Risk Management Suggestions
The physician's first response to a patient's
disregarding medical advice is likely to be anger and
frustration.5 However, if the physician is able to convert at
least some of that emotion into a search for the issues underlying the
patient's behavior,6 an answer, or, at the very least, a
compromise solution may be found. Some of the steps physicians may want
to take, first in an attempt to avoid, and then in an attempt to manage
these situations include the following:
Before noncompliance begins
- Determine the patient's understanding of
his/her problem or disease, any
religious or cultural factors that influence his/her beliefs about the
medical problem and its potential treatment, and his/her interest and
ability to participate in his/her own care.
- Educate the patient and, whenever
possible, his/her family about the
patient's health, his/her medical condition or disease, and the
importance of his/her role in maintaining health and co-managing illness
with the physician.
- Include the patient in planning the
treatment regimen. The largest single
determinant of the success of a treatment regimen may be a patient's
ability and willingness to carry it out. The patient who participates in
creating his/her treatment regimen and understands the rationale behind
it is far more likely to adhere to it than the one who is merely told
what to do.
- Consider a patient's support system when
planning a treatment regimen. The
elderly patient who lives alone should not be expected to apply
Lidocaine patches to his or her upper back.
- Consider the behavior changes the
treatment regimen will require and ask
the patient, "Do you think this will work for you?" If the answer is no,
an alternative may be required.
- Try to agree on common goals with the
patient. In the absence of common
goals, the physician and patient may be working at
cross-purposes.
- Give clear instructions. It may not be adequate to tell a patient to "lose
weight," to "take it easy," or to restrict work to "light duty." Specify
what each of those directions mean. The failure to do so may result in a
medical malpractice suit if a patient subsequently experiences injury or
harm and can show the directions given by the physician were
unclear.7
- Make sure verbal instructions are
accompanied by written ones. The
instructions may be pre-printed, standardized, or
individualized.
- Establish guidelines for telephone calls regarding prescription refills
and lab results. Some physicians have found it helpful to set aside
designated times for these calls.3
- Obtain an informed refusal from the patient who admits he/she either cannot or
will not follow all or part of a proposed treatment plan.
- Document thoroughly and completely
all instructions given to the patient and all
discussions about the treatment regimen. Good documentation may be the
most persuasive argument for the defense in a malpractice suit involving
a noncompliant patient. Consider the following case from ProMutual
Group's closed files.
3 David Karp Associates. Avoiding Liability When
Patients Are Noncompliant. ProNational Insurance Company Medical Risk
Management Advisor. Available at www.pronational.com/news/advisor/Noncompli1Q1997.htm.
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.
6 Kelly, C. Patients Uncooperative? Try These
Communication Tips. American College of Physicians-American Society of
Internal Medicine Observer. May 2002.
7 Effective Management of Problem Patients:
Managing Difficult Patients. Texas Medical Association. Available at www.texmed.org/ cme/phn/empp/managing.asp. Accessed
30 Sept. 2003.
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