Early into my intern year, I conducted a home visit for one of my favorite patients with heart failure. Despite his numerous medical problems and difficult life circumstances, this patient was always exceedingly respectful, polite and grateful for the care I provided.
I had taken a special interest in his case due to his history of multiple hospitalizations for heart failure exacerbation. Surely, there could be something I could do as his primary care doctor to reduce the frequency of his hospitalizations. The goal of the home visit was to develop a good schedule for organizing and taking his various heart failure medications — a task that had become admittedly overwhelming for him.
One of my internal medicine colleagues accompanied me on the visit. We arrived at the patient’s home on a beautiful fall afternoon. Seated on his front porch, the patient greeted us with a friendly handshake, ushered us inside, and offered us a seat. His house was immaculate and uncluttered.
We asked him to show us his medications. He pulled a large plastic bag out of his bedroom closet and emptied about 30 pill bottles onto the bed. Several of the medications were old prescriptions that he was no longer taking, so we put those in a separate bag. There were a couple of duplicates, as the pharmacy would deliver his medications on a regular schedule whether he needed the refill or not; we put the duplicates in a separate bag, as well.
There were 11 medications in total. Some required two to three times daily dosing. One of the medications had to be taken with food. One of the pills had to be split in half. The diuretics had to be taken in the first half of the day to avoid the need for excessive urination at night. Lastly, we had to set up a regimen that would not require taking an excessive number of pills in one sitting.
Between myself and my physician colleague, it took just under an hour to review all of the medications, come up with a dosing schedule, and fill the pill boxes appropriately for a one-week supply. It was surprisingly arduous. On several occasions, we second-guessed whether we had already distributed one of the medications into the pill boxes. Several of the pills looked like. Even for an organized patient, this would be an exhausting weekly regimen fraught with the potential for mistakes.
We discussed the possibility of blister packs with the patient, but he felt these would not be a good option because his dosages were frequently being adjusted, and the medication fill dates did not line up well. It seemed that the pill boxes would work best for the time being.
Afterward, I debriefed the visit with my colleague. It was certainly enlightening to be in the patient’s shoes for an afternoon, navigating the complexity involved in designing a workable medication regimen and filling the pill boxes appropriately.
In the five months that followed, the patient had three readmissions. Medications have since been added and dosages adjusted, and noncompliance remained a likely contributor to his hospitalizations. It turned out that for this patient, preventing readmission would require more than simply developing a workable schedule for taking his daily medications and filling one round of pill boxes. However, I do believe that the more we as physicians can experience the challenges of managing a chronic disease from a patient’s point of view, the more effectively we can design solutions to help patients self-manage their disease and stay well. This was just the start.
Nandini Kumar is a first-year resident with the Duke Family Medicine Residency Program. Email nandini.kumar@duke.edu with questions.
Editor’s note: Duke Family Medicine residents guest blog every month. Blogs represent the opinion of the author, not the Duke Family Medicine Residency Program, the Department of Community and Family Medicine or Duke University.