OUTSIDE THE OFFICE

California Highway Patrol Syndrome

By Sanjay Dhar, MD

On a recent Thursday, at 2:30 in the afternoon, I received a call from the local emergency room about a patient of mine, “DB” (not his real initials), who had been brought in by the EMS with evidence of an acute myocardial infarction. The EKG had been faxed to me, and the diagnosis was quite obvious. The cath lab personnel were informed, and the nurses were clocking the door-to-intervention time rigorously.

DB was a man in his late forties, whom I had seen almost eight years ago in almost the same circumstances. Back then, he had a cardiac arrest in the field, followed by a complicated coronary intervention, requiring three coronary stents and a prolonged hospitalization. He had been sent home with a host of medications, a long list of do’s and don’ts, and advice about preventing future cardiac events. I had followed him for six years but had not seen him since then because he was doing quite well.

As I rushed from the office to visit DB in the emergency room, several thoughts raced through my mind. Had he stopped taking his medications? Was he suffering from a rare predisposition for repeated heart attacks at a young age? Had we investigated him thoroughly when he had first come in eight years ago? No answers were obvious to me, but I was curious to know more.

The subsequent coronary intervention went smoothly. DB received only one stent. The previous three stents were in a different blood vessel and had developed only minimal nonobstructive scar tissue. DB had made the right decision to call for help quickly this time, thereby preventing a complicated course of follow-up treatment.

After the procedure, I sat down with DB to review all the previous events. Eight years ago he was overweight, smoked two packs of cigarettes a day, didn’t exercise, and had high blood pressure and high cholesterol. His father had died of a heart attack in his mid-forties. Several members of his family had also suffered heart attacks at a very young age.

After his first heart attack, DB had quit smoking and lost weight. He began eating better and exercised daily. He made several promises to his friends, family and physicians, and he was proud of being on track. In the last two years, however, he had slipped. He had gone back to smoking. He didn’t have time to exercise or maintain a diet because he was working two jobs to help pay his mortgage. He had also stopped taking some of the medications because he couldn’t get a prescription refill from his doctor, whom he had not seen for two years.

I was stunned by DB’s honesty. I asked, “DB, why were you not careful?” His response was even more stunning: “Doc, I felt lucky, I thought that if God saved me once, he would do it again.”

DB’s argument is similar to what one of my patients, a California Highway Patrol officer, told me several years back, something I have named the California Highway Patrol Syndrome. The officer said that people love to drive fast on winding California highways, surrounded by pastoral beauty and pristine views of rolling hills and vineyards. However, every time they see a CHP officer parked in the bushes, they slow down. They glide past the officer’s car and strike a calm, smiling pose while pretending to ignore the presence of another human being parked diagonally to their traveling vehicle.

By this time, the driver is going 60 mph in a 65 mph zone. Right after the next turn, however, he or she accelerates back up to the original speed, perhaps 80 mph. Now, why did the driver do that? Well, it was a calculated risk. The CHP doesn’t have enough financial resources or manpower to post an officer every five miles. Besides, cars are quite safe these days, so traveling a little faster than the speed limit doesn’t seem to increase the chances of having an accident.

Maybe patients think like that. Maybe they feel that we physicians are the CHP officers on the road of life. Maybe they act appropriately and make the right promises in our presence, only to forget us later on when they leave the “period of close supervision.” Maybe they think, as my patient did, that modern medicine with all its technical advances can rescue them again and again. Maybe they have a right to lead the life they want, and we should be available only when they are in trouble.

DB did follow our recommendations for almost six years. Was the duration of therapy (in his case lifelong) too much to ask of him? Can he be put into a category of being partially noncompliant? We physicians lack training in determining the causes of our patients’ noncompliant behavior. We also lack the time to sit down with each patient to reinforce the importance of every piece of advice.

Noncompliance could indicate an inability to afford the medications, to tolerate the side effects, or simply to deal with the illness. Maybe physicians are partially responsible as well. Do we always tell the truth, and nothing but the truth, to all our patients all the time? Do we always drive below the speed limit? If the answer is no, then how can we expect our patients to be honest with themselves?

Should the “fear factor” that often accompanies diagnosis and management of a medical condition be lessened to a different, friendlier approach? Should we say something other than, “Follow my advice or face the consequences”?

By providing comprehensive information at the initial meeting, increasing patient awareness of the disease, and keeping the therapy as simple as possible, we may be able to increase the patient’s awareness of the benefits of long-term therapy. Treatment strategies for young patients diagnosed with chronic conditions—such as diabetes, hypertension and high cholesterol—should focus on the fact that in their marathon, these patients are just at the starting line.

Certain responsibilities also lie on our shoulders. We need to monitor these patients and guide them through various strategies and stages. Maybe there is room for a California Highway Patrol officer in everyone’s lives. Are you ready to enroll yourself in the Academy?