Reading the name of the last patient on my schedule gave me a glum feeling of foreboding all day. She’s an 80-year-old woman who has been in my office frequently regarding poorly controlled rheumatoid arthritis. The nurse had sent me a note that read as follows: "[Insurance] won’t cover certolizumab. They prefer etanercept, adalimumab, or infliximab. Patient has appointment this afternoon to discuss. Not doing well." Little notes like this are usually a pretty reliable indicator that a long, difficult visit is impending.
My game plan was simple. I would tell her that her insurance didn’t cover certolizumab, so I would have her try one of the covered medications. The concept seemed clear to me. A younger patient would probably have asked me to simply change the prescription over the phone.
That afternoon, after exchanging the usual pleasantries, you can imagine my surprise when I found out that she was now doing well, contradicting the nurse’s note from just a few hours earlier. Her medications were suddenly helping her! I was so surprised that I thought perhaps she was just being ironic, but she really meant it.
I was delighted to hear that she was better, because shorter visits with fewer complaints are always a great way to end a long day of clinic, but my delight was dampened after I examined her. She had numerous swollen finger joints and she couldn’t close her hand into even a loose fist. It was hard to imagine that she could do much of anything with hands in that sorry condition.
I told her diplomatically that I didn’t think that her RA was doing well at all. She countered that she wasn’t having much pain, and she didn’t expect her hands to have further improvement with the addition of the biologic medication. To further complicate matters, her long-anticipated move to an assisted-living facility was going to occur in the next few weeks. After reading about certolizumab she felt that this was not a good time to start a new medication, and she was worried the medication would cause leukemia!
There was a yawning gap between my great expectations, and her low expectations. This scenario comes up more often with older patients. Lower expectations and fear of dire side effects cause patients to settle for a poor treatment outcome. My blood sugar and the late afternoon sun were both sinking. I wasn’t going to twist her arthritic arm to start a biologic, so I decided on a strategic retreat. After sending her home with a few pounds of glossy drug company literature regarding the medications her insurance preferred, I told her I hoped we could bridge the expectation gap at her next visit.