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Difficulty: MediumPatient Counseling and Health Education

A 61-year-old woman comes to the clinic to discuss the results of a recent dual-energy x-ray absorptiometry (DEXA) scan. The scan reveals a T-score of -2.8 at the lumbar spine and -2.3 at the femoral neck. Her past medical history is significant for an unprovoked deep vein thrombosis 4 years ago, for which she completed a 6-month course of anticoagulation, and gastroesophageal reflux disease. The physician explains the diagnosis of osteoporosis and recommends initiating oral alendronate. The patient becomes visibly anxious and states, "I read an article online about people whose jawbones completely rotted away after taking those pills. I am absolutely terrified of that happening. I refuse to take them and will just manage this with over-the-counter calcium supplements." Which of the following is the most appropriate next step in management?

  1. Explore the patient's underlying fears and assess her understanding of the medication's overall risks and benefitsAnswer
  2. B
    Recommend switching to raloxifene as an alternative therapy to alleviate her anxiety about jaw necrosis
  3. C
    Agree to a trial of calcium monotherapy and schedule a repeat bone density scan in two years
  4. D
    Consult psychiatry to evaluate the patient's legal competence to refuse medically indicated treatment
  5. E
    Order a panoramic dental radiograph to objectively evaluate her baseline risk before continuing the discussion

Answer

Explore the patient's underlying fears and assess her understanding of the medication's overall risks and benefits.
When a patient expresses hesitancy or explicitly refuses a recommended and indicated treatment due to fear of adverse effects, the most appropriate initial step is to engage in patient-centered counseling. The physician should first validate the patient's emotions and actively explore their specific concerns. Osteonecrosis of the jaw is a real but exceedingly rare complication of oral bisphosphonates (it is much more commonly associated with high-dose intravenous bisphosphonate therapy in oncology). By exploring the patient's understanding first, the physician builds therapeutic rapport and creates an opportunity to gently correct misconceptions. This allows for a discussion of the true risk-benefit ratio, comparing the high, immediate risk of a devastating fragility fracture against the exceptionally low risk of jaw necrosis. This foundational communication must occur before considering alternative therapies, ordering unnecessary diagnostics, or accepting a substandard treatment plan.

Step-by-Step Solution

1
Identify the primary clinical barrier
The patient is refusing standard-of-care treatment for osteoporosis due to profound fear induced by online information regarding osteonecrosis of the jaw.
Recognizing the root cause of nonadherence (fear and potential misinformation) is required before altering the treatment plan.
2
Select the appropriate communication strategy
The physician must validate the patient's emotional response and actively explore her specific concerns without judgment.
Patient-centered counseling dictates that exploring a patient's fears builds trust and opens the door for education, allowing the physician to clarify that osteonecrosis of the jaw is exceedingly rare with oral bisphosphonates.
3
Evaluate and rule out alternative actions
Alternative actions such as prescribing raloxifene, accepting calcium alone, or ordering tests are ruled out due to contraindications and guideline violations.
Raloxifene is contraindicated given her deep vein thrombosis history; calcium monotherapy is insufficient for a T-score of -2.8; and unnecessary tests or psychiatry consults bypass the core communication issue.

Key Concept

Patient-centered communication and shared decision-making in the setting of medication hesitancy.
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Topics

Patient Counseling and Health Education

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