Patient’s Guide: Cooperation Between the Doctor and the Patient in Peptic Ulcer Disease
Cooperation (or compliance) plays the superior role in the relationship between the doctor and the patient. It represents the degree to which the patient adheres to the physician’s advice, recommendations, and indications. It is not countable, yet if the patient’s adherence is strong, the outcomes of any therapy significantly increase. Many conditions build up the compliance. In this chapter, the major factors which contribute to the quality of cooperation between the patient and the doctor are described.
KeywordsCompliance Peptic ulcer Endoscopy Diagnosis
Proton pump inhibitor
9.1 First Look at the Appointment
First look always counts. And there are no exceptions in the doctor’s office. Even while the patient is bothered by their symptoms, the physician should not underestimate the level of the patient’s attention. And the impression on the first appointment is very important. A smile, words of greeting, a handshake—many things contribute to a successful “first meet.” The physician is often tired, especially after a long shift, but one should not show the noticeable fatigue and may dedicate the time to the patient. Patients might often misinterpret the doctor’s fatigue as impatience or even hostility. Also, the patient may be exhausted or even mad after a long appointment time. Adding to this the symptoms, which are frequently intensive and long-lasting, it all can evoke irritability in the patient. All these factors can disturb the cooperation between the two before the diagnosis process even begins and should be prevented at any cost.
9.2 Diagnosis Process
It is understandable that the patient is frequently absorbed by the symptoms. The commercialization of medicine evokes that portion of patients admits already with some knowledge. There are various routes of information which are available for the patient: the medicine-based websites, random links found by patients, or information from colleagues or persons related to the patient. Surprisingly, better knowledge does not need to come with a better well-being. A study on 258 patients with inflammatory bowel disease  showed that better knowledge about the disease is associated with greater anxiety levels in these patients. It can be due to many factors, i.e., poor quality of data obtained by the patient and a lack of experience to process the knowledge. Hence, the role of the physician is to broadly explain the diagnostic process from the top to bottom.
In case of suspecting the peptic ulcer disease, the diagnostic tools are not numerous. As in most cases, patient’s history, physical examination, and blood samples should be taken for specific tests. The preferable instrument nowadays is the upper gastrointestinal (GI) endoscopy (also called “gastroscopy”). Apart of the advantages on visibility of upper GI tract, it provides opportunities to collect samples and even to treat active bleeding. Radiological methods are archaic and are not widely used now; they suffer significant disadvantages compared with endoscopy. Endoscopic tests are the main reason that patients are afraid of gastroenterologists. Hence, the general practitioner or any physician to whom the patient first admits should clarify the need of procedure, the procedure itself, and possible complications. Of course, more thorough information is provided by the endoscopist, right before the procedure, but the patient has to understand the importance of endoscopy, its irreplaceability by other methods, and safety. Often patients inquire about the anesthesia during the endoscopy—this varies between the countries, so the physician needs to address it according to the national situation.
There is only one need that the patient should meet—to keep off eating solid foods for 6–8 h and liquids for 4 h. Additionally PPIs, antibiotics, bismuth preparations, and H2 antagonists in high doses should be restrained for at least 2 weeks prior to the gastroscopy. They may distort the result of urease test (also known as CLO-test) which is—along with the histopathological assessment of samples—the base when diagnosing the Helicobacter pylori infection. The procedure itself is rather straightforward. The endoscopist inserts the tube (which is around 1 cm in diameter) into the patient’s mouth and pushes the endoscope gently through the gullet, stomach, and ending in the duodenum. The samples should be taken from the surroundings of ulceration to exclude malignancies.
9.3 Explaining the Treatment
When the diagnosis is set and confirmed, this is the time to discuss the treatment process with the patient. The treatment varies whether the infection with H. pylori exists or not. The therapeutic regimens to treat H. pylori-associated ulcers can be found in the respective chapter. However, there are specific instructions the patient should learn when taking the drugs. Thus, the patient should understand to take proton pomp inhibitors (PPIs) on an empty stomach, about 30 min before the first meal. If the patient is taking additional drugs which require similar conditions, the fact should be communicated to the doctor; for instance, thyroid hormones should be taken 30 min before the PPI, so 1 h before the first meal, if the patient is taking both drugs. Taking the pill while eating or after the meal significantly reduces the bioavailability (efficacy) of PPIs. Also, PPIs reduce the absorption of oral iron preparations, oral contraceptive pills, and some antifungal and antiviral agents (the physician should ask accordingly). In case of antibiotics, special information should be provided, especially when administering metronidazole/tinidazole or tetracycline. In case of the former ones, it is absolutely forbidden to drink alcohol or take any other hepatotoxic agents. Tetracyclines, on the other hand, have plentiful of interactions with other drugs such as antacids and should be taken with dairy products (these antibiotics interact with calcium ions forming insoluble and inactive complexes). Efficacy of the antibiotics depends on their concentration in tissues which should be maintained at the proper level. Thus, antibiotics should be taken in regular cycles, and it should be underlined to the patient. The terms such as “one tablet every twelve hours” are generally preferred compared to “one tablet twice daily.” The cumulative time of the therapy should be provided.
Additional information about the lifestyle change should be discussed with the patient. There is no highly restrictive diet which the patient would follow. Nevertheless, the meals should be easily digestible, and the patient should avoid drinking alcohol in large quantities and eating spicy and too hot foods. Also, they should cease or at least reduce smoking. Following these advices would help heal the ulcer. There were contradictory data for negative influence of coffee drinking on gastric ulcer. Recent meta-analysis  resolves the doubts and showed that coffee drinking has no association with either peptic ulcers or reflux disease.
All these information should be handed to the patient in the written form. The time spent on writing clues in simple phrases on a sheet of paper is worth a minute. Patients usually comprehend only a portion of information during the admission. Thus, the patient could relate later to this short guide and remind themselves the most important notes.
The successful cooperation between the doctor and the patient lays in the communication. Of course, it is not something to be learnt instantly, just by reading the text. It requires experience what comes with time spent working with the patients. Below, some of the “golden rules” which facilitate the cooperation in the doctor’s office can be found.
Use simple, nonspecialist language.
Be careful which words you are using.
Explain the tests, procedures, and diagnosis.
Alert the patient about the possible results and complications of untreated disease.
Provide the information about the drug: route and time of administration, dose, duration of therapy, and the most common side effects. (Be careful not to scare off the patient with the severe effects which occur very rarely!)
Make the written list of indications.
While giving indications—give it slowly, accomplishing one step by the patient makes it easier to proceed with further therapy (for instance, in obese patients who smoke, it is hard to quit smoking, lose the weight, and start taking pills at the same time).
Not to discourage the patient when the therapy fails—explain the possible causes and repeat the diagnosis process.
Do not hesitate to ask questions on the admission.
Tell the doctor about the issues you are anxious about—the procedure and the diagnosis—they are here to explain everything and calm you down.
Health might not be the ultimate goal in your life, but remember that even if your condition is not that severe in your opinion, it might get worse in the future, so working earlier on your health pays off.
Follow the physician’s indications.
Do not be discouraged to tell the physician that the therapy is not well tolerated by you or it is hard for you to follow some of advice—sometimes the modifications in therapy can be implemented.
- 2.Shimamoto T, Yamamichi N, Kodashima S, Takahashi Y, Fujishiro M, Oka M, et al. No association of coffee consumption with gastric ulcer, duodenal ulcer, reflux esophagitis, and non-erosive reflux disease: a cross-sectional study of 8,013 healthy subjects in Japan. PLoS One. 2013;8(6):e65996.CrossRefPubMedPubMedCentralGoogle Scholar