The Blue Canister

Patients say the strangest things!

The first time I saw Rose she was sitting in the primary care waiting room reading from her Kindle. As the behavioral science faculty member, my job is to shadow residents to observe and evaluate their interpersonal, listening, and communication skills. As I moved from room to room, I noticed Rose sitting there. Imagining she might not have checked in with staff, or that residents were running late, I approached her to ensure that all was well.

We started to talk. I intuited immediately that Rose enjoyed conversation and talking about her life. I sensed a certain pride. At age 90, Rose had agreed to hip replacement surgery. Recovery had gone well. She walks with the aid of a cane and had resumed her life, including swimming laps and water aerobics. One day, while stepping out of the pool and walking to the locker room, Rose slipped, fell, and broke her leg. She was hospitalized and returned to rehab. Now she was back to playing nine holes of golf twice a week. Ever health conscious, Rose refused to ride in a cart, preferring to walk and talk with her friends.

She also resumed playing doubles tennis. I asked Rose how she managed the physical demands of these sports, and in a self-satisfied tone she told me, “I’m a jock.” I was drawn to Rose and to her story, impressed by her feisty love of life, her intelligence, and her commitment to physical health and activity.

As we talked, Rose paused to catch her breath. She took an orange canister, an inhaler, from her purse and told me she must take this medication twice a day. She then pulled from her purse a blue canister inhaler and confided, “My doctor said I don’t need to use this one any longer,” smiling happily, she added, “but I take it anyway…because I like it.”

Surprised, I asked, “What do you like about it?”

Rose hesitated and then replied, “The color blue.”

I could not believe what I was hearing. I struggled with my own judgement about her decision which seemed irresponsible and dangerous.

I asked Rose, “Do you know why your doctor told you that you don’t need to take the medication in the blue canister anymore?”

“No,” Rose hesitated, “he just said I can discontinue taking the blue one and start taking the orange one.”

At this point I was really upset. “Do you know that taking the blue one could be harmful to you?”

Rose stared at me, saying, “Well the doctor didn’t tell me that. He just told me to start taking the orange one. He didn’t say the blue one was bad for me. So I’m taking the orange one like he said. And I like the blue one so I am taking that one too, like I did before.”

“You should tell your doctor that you still take the blue one and ask him if that’s okay,” I urged her somewhat helplessly. Before she could respond, the nurse called her for her appointment. And that was the last I saw of Rose. I never learned if she stopped using the blue inhaler she liked so much.

There can be myriad reasons why a patient is noncomplaint or perceived as ignoring or unable to comprehend a doctor’s instruction. I was convinced that Rose’s decision to continue to take the unneeded medication was not about inadequate intelligence or limited comprehension, mistrust of her physician, apathy, or a desire to be disruptive. Her decision was based on a positive and idiosyncratic association to the color blue. When making her choice, she wasn’t thinking about the possible detrimental side effects of her decision. She just liked the blue canister.

Initially, I struggled with many judgmental feelings in response to Rose’s idiosyncratic behavior. I thought of her as self-centered compared to so many patients who suffer from illnesses for which nothing can be done. I felt irritated that Rose flaunted her stubborn will to do as she wished. What she was thinking was hard for me to discern.

Yet, as I watched Rose follow the nurse into the office, I began to see her with fresh eyes. I saw the forward slump of her shoulders, her slow pace, and the tilt of her head as if for a moment confused by the nurse’s direction. I thought of her as an aging woman losing much and determined to hang onto to what she could, and I felt compassion.

I continued to think about Rose, so perhaps it’s not surprising that I would be sensitive to a resident’s lack of curiosity when a patient presented with an equally surprising attachment. The patient, Mr L, who presented with a nagging cough and wheeze, admitted he smoked. The resident ran through a series of interventions—nicotine patch, nicotine replacement therapy, medications. Mr L did not outright reject these suggestions as much as counter with statements that indicated some frustration that he was not being heard. At one point, Mr L revealed that he really didn’t like to smoke, but liked the feel of the cigarette in his mouth. Rather than picking up on these comments, the resident ended the exchange and the visit with this conclusion: “Smoking kills people. You should stop.”

I spoke with this resident about the importance about being curious instead of prescriptive, even when patients’ comments seem irrelevant, irritating, or bewildering. We talked about how attitudes of respect and curiosity could lead to a goldmine of information about the patient and build rapport. The resident was receptive, and mentally, I thanked Rose and her blue canister.