Sunday, September 18, 2011

Chicken Pox Makes a Re-Visit

I was covering for another clinician in the urgent care clinic I worked in.  It had been a busy morning seeing all sorts of patients, but then after my lunch break it quieted down, I thought it was due to the torrential rainstorm going on outside.  But once the rain quit, it started getting busy again.
One of the patients I saw after the rain storm was a late 40ish Caucasian woman.  I walked into the exam room after the medical assistant had taken her vital signs. 
“Hi, my name is Sharon, I’m a physician assistant.  How can I help you?
“Well I’m Carla, first off.  The reason I’m here is due to this pain that I’ve been having on my right side of my waist and sometimes going down my right leg.  I saw my primary care physician on Monday (5 days ago) and he examined me and told me that I had sciatica on my right side.  He gave me some muscle
relaxants to take at night, but they aren’t helping.  Then yesterday these skin lesions showed up and they burn and itch like crazy.”
“Okay, let me see the lesions.”
With that, Karla lifted up her blouse and pushed down her waistband of her shorts.  She had erythematous macular-papular lesions in a linear fashion from her spine around the right side of her lower abdomen, which stopped at her abdominal midline.  The skin lesions on her posterior side had a few clear vesicles on them, the skin macules on her anterior side were not as well developed, they were just raised red macules in small groups spread along in a linear line.

 Karla has the typical presentation of herpes zoster, what is typically called shingles.  There are two presenting signs to this disease, one is the classic skin rash which is a macular-papular erythematous rash with clear vesicles on the top of the lesions along with acute pain.  The rash also typically forms into small groups of papules/vesicles and as they age they can become pustular.  They will eventually scab over, heal up and resolve. 
Shingles typically occurs in a dermatome, i.e. it travels along one nerve root (either right or left side) from the spinal cord and breaks out with lesions all along that nerve root as it travels around the body to the midline in front.  Generally, but not always, when herpes zoster breaks out it stays in one dermatome.  It typically breaks out along the thoracic or lumbar nerve roots.  It can break out elsewhere such as the cranial nerves (affecting the eye, face, ears).  If it affects the ear it is called Ramsey Hunt syndrome.  If it affects the eye, then the patient has to be seen by an ophthalmologist, due to their being potential complications associated with the virus attacking the ocular nerves, such as blindness. 
Most patients will also complain of pain along the same nerve root the virus will eventually break out from.  This prodromal pain can occur either days to weeks prior to the actual rash occurring. 

“These really itch like you can’t believe,” said Karla.  “Then I also noticed that when I touch them they have this funny feeling to them like my skin is somewhat numb or something, I can’t explain it.  What’s going on?”
“Well, Karla you have shingles, more specifically what we call herpes zoster.”
“Shingles?  I thought only old people got that?”
“Well actually any middle aged to older adult can get shingles.  It’s a reactivation of the chicken pox virus in your system.  You had chicken pox when you were younger and after it went away, the virus went into hiding, and in the case of the chicken pox virus it hid at the end of all of your nerve endings.  Then when your immune system wasn’t looking and was paying attention to something else going on in your system, the chicken pox virus took advantage of that opening and popped open with new viral lesions along the nerve root that it had been hiding along.  In your case one of your lumbar spine roots on the right side of your body.”
Karla stood there uncomfortable.  She was trying very hard not to itch her skin lesions.    “So are these things infectious to other people?”
“Yes, they are.  You can’t let anyone touch them, especially those lesions right now that are forming on your back side.  And you can’t be around anyone who hasn’t had chicken pox themselves or has not been vaccinated for it.”
“Are these going to spread anymore than where they are right now?”
“They could.  You could still have a batch of the lesions break out on the right side of your midline, right here where you have some redness to your skin.  It’s unlikely that the lesions will also break out in another area of your body.  They generally only break out in one dermatome. I’m going to give you a medication called acyclovir, you have to take it five times a day for one week.  I’m also going to give you some acyclovir cream to help with the itchiness.  You can apply the cream as frequently as you want.  After you apply the cream make sure to wash your hands really good.  Don’t be surprised if the lesions get worse before they get better.  Also many patients have pain that is much worse after the lesions have gone away and cleared up.  This is called post-herpetic neuralgia.  If you have this pain, it can be pretty bad, and if it shows up go to your primary care physician and tell him what happened.  He may have to give you some pain meds for this condition.”
“Oh, I just want to itch these things, between the pain and the itch I don’t know which is worse,” said Karla.
“One other thing, Karla.  After these lesions are all gone, I would seriously think about getting the shingles vaccine in about six months.  It’s rather expensive, but it can help prevent another potential outbreak for you.”
“Okay.  Thanks for the prescriptions.” 

When patients come in and are diagnosed with herpes zoster we give them a one week prescription of a medication called acyclovir.  They take this five times a day.  This medication helps to kill the herpes zoster and put it back into hibernation.  The cream is used to help control the itch (albeit not always effectively) associated with the lesions. 
Many patients unfortunately also have what is called post-herpetic neuralgia.  This can be very painful.  It is typically pain that is felt along the dermatome where the lesions broke out.  It can last for up to several months after the lesions have healed.  Patients who typically get this post-herpetic pain are those patients who are elderly, > 80 years of age.  But it has been known to occur in the younger age groups. 

Patients who are >50 years and older can now receive a vaccine to help prevent herpes zoster from breaking out.  The FDA has just recently changed their recommendations for this vaccine from age 60 and above to age 50 and above. 
With that she somewhat hobbled out of the exam room and out into the foyer of the clinic to meet up with her husband.  I could only hope she wouldn’t end up with post-herpetic neuralgia.

Tuesday, September 13, 2011

A Newborn with Jaundice

I was working in a newborn nursery, and of course a part of this position involved an exam of all of the newborns brought into the nursery.  We would give them their first of three hepatitis B injections and then do their first physical exam.  We checked them out for any cardiac abnormality, genetic defect, problems with jaundice (yellowing of the newborn’s skin), and removed any extra finger digits they may have inadvertently been born with. 

Most newborns do not have any problems.  A few will have cardiac abnormalities which can be anything as benign as their patent ductus arteriosus having not closed (a valve between the newborn’s pulmonary and systemic circulation) to the newborn having tetralogy of fallot (4 defects to their heart), to their not developing the left side of their heart (hypoplastic left heart syndrome).  They can also have an opening between their two lower ventricles (what is called a VSD, or ventricular septal defect), an opening in their two upper chambers (an atrial septal defect), or a problem with one of the heart valves.

Genetic defects in a newborn run the gamut from down’s syndrome (mild mental retardation) from having an extra portion of chromosome 21, to a deadly trisomy 18 defect, which means that the child has extra portions of chromosome 18, in which many of these children not living beyond the first week of life.  Then there are those children who have genetic defects which are visible to us on examination and these include skeletal deformities or brittle bones (these children can be born with a broken shoulder for instance, or by just holding them they can break a bone).  This disease is called osteogenesis imperfecta. 

Much more common is the jaundiced newborn.  Jaundice occurs in newborns due to their having a higher red blood cell count than adults and their having breakdown of these red blood cells sooner than adults.  Most adults have red blood cells that last for 120 days, newborns have red blood cells that last for 85 days. This combined with initially a low enzyme level in the newborn’s liver which is responsible for catabolizing the red blood cells components, is what gives the newborn jaundice.   If the newborn’s bilirubin goes above 25.0 then they are at risk for having neurological involvement, in other words, their brain is affected by the bilirubin in their blood.

Newborn bilirubin will typically peak at 48-96 hours of age with a level of 7-9.0.  A normal adult level for bilirubin is 1.0.  It can take up to two weeks for the newborn’s jaundice to resolve completely.

Typically the newborns would come into the nursery and after having their first physical exam the newborn would be wrapped up in small blanket and placed in a bassinet.  After about 2-3 hours we would take the newborn back into the maternity ward, to bond with mom and begin teaching mom about how to appropriately breast feed their newborn.

We taught them the appropriate ‘latch’ technique.  If the mom ended up having problems with her newborn latching on, so they could feed properly, then when the mom was sent home we would give them the local ‘La Lache’ Society (breastfeeding moms) phone number whom they could call if they had a problem.  We also make sure that these mothers would be seen in our follow-up clinic a week after their newborns were discharged.  At that time, we not only addressed any remaining problems with breastfeeding but we made sure the moms had made an appointment for their newborns to be seen by their pediatrician at two weeks of age. 

Of course, I saw many newborns who had jaundice and I would explain to the new moms what jaundice was all about.  Many of these new moms would be concerned about it, so we also saw these newborns in our follow-up clinic one week after we discharged them. 

A typical scenario I ended up handling was a newborn I remembered who had a bilirubin of 22, at one day of age.  We put him under the ‘bili-lights’ with an eye shade on. He had a scheduled lab draw every 12 hours for his bilirubin level.  We only would take him out from under the ‘bili-lights’ when we brought him into to see his mom for his breastfeeding. 

‘Bili-lights’ is phototherapy for jaundice.  Direct intense light upon a newborn, who is typically only dressed in a diaper will help the newborn’s system break down the byproducts of the red blood cells and therefore aid the newborn in getting rid of it.  Once their own system is able to rev up their own  production of the liver enzyme which is responsible for handling the byproducts of the broken down red blood cells, then they no longer need the direct light upon them. 

When a newborn has jaundice we also have to explain to the breastfeeding mother that the mere act of breastfeeding can increase the newborn’s jaundice.  Their bilirubin can go up.  We know this, understand this, accept this and work with it.  The bonding and the nutrition the newborn acquires from breastfeeding far outweighs any negative they could acquire from having their bilirubin bumped a little bit up from the breast milk. 

It took two days for the newborn’s bilirubin I saw, to begin to safely come down, to the point of where we felt he could go home.  When we discharged him his bilirubin was 12.   We advised the mom to make sure to expose him to direct sunlight during the afternoon.  With the sun shining on him, it would continue to help to resolve his bilirubin.  We told her to also make sure his eyes were covered while she did this.  We also told her to leave him in the sunlight with only his diaper on so that he would get as much skin exposure as possible. 

She brought him back into our follow-up clinic 5 days after his discharge, which was day 8 of his life.  His bilirubin at that time had come down to 8 and he was doing better.  So we made sure that she was comfortable breastfeeding her newborn and understood that even though breastfeeding could increase his ‘yellow skin’ look, breastfeeding him was the best nutrition for him overall.   She left the clinic happy and contently holding her newborn in her arms.     

Saturday, September 3, 2011

A Patient with Elevated Liver Enzymes

I was working in the hepatitis clinic when I went into see a new patient.  By this time I had been working in this clinic for several years.                                                                                                                                                                                                                            
I walked into the exam room and introduced myself.  The patient whom I’ll name, Carlos was a Hispanic male in his mid-30s who was sent into be seen by us in the hepatitis clinic for elevated liver function tests.  He was obese and carried a lot of extra weight on his abdomen.  He worked as a carpenter.  I took his medical history, he had type two diabetes, high blood pressure, and elevated lipids.  Based on his history I could easily have jumped to the conclusion that he had what we in medicine call, fatty liver, or NASH, which stands for non-alcoholic steatohepatitis.  But first, I needed to work him up.  I had learned to never assume anything, you always worked patients up.
Patients who have liver disease will have elevated liver enzymes.  Enzyme levels are tested by acquiring a blood test and sending it to the lab for analysis.  The lab will then give us levels of both transaminases, AST and ALT.  These are the two liver enzyme levels that we look at.  In patients who have fatty liver or NASH these two enzyme levels are typically about 2-3 times the normal value.  To totally work up a patient who has a liver disease we have to acquire all sorts of blood tests to look at their enzyme levels, iron levels, auto immune levels (which will tell us whether they have auto-immune hepatitis, a disease where the patient is attacking their own liver with their own T cells) and viral serologies to rule out chronic hepatitis B and C.  We typically also acquire an abdominal ultrasound to assess the liver size and consistency. 

After acquiring his history, and doing his physical exam, I sent him off for his blood work and abdominal ultrasound.  He came back in 3 months for his follow-up appointment. 
“Hi, Carlos, glad to see you back.  How are you doing?” I asked.

“Fine, I guess.”

I looked quizzical at him and said, “I see.  Well, why don’t you come over her and sit by the computer so that I can go over all of your test results.”

With that, Carlos came over to the computer desk and sat down.  “Okay, Carlos take a look at this, here’s your blood tests results.  All of your work-up for auto-immune disease, in other words this tells us whether your immune system is turning against your liver and attacking it, is negative.  See here, your ANA (anti-nuclear antibodies), ASMA (anti-smooth muscle antibody) are both negative.  Then we take a look at your viral hepatitis serologies and they are negative, in other words you don’t have hepatitis B or C causing your elevated liver enzymes.  You see here your hepatitis B antigen and antibody are negative.  And your hepatitis C antibody is negative.  So the next thing we look at is your iron levels.  Those tests are your ferritin, transferritin and iron saturation.  All three of them are normal.  So that means you don’t have a disease called hemochromatosis, which is just a fancy word for iron overload.  So with your telling me that you don’t drink alcohol except an occasional beer with your friends on the weekend this leaves me with believing you have what is called ‘fatty liver.’  You have the usual risk factors for it, in other words, you have high blood pressure, your lipids are abnormal, you have diabetes and you are overweight.  When we put this whole picture together your condition is what we call the ‘metabolic syndrome.’    Are you with me so far?”

“I think so.  You’re telling me that my being overweight, and a diabetic has given me a problem with my liver.”

“Well you’re partially right.  It’s not just your diabetes, but it’s also the fact that you have high blood pressure and a problem with your cholesterol levels.  They have all worked against you.  The end result is that you are depositing fat in your liver.  Over time this fat can lead to your liver failing, if we don’t get it reversed.  Do you understand that?”

“Okay, now I want to show you the results of your abdominal ultrasound, remember that was the test that you had done where they put a probe on your abdomen and moved it all around with some cold blue goop?”
“Yeah, I remember that test, and they warmed the goop up for me so it wasn’t cold.”                                                                            

“Good.  Well the results of the ultrasound show fat depositions in your liver.  So all of our blood tests and the ultrasound agree with each other.  So now we need to get these elevated liver enzymes back down to normal and keep them there, would you agree?”

“Yeah, how do we do that?”

“What lead you here was your being overweight, having high blood pressure, being a diabetic and having high cholesterol levels, in particular high triglycerides.  So to get your liver enzymes to go down we have to work at it from many angles.  The first angle is to have your start exercising by walking every day.”
“But I do a lot of walking at work, I also lift a lot of heavy wood and my equipment.  Why isn’t  that enough?”

“Well the walking and lifting you do at work is not for an extended period of time, it’s being done in short bursts.  When I talk about exercising I’m talking about an extended, continuous period of time.  I want you to walk every day for at least 30 minutes at a pace where you are slightly out of breathe.   This will over the long haul help you lose weight, I’m talking about a half a pound a week.  Then you also need to stop your occasional beer drinking on the weekends.  You can still go out with your buddies, but just drink coffee instead, or water.  Next, you need to keep your hemoglobin A1C in the 6-7 range, right now it is a little high at 7.3.  Work with your primary care physician to get that down.  Your blood pressures are fine on your current medication, and your lipid levels are fine now that you are on a statin.  I also want you to meet with a nutritionist who can go over your diet in detail to make sure that it is helping you to lose weight.  Lastly I want you to start taking 800 units of Vitamin E a day as well as 3,000 units of omega 3 a day.  Both of these are anti-oxidants and they will help your liver oxidize the fat cells by breaking them open, then you will be able to use the energy stored inside.  If you don’t like burping up fish oil, then you can freeze the omega 3 capsules and take them frozen.  This will prevent you from ‘fish burp.’  Okay, now what questions do you have?”
“That’s a lot of information, can you write it all down for me?”

“How long will it take if I do all of this before my liver enzymes will become normal again?”

“Well, we’ve done this in 30 other patients, much like yourself, and we’ve found that they normalize their liver enzymes after 1 year.  But even after the enzymes are normal, that doesn’t mean you can go back to what you were doing before.  You have to stay the course, if you know what I mean.”

“Alright, I’ll give it a try.  Where do I find this omega 3 and Vitamin E stuff?”

“You’ll find them in any of the vitamin sections of your grocery store, or Sam’s club, or your local drugstore.  They won’t cost very much, about $7 a month.  And here’s your consult for the nutritionist.  Give it to the front desk clerks and they can set up your appointment.  Come back in and see me in 3 months and I’ll get a new set of liver enzymes on you then.”

“Okay, thanks.”
At the hospital I was working at I had done some research on patients with fatty liver or NASH and we had found in the 30 patients we were tracking so far that their liver enzymes normalized after 1 year. We hypothesized that by using the Vitamin E and omega 3 (both of which are anti-oxidants) we not only oxidized the fat cells in the liver, helping the body to get rid of them, but we also helped to address their elevated triglyceride levels.   If they kept the weight off and stay on their diet and away from alcohol then fat did not re-appear in their liver and their enzyme levels stayed in the normal range. 

As with so many other diseases, having NASH or fatty liver is a chronic disease, it took years to form and create a problem with the liver enzymes, and hence it would take years to un-form and allow the liver to heal back up.  If left unaddressed, fat in the liver continues to create inflammation, which over time creates scarring, which over time finally creates a cirrhotic liver, or end stage liver disease.  And end stage liver disease can lead to liver failure or liver cancer.  So the bottom line is that fatty liver or NASH is not a benign disease. 
Within the medical literature there is not a lot of information on treatment that has shown itself to be useful in this disease.  Most physicians are only able to advise their patients to lose weight, work on their diabetes (if they are one) and exercise. 
I saw Carlos back in the clinic in 3 months.  He was doing better, he had initiated a walking program with his wife after dinner every day.  And his primary care physician note stated that he was motivated to get his diabetes under better control.  He had also meet with the nutritionist.  He had lost 7 pounds of weight.  His liver enzymes drawn that morning showed that they were down by about 10 points each, so things were looking good for him.  After 1 year his liver enzymes had normalized, he had lost a total of 35 pounds, his marriage was much better with him and his wife talking on their daily walks, and his blood pressure readings were better.  After two years of his being on the omega 3 and Vitamin E he had lost a total of 50 pounds, his body mass index was now normal, he was off of his diabetic meds except metformin, and he had been able to cut down on his blood pressure meds to just taking a small dose of one medication once a day.  So with this progress, I discharged him from the clinic and just had his primary care physician do his follow-ups. 

Friday, September 2, 2011

Above All Else, Hold Onto Your Integrity

In medicine there is an unwritten rule of professional conduct.  It states that the hospital attending is the only one who is supposed to go in and tell a patient their medical diagnosis and treatment.  Anyone else on the medical team is just supposed to pretend as though they don’t know anything until after the attending has discussed the diagnosis with the patient.  Usually this works out, but it can also lead to a breakdown in patient’s trusting their providers  and/or asking team members to lie to patients until the attending can have their discussion with them.  We as medical providers need to have integrity in everything we do, and that includes being truthful with our patients which helps them build trust in our capabilities.
I remember one such instance where I was asked to compromise my integrity.   It eventually led to me leaving this position in the bone marrow transplant unit and moving out of state to take another PA position.  As I have done in the past, I will continue to do in the future, and that is to hold onto my integrity.  I will always put my patient’s well-being ahead of myself and tell them the truth so as to allow them to trust me then, and in the future.

I was working in a bone marrow transplant unit at a major academic hospital, and as such was responsible for 5-6 patients every day.  I made rounds with the attending physician, wrote progress notes, ordered labs, radiology, called for consults, etc. 

I had been assigned an 18 year old patient who had acute myelogenous leukemia and was being admitted for an allogeneic bone marrow transplant, using her sister as her donor.  Cheryl was my patient all the way through her pre and immediate post-transplant period.  She was doing as expected by day 30 post-transplant and was therefore discharged.  Afterwards, she was followed in the out-patient clinic where I saw her and then checked her out with the attending physician. 

Cheryl was doing as expected until day 60 post-transplant.  That’s when I received a phone call from the in-patient attending telling me that she was being re-admitted due to her having a grand mal seizure at home. 

The first thing I thought of was she had relapsed with her leukemia.    She arrived by ambulance and was immediately brought up from the emergency room.  I was ready for her, I had written her admission orders and had my lumbar puncture kit ready with a consent form that she and her mother would have to sign. 

“Hi, Cheryl, I’ve been told what happened with you at home.  I know that you are thinking the same thing I am, as well as the attending physician is, and that is the issue of whether your leukemia is back.   For us to rule this out or in I have to do a lumbar puncture on you right now.  We have to get some spinal fluid down to the lab for them to look for any leukemia cells.”

“I know,” Cheryl said, her face reflecting the image of sadness.

“Okay, well then let me go over this consent form with you and then get the lumbar puncture done.”


Consent form signed, lumbar puncture was quickly done and I sent the spinal fluid down to the laboratory for analysis.  Several hours later her cell count came back normal, as well as her glucose and protein levels.  But the spinal fluid results didn’t totally rule out a leukemia relapse.  She could have a negative spinal tap and still have leukemia.  The only way to rule this out was to do a cranial MRI and look for thickened nerve sheaths.  Her MRI was scheduled for the following morning.

I can only imagine Cheryl had a restless night trying to sleep.  Her mom was in the cot next to her.  First thing in the morning she was down in the MRI machine having her contrast MRI done. 

After rounds were done, our team headed down to visit with the neuro-radiologist to go over her results.  He quickly put the scans up for us to see.  To educate all of us, he went over the differences between T1 and T2 images.  Then he pointed out that Cheryl did not have any evidence of leukemia, no thickened nerve sheaths. 

Then he said,” what she did have was a difference in her uptake between T1 and T2, which he said was seen in patients who were having problems with cyclosporine.  Therefore she had cyclosporine related seizures. “

“What a relief,” I thought to myself.  “That’s easy to take care of, we just have to switch her immunosuppressant medications and her seizures will stop!”

The team finished looking at the other radiology reports we needed to see and then the attending said he would discuss what to change Cheryl over to with another attending and then be up to see her. 

I went back up to the floor and was busy writing my progress notes, when Cheryl’s nurse came to find me.  She told me that Cheryl was nauseated and vomiting and she needed an order for meds.  I got up and immediately went into Cheryl’s room. 

“Cheryl what’s going on, when did your nausea and vomiting start?”

Through dry heaves, Cheryl answered me, “about thirty minutes ago.”

 A quick scan of Cheryl’s teary demeanor, her tightly holding onto her mother’s hand, her mom hugging her daughter so tight it must have hurt, and Cheryl hugging the upchuck bucket, was all I needed to see.  Cheryl and her mom had worked themselves up into an anxious almost panicky mode of operation over whether she had relapsed.  I turned to her nurse standing in the room and gave her a verbal order for 1 mg of Ativan IV now. 

As I turned to leave the room, Cheryl asked me a direct question I couldn’t ignore. 

“I know you know, Sharon.  You have to tell me, is my leukemia back?”

I turned back around to Cheryl and took in a deep breath.  Quickly I thought to myself, “did I break the accepted professional medical code of conduct and tell her the truth?  Or do I somehow wiggle out of answering her question, and wait for the attending to show up to tell her, even though by now it was 4-5 hours after rounds had ended.  If I answered her with the truth, all of her anxiety and panic over a possible leukemia relapse would immediately dissipate into nothing.  But I knew withholding the truth would be mean and dishonest to her. “

I had to take the plunge and in so doing, hold onto my integrity. 

“Cheryl your MRI showed that your leukemia is not back.  It showed that you are having a problem with your cyclosporine medication and we have to switch you over to another immunosuppressant medication.  The attending will be up here to discuss it with you hopefully before too long.”

Hearing this, Cheryl and her mom turned to each other and hugged each other through their tears of relief. 

“Thank you, Sharon” was all Cheryl was able to mouth back to me. 

By then her nurse had left the room in an angry huff and immediately went across the hall to the head nurse’s office. 

I turned to leave the room to finish up my progress notes.  Only now it was me who had the upset stomach, I knew I hadn’t heard the last of what I had just done.  An hour later the attending finally did show up and go into her room to discuss the change of medications with her and her mom.  Thankfully Cheryl did just fine on her new medication and was sent home a day later to be followed up in the out-patient clinic.

As I was handing Cheryl her discharge orders, she said, “Sharon I heard what happened to you yesterday and I’m sorry about it.”

“Cheryl, what happens to me because of my discussion with you yesterday, is my concern.  What I would like to explain to you is why I did it.  You asked me a direct question that I couldn’t ignore.  You deserved an answer that was truthful and honest.  There was no reason for you to be in this room upchucking your stomach contents into the yellow bucket.  I could have lied to you, and told you that I didn’t know anything, when I did.  But then I would have compromised my integrity in the process.  And if you knew that I had lied to you, where would that have lead you in the future when you see me in clinic?  Would you have been able to totally trust what I told you then?  I doubt it.  You need to be able to trust your providers, you need to know that they are telling you the truth, even when it costs them to do so.  Otherwise the relationship that you need to have with your medical providers, which has to be built on trust, can too easily be shattered.  You need to know that when I see you in the clinic and advise you to do something, or change your medications, you can trust my word about it and do it.  Had I lied to you yesterday, the possibility of your compiling with your medical treatment program decreased.  I want you to understand that and know that I was looking out for your benefit yesterday, no matter what happens to me.  Understood?”

 “Yes, I understand and I want to then say ‘thank you’ for doing it.”

“You’re welcome, and I’ll see you next week in clinic, do well until then.”