I encourage my team to order that patients get out of bed, at a minimum to sit in a chair every day. I call this type of inertia bedrest. Bedrest is a time-honored therapy that has been shown in condition after condition to be counterproductive. I hate bedrest inertia.

Sometimes patients get better, at least to a plateau point where they no longer need ‘acute care’ hospitalization.  They may not be well enough to go home or resume their normal activities, thus requiring a short stay in a rehabilitation hospital or at a skilled nursing facility (i.e. nursing home).

For many reasons, but usually having to do with their insurance benefits, these patients may stay longer in our hospital than is medically necessary or justifiable. The hospital doesn’t like this since the insurer will decline payment for the ‘extra’ hospital days. Also, a well patient occupies a bed that might go to a sicker patient in greater need.  This is discharge inertia.

Patients that I care for in my office have their own type of inertia.  I call it denial or pre-contemplativeness’ inertia.  This occurs when a patient is overweight, or has high cholesterol, and pledges to make appropriate dietary and exercise interventions to counter these risk factors.

Maybe I’m too soft: At visit after visit, some of these patients continue to tell me what they think I want to hear (and genuinely do!)–that they’re going to make the changes necessary to improve their health.  But they don’t do it. I think almost everyone can relate to that.

The same type of inertia holds true for medications.  I can prescribe what I know to be safe and effective therapy; even though some patients insist they’re taking their medications, I know they don’t take their pills. Should I yell? Some doctors do–and they have their adherents, people whose lives they’ve changed (e.g. by getting them to quit smoking or stop eating junk food), but yelling usually winds up alienating more than it helps.

Let’s not forget that doctors are complicit, too. We engage in therapeutic inertia. This type of inertia occurs with patients on medication, e.g. blood pressure medication. At their office visit the blood pressure is improved but not yet optimal. Often we chicken out of making a necessary adjustment. Maybe because it’s easier not to rock the boat. Maybe the patient has indicated they are happy with their regimen and do not wish to change.

If I had to summarize, I’d say that in health, inertia is a positive: If you’re in homeostasis–biologic balance–and feeling good, resisting change is probably the way to go.  But in health care, my examples above show that inertia is a counterproductive force when one is ill and trying to return to a state of health.

3 Comments

  1. I definitely listen to my doctors! But I can see how it’s difficult for people to be compliant in all areas of health. Staying healthy in the US is very expensive and our daily habits are poor (healthy food is much more expensive than junk food and we rely way too much on our cars when we could often just walk!). In my naive and simplistic view, it seems like doctors would be happy with whatever kind of compliance they can get from their patients. Eating healthy, not smoking, not drinking too much, exercising, taking the proper meds—if some of these are met, but not all, well, then that might be all one can ask for.

    • glasshospital

      March 20, 2010 at 10:04 am

      “Eating healthy, not smoking, not drinking too much, exercising, taking the proper meds…”

      If everyone did these simple things, we’d practically not need hospitals anymore. And we could divert ambitious young doctors into other fields, like rebuilding our nation’s infrastructure and setting them up to monitor fairness and compliance in the financial sector.

      But seriously, if as a nation, we practiced those healthy habits, our national health expenditure would go WAY down.

      Thanks for your comment, Susan!
      -GH

  2. Hi Doctor,
    I wanted to throw out a tiny different patient side point of view that I think is quite easy to forget from the doctor’s perspective sometimes. Keyword being sometimes.
    You have a great theme throughout the post, but towards the end when you explain many patients who give you the yes that they are taking their medications, but in reality are not, there could be several reasons for why patients say “Yes I am taking my pills” but really are not.

    1. Not comfortable with telling their doctor(s) they disagree with the treatment plan
    2. Have been taking their blood medications for years an saw no results, so decided to finally stop
    3. Had side effects from the medications that were told to be “very unlikely” but are now reality

    I think there are reasons for why patients do the things they do, more than sometimes may meet the eye. Especially when it comes to not taking medications. From personal experience with that, the issue could have been avoided had the doctor not had such an ego, and been more open to other perspectives.

    Great site, and thanks for sharing your perspective from an MD’s point of view, seems very rare to find a site like this.

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