I had a patient, seventy-five years old, whose kidney disease had been stable for many years. Since lowering blood pressure is one way kidney doctors relieve stress on the filtering mechanism of the kidney, at our most recent appointment, I prescribed an antihypertensive to help maintain his function. The man turned to me in some distress and said, "Do I have to take this for the rest of my life?"
Patients don't like medication--except for the ones who do. People have strong reactions to the idea of drugs, depending on the particulars of their history and temperament, and sorting out these factors is a key part of practicing good medicine. Without patient participation, "compliance" can easily feel like coercion.
People aren't entirely wrong to fear medication. We live in a drug-happy society, where there is supposedly a cure for every ill, a pill for every occasion. (Just watch TV for a minute, and check out those "ask your doctor" ads.) But a drug that works is also a drug that changes the body's physiology, and the line between a therapeutic and a toxic dose is a fine one. Side effects-evidence of some degree of toxicity-are an almost inevitable feature of taking medication. Take the case of blood pressure medication: many of my patients with severe renal insufficiency are on high doses, which present the possibility of very low pressures that could lead to dizziness, weakness, nausea, even blackouts. Patients have to do their own cost-benefit analysis in these cases: how much discomfort and uncertainty are they willing to tolerate in their daily lives to preserve the long-term function of their kidneys? In my own life, I've had struggles with taking enough insulin to cover my meals because the sensation of hypoglycemia is so unpleasant and threatening. A sugar that bottoms out deprives the brain of needed glucose and can lead to unconsciousness, even death, so I've always erred on the side of higher sugars, despite the potential complications stemming from poor control. For me, having a reliable brain and a sense of minute-by-minute safety has allowed me to have the active life I wanted as a physician and a traveler. That's the deal I've made with my illness.