Of all the malapropisms I learned in my training, calling gout "the gouch" is my favorite, since it captures vividly the unhappy nature of this ailment. The 43-year-old man whom I saw for a follow-up visit was certainly unhappy. Everywhere I looked I found swollen, tender joints; large effusions in his knees; tophi; extremely limited hand function; and difficulty walking. He was unhappy, and he let me know it.
"I’m doing everything that I’m supposed to, but I’m not getting any better."
In the face of these accusations, I decided to take a better look at his chart in the hopes that I’d find something to help guide his treatment. His gout was so bad, and his uric acid was so high, that I was concerned he might have some sort of myeloproliferative disorder. I ordered additional labs and I wasted some time looking for the results before I asked the obvious question. "Did you do those labs that I ordered?" I got a sheepish reply of "no." It turned out that he wasn’t taking his allopurinol either. So, Mr. I’m-doing-everything-that-I’m-supposed-to-do-but-I’m-not-getting-any-better had not done his labs or started his medication. If you can figure that out, let me know.
Compliance was obviously not his forte.
I can’t help but wonder how health care reform will ever work if we can’t find creative ways to get our patients to follow instructions. Some of my patients who work for one of the local hospitals get a discount on their health insurance if they maintain a normal weight and refrain from smoking. The insurance does urine testing to make sure that they are not smoking, but I’m still in the dark ages and rely on the honor system by asking my patients if they are smoking or not.
I doubt that doing urine screens for colchicine and allopurinol will be feasible, but it would be really easy for insurers to check our electronic prescriptions against the pharmacies’ electronic records. If a year goes by and the patient only buys enough medication for a month or two, that is a marvelously helpful bit of information.
I had a little taste of that once. I had a patient who was on three different gout medications but continued to do poorly. I was at my wits end trying to solve his problem until I had the nurse call the pharmacy and we found out that he wasn’t filling his prescriptions regularly.
A friend told me, "I take my medication religiously." After a brief pause he added the qualifying phrase, "Once a year!"
Dr. Greenbaum is a rheumatologist who practices in Greenwood, Ind.