Case Studies
Case 1: A
52-year-old female was the patient of the same internist for 24 years.
She was on record as stating she "did not want to look for trouble" and
wanted to know nothing about a medical condition until she was
symptomatic. For years, she declined pelvic examinations and
consultations with gynecologists and other physicians. The PCP
documented talking with her and giving her brochures about the
importance of routine Pap smears. The patient refused until she
developed vaginal spotting and cramps. Diagnosed with metastatic
cervical cancer, she died two months later. The family sued the
PCP.
This case closed with no indemnity payment. One
expert opined, "This case is entirely defensible because of the
patient's intractability and repeated documented refusals to accept
care...." Another stated, "There is serial documentation that the
physician [informed the patient of the risks of refusing to seek
care]."
When noncompliance is a factor
- Treat the patient's noncompliance as a
symptom and develop a differential
diagnosis.5 The real problem may be something quite other
than noncompliance.
- Name the specific problem and ask the
patient why he/she is engaging in it. Some patients may not believe they have a problem.
Naming the behavior that is at issue may shed light on the issue. The
patient of one physician was taking only half the dose of a medication
that had been prescribed. When the physician asked why she was not
taking a whole pill, the patient replied, "I only had to take half when
the pill was green."8
- Take into account circumstances that may
make compliance difficult. Some
patients may want to do exactly as the physician says but cannot because
of some of the reasons cited earlier. The physician may need to make
concessions or compromises.
- Try to limit the problem. Some patients may be overwhelmed by a multi-task
treatment regimen. Asking the patient to name his/her greatest health
concern and what part of the treatment regimen is proving most difficult
may help the physician work with the patient to structure a workable
treatment plan.
- Help the patient solve the
problem. It is tempting, but not
helpful, for the physician to offer an immediate solution to the problem
identified by the patient.9 In general, however, patients who
assume an active role in their health care planning are more invested in
the plan and have better outcomes than those who are simply told what to
do.4
- Document all indications of noncompliance
on the part of the patient. Establishing a pattern of "contributory negligence"
can be extremely important in a malpractice case.
- Consider terminating the professional
relationship with the patient who,
despite all efforts on the part of the physician, willfully, flagrantly,
or repeatedly disregards the physician's advice and/or otherwise abuses
the professional relationship. In the case below, which reflects a
telephone call made to ProMutual Group's Risk Management Department,
termination was advised before repeated disregard could be
established.
Case 2: A
38-year-old woman made an appointment with a surgeon for biopsy of a
breast mass. At the first meeting, the patient told the physician she
was a "privacy specialist" and was in his office under an assumed name
because she "did not want to leave a paper trail." She refused to name
her primary care provider or gynecologist and refused to have a
mammogram report forwarded to the current physician. She said she wanted
this physician to perform the biopsy but noted that she would be going
to another physician if surgery was indicated.
This patient presented a challenge that was more
than difficult; it was impossible. She admitted lying about her name and
her history, and acknowledged that this physician was just one in a
series she planned to see during her illness. The physician was advised
to follow the standard risk management protocol for terminating a
professional relationship, that is:
- explain to the patient, both in person
and in writing, why he could not care for her
- give her 30 days to find a new
surgeon
- provide her with the resources for
finding a new physician, for example, the telephone number of the local
medical society
- offer to send her record to the new
provider
- meet any emergency needs she might
develop during that time
- suggest she go to an emergency department
if, after one month, she had not yet found a new physician
To help protect against a claim of abandonment,
termination should be reserved for patients who are not at a critical
point in their treatment.
4 Funnell, M. Helping Patients Take Charge of
Their Chronic Illnesses. Family
Practice Management. March 2000. Available at www.aafp.org/fpm/20000300/47help.html. Accessed 30
Sept. 2003.
5 Nymberg, JH and Selby, JW. Why Can't This
Patient Take Insulin? Curbside Consultation. American Family Physician. January 1,
2000. Available at www.aafp.org/afp/20000101/curbside.html. Accessed 30
Sept. 2003.
8 Atkins, C. Patients Usually Have Reasons for
Being Noncompliant. American Medical
News. 9 April 2001: 24.
9 Helping Patients Achieve Compliance. Chapter
One - Patient Education: Empowering Patients and Families. NurseWeek. Available at www.nurseweekce.com/courses/Nurseweek/NW0660/c1/p04.htm.
Accessed 30 Sept. 2003.
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