Doc, your medicine makes me sick

“I don’t know,” Gideon remarked, “why I stopped taking the medication without telling you. I guess I just wanted to run an experiment. I wanted to see if I could do it on my own without the medicine. But it wasn’t only that. It was about power, too. I wanted to show that I was the one with the power. This primarily concerns me and I need to have the power.”

“Can you believe I have to take eleven different medications each day,” said Diana, a highly educated eighty year old woman. “I’m not even sure that they’re helping me. I’m not sure that I could tell you what they’re all for. Every time I go to the doctor, he has to look at the chart to see what I’m taking, even though he’s the one who prescribes the whole mess. Sometimes I think I should just stop and throw all the pills away. I think I’d be better off without them. As it is, at this point in my life I feel like I’m just a pill taking machine. Is this any way to live? And it costs so much.”

“Compliance” was until recently the term of art for a patient’s taking medicine reliably as prescribed. “Non-compliance” was the term for a patient’s not taking medicine reliably as prescribed. One may be quite as common as the other. This state of affairs calls for serious consideration, as medicine that is not taken reliably as prescribed is not likely to be of much help. Of course, the incidence of side effects will be lower if the medicine is not taken, as will the cost be if the medication is not only not taken but also not acquired.

Many have objected, appropriately in my view, to the term “compliance” because it seemed to represent the patient as too passive, someone who received an order and then followed it without any opportunity to object or consider, to reach for understanding in dialog or to ask for help in reconciling personal and cultural conflict.. It marginalized the patient as agent in a way that smacked of both authoritarianism and paternalism, qualities that have characterized doctors’ relating to patients for a very long time.

This is not to say that all doctors proceed in this way or that these aspects of the doctor-patient relationship are not under intense review in many quarters now. The “compliant” patient was envisaged as very pliable, able to follow directions without understanding on the basis of a belief that the doctor had the patient’s best interest at heart and knew best how to pursue it. The “non-compliant” patient was exasperating, a thorn in the side of medicine, most often ignored or condemned without too much effort to understand this complex piece of behavior. Needless to say, this response to a patient who did not do what he was told could be very destructive.

Recently, “adherence” has replaced “compliance” as the term of art for following a medical regimen faithfully and accurately. This is a better term than “compliance” because it locates the agency more properly, that is, in the patient. Taking medicine is something that a patient does or does not do, according to the interplay of many factors within the patient and many interpersonal factors that depend both on the doctor and the patient. “Adherence” implies some sort of an adhesive, or at least an adhesive process, which, of course, the mere use of the term, “adherence” does not specify. Perhaps, if we return to what I have quoted from patients and examine it closely, it will guide us at least to some understanding of how complicated the “adherence” process is.

2.
Walt, the young man who protested, “Doc your medicine makes me sick,” meant what he said very literally and concretely. When he was not face-to-face with the medicine, in this case lithium, his representation of himself did not include the fact that he suffered from bipolar illness, despite the fact that he had had a number of hospitalizations for this condition. The idea of having bipolar illness was really too noxious for him to countenance. He was very much attached to rather grandiose ideas of himself as very strong, very able to dictate the terms of his own living, very far from vulnerable. This grandiosity was most in evidence when he was hypo-manic, but could be discerned even in periods of depression

When the pill headed for his lips, it represented to him not only a diagnosis, but also a major change in self-state. His thinking and feeling had very much the all-or-nothing flavor. If he was well, he was all well, entirely without any problem in regard to his health. If he was sick, then he was totally sick, nothing but sick, existentially utterly invalidated. In order to accept and use medication, it is as important for a person to be aware of how much about him is healthy and not in need of assistance, as it is for him to be aware that something about him is problematic and, therefore, needs for him to attend to it, using medication if necessary. It may seem paradoxical, but we must feel at core a positive sense of our own reliability in order to be able to experience a problem as bounded and manageable.

We see patients who are very ill who are calm and collected, coping as best they can with situations that are very difficult. On the other hand we see patients without a stable core, who are completely disorganized by relatively minor problems. It follows that, if we wish to help a patient adhere to the treatment we have to offer, we must help a patient stabilize his sense of himself so that the patient can undertake the work of taking care of what needs to be addressed. This is no simple task, as any doctor who has seriously devoted attention to it knows. The idea that a doctor can see patients for very short periods of time in an industrial form of organization of care and only “for medication,” as the phrase goes, is an invidious one., because it leaves aside the patient as a person and a real examination of the patient’s world as it comes to bear in treatment.

The threats that an illness poses for a particular patient, the threats that a treatment poses for that individual depend on the meanings that the individual locates in the illness and in the treatment. For Walt, the pill headed for his lips might just as well have been a precisely targeted missile loaded with psychological explosives. For him, taking medication was not something with which he could readily “comply” or to which he could readily “adhere.” It made him considerably less of a nuisance to the world around him, but only at the price of thrusting him into internal situations which were difficult for him to manage. He started and stopped his medication on the basis of momentary and changeable whims, depending on how he was feeling about himself.

2.
Walt was a patient who made not infrequent excursions into psychosis. But it is by no means only such patients for whom taking medication is a vexing question. We need to remember that it is not unusual for a relatively newly diagnosed adolescent Type 1 diabetic to decide that she is not having any more of the restrictions imposed by the illness. When she goes to a birthday party and eats both the chocolate cake and the ice cream that everyone around her is eating, she has a good chance of ending up in the emergency room in ketoacidosis with a fabulously high blood sugar. In this case, the feedback loop that pairs eating cake and ice cream with requiring treatment in an emergency room is most often a powerful help to finding a way to take better care. However, there are patients who need to make this trip so many times that it is frightening, They can not bear having the illness that they feel has them unjustly in its grip and launch rebellions over and over to their own detriment. It is no small task to help a patient have an illness rather than allowing it to have her. A patient need not be a teen-ager to have trouble taking medication.

“Looking back on it, I really don’t understand it, ” said Stan, a physician in his early fifties. “I knew that I had high blood pressure starting in my early thirties. I lost weight, but that didn’t fix the problem, although it helped. I toyed with the idea of taking medication for ten years before I finally did it. I knew what I was doing wasn’t smart, but I wasn’t ready to admit a defect. I think I thought something like, ‘If I concede that there’s anything wrong with me, then I’ll be done. It will be over. I’ll just a fall apart’ I suppose it was a mixture of pride and fear and that’s not a good mixture. I don’t know if waiting that long did me any damage. I was lucky, too, that I found a medication that doesn’t cause me any problems. As far as I can tell, there are no side effects.

“I don’t know what I would have done if there were annoying side effects. I might have stuck with it, but I doubt it. The one thing that I really did get out of this is that I understand how hard it is to take medicine and I’m very sympathetic to my patients’ troubles with it. I can’t sit in judgment on them because I remember about me.
If I’ve had such a hard time with all I know about physiology and risk factors and diseases, imagine how much trouble patients are going to have. Maybe pride and fear were what held me back or maybe it was just vanity.”

3.
Gideon, a man in his late forties, illustrates a special difficulty that is terribly common. If a patient stops taking a medication and tells his doctor that he has done so, then there is room for a discussion, for a search to try to understand the stopping, a chance to inquire about side effects and beyond that a chance to have a dialog about what taking the medication means to the patient and what stopping the medication might mean to the patient. Sometimes we are able to infer that a patient has stopped a medication from a return of symptoms of anxiety or depression, from a blood pressure that is out of control, from a lab test like a hemoglobin A1c that provides a measure of what the circulating level of sugar in blood has been over an extended period. When we are able to make such an inference, then we can ask about it. Sometimes patients deny it out of embarrassment or out of a feeling of being blamed by the doctor.

Many doctors, in fact, do have rigid and righteous attitudes towards patients’ taking their medications, along the lines of “I’m the doctor. You’re the patient. If you don’t take my advice, how can I help you? If you don’t take the medicine, how can I help you?’ Such attitudes introduce an interpersonal chill that keeps so much from being said and understood, A marvelous exploration of misadventures between doctors and patients is “The Spirit Catches You And You Fall Down” in which the culture of medicine and the very different culture of the Hmong patient and her family come into sustained conflict with mutual incomprehension and a very sad outcome.

Doctor – patient relationships are not simply relationships between doctors and patients, but also relationships between persons who are in the world together and share both hopes and vulnerabilities. They also share knowledge and ignorance. That is to say, role does not wholly define either the existence of the patient or the existence of the doctor. A common shared humanity, construed within the set of encounters that creates each relationship, rather than simply in a stereotyped fashion, makes possible the emergence of channels of communication able to bear the traffic that is needed for helping and for healing. In working with patients, remaining open and receptive, being the kind of person in whom it is possible to confide about what is difficult and shaming, is a central and very taxing task. Nothing is simpler than to have the listening apparatus ossify into a pseudo-listening apparatus, so that we may appear to attend but, at a deeper level, we are closed, believing that we already have in mind a full list of what can be said and heard.

If a patient’s lips are sealed, whether because of our trouble in listening or the patient’s own reluctance in speaking, so that the patient does not tell us what unilateral decisions he has made regarding his medication, then, in trying to treat the patient, we are not playing with a full deck. We may be terribly surprised by the ensuing stroke, the ensuing relapse into depression, the recrudescence of psychotic symptoms. What patients do not tell their doctors is one of the most important categories in the care of patients. Our responsibility is to try in every way we can to minimize the breadth and depth of this category. It may sound simple-minded to say this, but, in my opinion, what is most crucial in making communication possible, is an unhurried devotion on the part of the doctor, not to be confused with over-zealous dedication. When patients experience their doctors as genuinely there to try to be of help and not in such a rush that the main purpose of the encounter is to bring it to an end, this speaks to something very deep in each and every one of us, namely the ability to depend, probably a central feature of our common mammalian heritage.

Once Gideon admitted that he had stopped taking his medication without telling me, then it was possible to start a dialog about what the experiment he was running was designed to investigate. He felt that his illness had given other people license to tell him what to do and that his wishes were often not consulted. He was aware that some of his feeling had to do with the fact that he came from a family where communication most often did not have an affective dimension, but dealt with matters of external fact. The idea that it might be possible to discuss and even to negotiate about the taking of medication was not one that came naturally. In fact, he seemed to approach chances for discussion as if they were virtually guaranteed to lead in directions he did not wish to go, so that to enter in upon them was to run a large set of risks without too many benefits. When I suggested to him that the way I saw it was that he had full control over the taking of his medication, while all I could do was advise, he seemed a bit surprised, even taken aback.

In imagery I often use with patients, I told him that he was the Sultan, with full authority to decide, while I was only his Grand Vizier, who could provide him with advice at his request, but had no way to determine what use he made of the advice. I also spoke with him about the ways in which illness made us feel vulnerable and powerless. In most cases our understanding of illness and its precipitating factors falls far short of any satisfactory robustness, let alone completion. Nor, certainly in emotional illness, is our knowledge of prognosis what we would wish. We do know something, however, Depression, for example, is characterized by recurrence and the more episodes that have occurred the more likely is recurrence and the more likely is it to come at a shorter interval. I said that studies showed that medication often served as prophylaxis against recurrence, preventing or delaying it.

I told him that I was very appreciative that he had decided to tell me about stopping the medication, because that afforded us an opportunity to speak about the medication and to take stock of where things stood and how we might proceed in a way that was helpful to him. He decided that he could see his way clear to starting his medication back up again., but that he had no regrets about having stopped. I told him that I knew taking medication was not simple and that I hoped we could go on talking about it because I knew from experience that taking medication could take on different aspects at different times. A patient may be “on” a medication, but that being “on” may actually be a lot like being “on ” a horse – that is, it may go smoothly for a long time, then get rougher to the point where the rider is thrown. So alertness and openness are demanded of us over the long haul. The meanings of medications may change in the course of treatment.

This is perhaps never quite so true as when a woman who has found medication for a psychiatric difficulty very helpful wants to be come pregnant, so that the medication that has been so helpful is now inflected to be seen as potentially disastrously toxic to an as yet unconceived and necessarily unborn child. Going off the medication poses certain risks to the parent-patient, while staying on it poses certain quite unquantifiable risks to the intended child. To add further to the quandary, deteriorations in the mother’s emotional health are likely to have unquantifiable physiological impact on the intended child. This is a very complex and ambiguous situation calling for long and careful consideration by those involved. The previous history is important, as is the family history, as is all that is known or hypothesized about the medication or medications involved. This is a situation where different people may make quite different choices, preferring one or another of the attendant kinds of risk, Most often, the woman feels a push to go off medication in order to be a good mother to the intended child. It is important that to be a good mother also involves taking good care of oneself, because one’s own state impacts a fetus. This kind of consideration necessarily brings everyone up against the fact that we choose without certainty, weighing probabilities and possibilities as best we can, which may not be terribly well.

4.
“Growing old is not for cowards,” a patient’s one hundred year old grandmother told him with emphasis when he went to visit her. He was impressed with the sentiment. Aging is so much about limitations and so much about managing to retain a sense of integrity and vigor as we cope with limitations that become stricter and stricter as the years advance. There are some people in their eighties whose involvement with the health care system is not profound. These form a fortunate minority, but the majority have chronic ailments and chronic involvements with doctors and with medications. These are some of their companions of the road. It can be a tremendously hard and discouraging road. The goal is to live one life and die one death, a death of the brave, hopefully as soft as the death from the sea that Odysseus was promised in Homer’s epic, but not the thousand deaths of a coward.

Diana, eighty years old, had asthma, rheumatoid arthritis, a chronic bladder infection, osteoporosis, heart disease and hypertension, not to mention depression. She was heavy of body as well of spirit. Movement evoked for her not pleasure but difficult effort. Under the influence of her depression, she perceived her various ailments not so much as limitations, but as shameful emblems of her inadequacy. She felt passive and resentful in the face of her difficulties and did her best to deny her shame, her passivity and her resentfulness. She would not engage with anyone, including her doctor, concerning her difficulties. For his part, he was aware that she was hard to read and that she was not telling him anything like a complete story concerning her condition. Whether she was lying by omission or denying was purely a semantic dispute.

There are countless persons, most of them elderly, in the United States taking eleven different medications. There is nothing unusual about this kind of proliferation of medical conditions and the corresponding proliferation of medications. For a person like Diana, the inventory of her medications represented an inventory of her failures, of her shame, of her falling short in her stewardship of herself. The eleven different pills were like the counts in an indictment to which she had no recourse but to plead guilty. This view of her situation followed not just from her depression but from her character, which was disposed in the direction of a subtle grandiosity not easy to observe because of how uncommunicative she kept herself, as if others posed much more of a threat than they were aware.

When Diana allowed that she felt she might be better off without the pills, she was not far from where Walt found himself when he declared indignantly, “Doc , your medicine makes me sick.” If the presence of medications functions as the sign of the presence of illness, then, perhaps, the absence of medications could be impressed into service as the sign of lack of illness. More than one patient has pitched a host of medications into the trash, relishing the rattle of pills never to be taken, on the basis of similar logic, really a kind of psycho-logic, that is, something unrealistic and driven by fierce feeling.

We should stop to notice that sometimes elderly patients are, in fact, better off with all their medications stopped. It is not unusual to hear of an obtunded elderly person who is brought to the emergency room and even admitted to the hospital, only to perk up, markedly and relatively quickly, after all medications are stopped. Medication induced delirium is a not uncommon effect of polypharmacy. Also, the more medications we prescribe the more likely we are to produce an interaction or interactions that adversely impact the patient’s welfare.

“At this point in my life I feel like I’m just a pill-taking machine.” expresses Diana’s frustration. She feels that she has been subjugated by medications and medical treatment, She feels like she receives orders and must comply with them, even though this makes her feel like a machine, not a supple and animate human being. There is anger simmering in this and discouragement and, perhaps most difficult of all, self-disgust. The anger is not the kind that is effectively brought to bear to try to adapt, but rather a more nihilistic kind. She belongs to her medications, rather than their belonging to her. It is as if they are the colonial masters and she is the colony. Nor does she have any real and practical program to gain independence. There is even a hint of the suicidal.

Diana was not wholly convinced either of her doctor’s integrity or of his commitment to her. In fact, she was one of the lucky patients who has found a doctor who means to provide care as a vocation, rather than as part of an industrial process, However, she felt that he should know everything about her and her treatment without reference to the chart. She wanted to be, if not his only patient, then the kind of patient who is never far from his mind. She was the kind of patient who wanted everything from her doctor and would accept nothing. Her fundamental struggle was to be complete and perfect without the need for help, because help meant jeopardy.

Diana’s relationship with her medications was almost a paranoid one. Certainly, she did not have a relationship with them like the relationship a person might have with a teddy bear or other transitional object. She would never have said, as Felicia did, “My life is really a whole lot better since I started the medication. My co-workers just don’t get to me the way they used to do. It’s like I have a few extra layers on and they can’t get through them. People have told me I’m just more mellow and I like the way I am.”

Felicia’s testimony came from a time two decades earlier in life than Diana’s position.
However, Diana’s stance not solely in regard to medications but in general in life just skirted the edge of paranoia. Beneath the paranoia was a massive dependency appeal, but a problematic one, because much as she wanted care, equally much did she far loss of herself in receiving care.

Diana represents an extremely difficult class of patient to treat, because it is so hard to achieve the requisite kind of standing in her eyes. Easily wounded, she was also so passive that she did not take initiatives. Whatever a doctor might offer in the way of a consult – for example, that it seemed that she was depressed and that her depression was making her life difficult – was taken as an insult. Nothing was seen as descriptive, but rather everything was taken as judgmental, illustrating just how powerful and oppressive her conscience was. When Diana walked into the room, it was possible to feel simultaneously the distrust and the need, so that an existential bind was present from the very outset.

Certainly, patients like Diana are caught between their need, which is vast and inchoate, and their mistrust, which is similarly vast and inchoate, able to condense around any object that comes near. Diana’s position was a compromise. She wanted not just to reach out to others but also to do something we might characterize as “reach in to herself.” Yet this felt too dangerous to her. If she put herself on the line, she was convinced that she would be hurt. Yet, there was a kind of loneliness that no pill could assuage. Patients like Diana are so frustrating that it is hard for us to reach a position where we are able actually to respect their compromises and not to be so eager to disturb them. Often, with these patients the issue is more how to stabilize the status quo and to prevent the emergence of even worse situations.

Reassurance and hope are the coins of the realm when working with people like Diana,
who after all are facing the end of life, often of lives about which they secretly despair, lives which seem as nothing in their eyes compared to their fantasies of what might have been or should have been. Reassurance and hope are quite different than fatuous optimism. Both can be quite stern and firm. If we can be successful with the reassurance and hope, these patients may volunteer what they could not bear to have pointed out to them. However, it is vital that we not ask more than they can do, but appreciatively accept what they can offer. Sometimes we must simply be with them as nothing improves, even as things deteriorate, Often, these patients are so disappointed in themselves that it is hard to guard against being disappointed in them. If medications disappoint, we should remember not to despair. It simply means that the medications have found a place in the world of a patient like Diana.

5,
Taking medicine is a much more peculiar process than we normally emphasize. We go to see a doctor. We talk with the doctor. The doctor examines us, producing a bodily intimacy which is at once charged with feeling and shrouded in neutrality and detachment. Some blood may be taken to be scrutinized. We confer with the doctor in a clothed state. He writes – or, if he is like most doctors – scribbles something on a piece of paper which we carry to a pharmacy where we receive pills or capsules in a plastic bottle. These we carry home with us along with our attendant hopes and fears. At home, we do as the doctor has told us to do, as he or she has prescribed. We fish a small pill or capsule, white or pastel colored, or perhaps brighter, out of the bottle. We put some water in a glass, put a pill on the tongue and then down it, so that we have made it a part of itself. But what have we swallowed?

We animate medications. This is a crucial perception with enormous implications. We give what we take in when we take medication a mental and symbolic significance that exists side by side with the medication’s biochemical physiological action. The realms are separate, but both powerful. We give the medication life in our minds in the process of getting ready to take it into our bodies and then actually taking it into our bodies. It might even be fair to say that we are the shamans of our own pill taking, even if we do not dress up in feathers and chant and dance and burn pungent substances. We still have that authority, a mighty one, indeed.

Of course, in becoming the shamans of our own pill-taking (or capsule-taking, if that is the form in which the medication is presented), we get a spectacular, even an embarrassing boost from the pharmaceutical companies, who are perfectly well aware that their products must inspire desire as well as respect, not only in patients, but in physicians and pharmacists, if they are to realize vast market potential. Consider for a moment just a list of newer anti-depressants: Prozac (how upbeat and skilled the “pro,”
how full of energy, of zip and zing, the “zac”), Paxil, (how sublimely peaceful the “pax”.
how calmingly liquid the last “il”), Zoloft (how lithe and lovely the “loft,” the
ascent from depression’s depths), Wellbutrin, (effective bringer of the “well”), “Celexa (selective and celestial), Lexapro (the return of the “pro”, but allied now with “lex” the law to end depression), Effexor (unparalleled in effectiveness), Cymbalta (hear the cymbals crash as depression is routed).

The names of drugs of other classes, “Ambien,” “Abilify,” “Xanax”, to name but three are no more neutral than the names of the newer anti-depressants. They are chosen for
psychic dynamism and tested in many different ways before release. I have given the beginnings of my own associative pathways in parentheses after the names of the newer anti-depressants, but I claim no privilege for these associations. My only point is to highlight how irresistible these names are, how they do not just enter our minds but fizz as they do so, Even with the pharmaceutical companies’ marvelous advertising acrobatics, we remain the principal shamans of our pill-taking. It is we who give the pills symbolic life within ourselves, we who give the vital forces to this symbolism within ourselves. Symbolism is, of course, a major psycho-physical force on us and within ourselves.

Guillaume, a man in his sixties, was taking a small supplemental dose of thyroid hormone. He said it was the most effective medication he was taking for his apathetic state. He said that he could feel it “kick in” and that it gave him two or three hours of increased alertness. He wondered why it petered out, but had no explanation why it should be this way. He said this was a reliable effect, day after day. What makes this interesting is that the endocrinologist believes that this supplemental dose of thyroid hormone is strictly a tonic medication, not one that announces its presence at once or whose effect fades so quickly. From the endocrinologist’s perspective, the effects described are mind manufactured, the work of an inner shaman, not driven by the physiology of the interaction between the medication and the body. So we have, in what is not at all an unusual case, two different and incompatible realities, side-by-side. Neither party would budge if confronted with the other’s view.

Wendy, a woman in her mid-forties, a successful career woman, said one day, “I’ve noticed something really odd. That anxiety medicine you prescribed for me that I’ve been taking for years…you know…I always forget the name. Well, I’ve noticed that it works just as well if I don’t take it, but I just keep it in my purse. Of course, I do take it sometimes, like if I have a big meeting that has me on edge, but most of the time it works just as well if I take it with me in my purse and don’t take it. I just like to know that I can take it…”

We might say that the anxiety disorder has mutated over the years, so that it no longer requires direct chemical intervention to produce major psycho-physiological change. For this patient, the medication has become a presence, a mental object along the lines of a teddy bear or other soothing object. We could hypothesize that her relationship with her therapist had supported this transformation, that she had taken her therapist in more deeply, so that she felt a greater sense of security, one that allowed her to make a more abstract use of the medication than swallowing it, This illustrates how symbolic inputs – the medicine in the purse as a token of the therapist – can be both biochemical and neurophysiologic inputs.

A man in his forties told his doctor, apologetically, “This stuff you gave me is just too strong for me. I want you to know that I’ve struggled with it. I’ve done everything I could think of to be able to take it. But it makes me feel strange like my muscles were just a little too loose. I think we’ll have to try something else.”

For this man, the medication was an adversary, something to be struggled with. As his inner shaman construed the matter, it was a wrestling match, one in which he was defeated. His encounter with the medication also produced an unusual body sensation, namely that his muscles felt a little too loose. This was a personal perception not really subject to consensual validation. When he said that he thought it would be necessary o try another medication, his therapist had the fantasy that the patient was actually a triumphant wrestler offering to take on all comers.

Illustrations of the idiosyncratic ways that we animate and are the shamans of our pill taking could easily be multiplied. The process is ubiquitous and has enormous influence. It has profound implications for psychopharmacological treatment, in fact, for all pharmacological treatments. If a patient does not take the medication, then it has no chance of helping physiologically. Nor, of course, does it run any risk of hurting. Shamanism has not gone quite as far out of style as most imagine. We are all involved in it in the privacy of our own minds as we go about that most mundane of activities, taking our medication.

6.
We noted early on that the term “compliance” was in the process of being replaced by the term “adherence” in discussions of patients’ taking their medicine as their treating physicians advised. We also noted that, while “adherence” did seem preferable to “compliance” as a term of art because it returned agency to the patients, the question still arose concerning what sort of adhesive made adherence possible.

In the production of the psychological adhesive that makes “adherence” to a medication possible, meaning and meeting both have their places. In determining who will use a medication and how, the meanings that a patient gives to taking the medication and to his experience with it play a crucial part. The meeting of the minds and hearts that occurs between him and his physician plays a very important role, if not a determining one, in how the patient takes the medication on and therefore in.

There is a tendency to reify the process by which we go about taking medications, as if the stuff were active and we were not. If we submit to this, then we miss a realm that can be decisive for the care that we give and the care that we receive. A more lively view opens up a wider range of possibilities in the space occupied by patient, doctor and medication.