Tuesday, May 3, 2011

Patient Negotiation

Over the course of any given day I sometimes find myself either pleading or negotiating with patients to take steps to improve their health. Am I the only one who has found this to be the case? It is becoming increasingly frustrating. Sometimes I just want to say, “Listen, you came to me for help. I am telling you to do ____ it is up to you to do so. Please feel free to come back when you are ready to listen to the advice you paid for."

Sometimes I think parenting has prepared me more for medicine than medical school. Raising teenagers has taught me the skill of listening and then collaborating to reach an agreement without inciting a rebellion. These can be tricky, shark infested waters, one must tread lightly. The last thing I want is a patient stopping his medications or a teenager sneaking around. Unfortunately, I did not raise my patients from infancy. Their previous doctor relationships could have been positive or negative. Their perception of the doctor-patient relationship could be completely skewed from what I would want to instill.

Or maybe this phenomenon is a result of an American culture that encourages instant gratification and looking for the easy solution. Yes, you must give of your liter of soda a day to get your blood sugars under control, and yes, you must exercise to lose weight and feel better and no I don’t have a pill that will fix all of your personal problems. What is a doctor to do? Give up or continue to chip away at a brick wall with a wet noodle? When these patients start to bother you, is this the beginning of burn out?

Don’t get me wrong though. I have many patients that are more than willing to do the work that is needed. They may grumble and tell me I am ruining their fun but they make some changes for the better. I usually thank these patients for doing the right thing and tell them I am going to brag to the other doctors what “good patients” I have. Oh my, I feel like I am bragging to the other mothers in the play group.


  1. Noncompliance-ugh! We deal with that on so many levels every day, sometimes I don't even know why some patients come in since they rarely follow my advice.Obviously there are some patients who do stop smoking, lose weight, stop drinking alcohol so much, go to therapy etc but I find this is the minority. It is incredibly frustrating but at least for me, there is always still that little hope with each patient that something I say will spark a positive change and once in a while it does happen.

  2. I went through an AlAnon type of course with a gentleman who was a physician (treated diabetic patients) and he said he used a lot of the same things he learned in that class on his patients and he found it liberating. : )

  3. In the 12 step programs there is a lot of emphasis on "when you are ready..." This can apply to alcohol, cigarettes, losing weight; you name it, it applies.

    To the recovering alcoholic who says, "Why didn't I do this 20 years ago!" The reply is "because you weren't ready. But you are doing it now."

    Yes, there are critical times when cessation of a bad habit or beginning a good one are absolute RIGHT NOW! issues, but in general, a patient is not going to follow your advice right away. The ideas and suggestions need some time to percolate. The best thing that you can do as a practitioner is to keep repeating yourself (gently), encourage the patient in the belief that ANY step that they take is a step in the right direction, and that even if they falter and fall short, the important thing is to keep on trying. Let them know that sooner or later, if they really want to, they will "get it".

    I'm not speaking here of people already VERY sick, I'm talking about the overweight woman who keeps failing at diet after diet. If she can just leave out one dessert a day and replace it with fruit...that is a step in the right direction.

    I speak from experience. I am a "busy" woman with children. My doctor has been telling me for years that that "5 pounds a year" is going to catch up with me. Well, two years ago it did during a bone scan when my result came back "low normal"...
    About a week later I joined a gym and added weights to my daily calcium pills...
    I have now lost 30 pounds, increased my stamina and installed a small gym set up in my home so I can just roll out of bed and hit the "gym corner" in my garage. The doctor was persistent over years. I was finally "ready"...

  4. Your thoughts are right on with primary care's. I have known very qualified (young) physicians who quit clinical practice and went to research because they could not tolerate dealing with challenging patients. We all face this situation almost on a daily basis. I particularly liked recent talk by psychiatrist at Women's Congress last month. He specified types of physicians and types of patients that increase risk of difficult interaction. When I started practice I had all physician risk factors. What an astounding discovery. Understanding and changing yourself helps. I recommend this speaker's book
    "Patient-Centered Interviewing: An Evidence-Based Method" by
    Robert C. Smith
    Sounds like you found a lot of asnwers yourself though. Congratulations!

  5. It's so frustrating, but it's also so important to persist. And celebrate small victories.

  6. I know. It annoys the snot out of me. After 30 years it still does. One day I just asked one "why do you come here? You don't do a thing I say and argue with every suggestion." By golly if she didn't turn around and was actually quite pleasant to work with.

  7. Here's the other side: I go to the doctor because I want access to birth control pills. That's it.

    In order to get access, I have to do the pap smear, the mammogram, the weight, the blood pressure, etc. I have to get poked and prodded. I have to fill out a questionnaire about whether I drink or wear a seat belt. All under the veiled threat that non-compliance will mean no access.

    (My insurance pays for this clinic, but Planned Parenthood isn't on the list.)

    I came for birth control. Why put me through all the rest?

  8. Some therapists have done away with the concept of "noncompliance," instead postulating that a) if the client/patient isn't doing what you ask it's probably because it doesn't work for them and b) the whole concept of compliance is paternalistic. I've worked with clients who wanted to change their behavior WRT their health care, but didn't quite know how. (Eat healthier and exercise sounds simple, but of course we all know that issues of motivation are rarely as easy as they seem, especially if you're suffering depression or anxiety).

    At the same time, I relate to the frustration. "You expect me to help you, and yet you don't try anything I suggest!"

    I wonder if the good patient/bad patient dichotomy is a helpful one (although it certainly is an easy one to develop). The patients that you praise for being "good" may later be "bad" for whatever reasons...and my personal idea about building a good doctor/patient relationship would be that patients could "admit" when they were having trouble with maintaining their care and could have an open dialog about their struggles and potential ways of addressing those struggles. I wonder if part of what keeps a "bad patient" being a "bad patient" is the negative feedback loop of feeling ashamed/guilty about not taking care and thus avoiding coming in for appointments or continuing to not make progress.

  9. To Anonymous: We "poke and prod" and check your weight, blood pressure, pap, mammo etc. because we CARE ABOUT YOUR HEALTH. That's what we want to do and what we're trained for. I cannot even guess how many patients I've had who have had breast cancers picked up on mammo and are in remission because of early detection as well as early cervical cancers found on pap that were curable at an early stage. I may be a doctor but I'm a patient too and guess what, I go through the same process at my doctor and I appreciate it. We are all doing the best we can out there to help people be as healthy as they can be.

  10. Look up Motivational Interviewing. It might help. I like this resource: http://casaa.unm.edu/mi.html

  11. LauraFP,

    I think that a doctor could care about a patient's health, and still allow them to make informed decisions about their own actions - e.g. declining a pap smear (which of course is a beneficial screening tool..but which also can be extremely traumatic for some people) and still having access to birth control. After all, you can safely prescribe birth control in the absence of info provided by a pap, so why do providers link them?

    Its comfortable to sort of convince people to get their paps in this way, and say you're improving their health. And you probably are...but you are doing so at the expense of their autonomy.

  12. I would have to say from a personal experience of not listening to my doctor's advice, that is can all boil down to feeling like your doctor cares or just giving you something to do. It was very shocking to myself, my doctor, my family and friends when I did not listen to something my doctors told me years ago that could have resulted in death because I was a pre-med student who trusted in doctors, medicine, and the science of medicine. Well I reluctantly did not want to seek treatment because I thought they were just going to use me as a guinea pig and that my doctor wasn't really concerned about me, just wanted to have surgery, etc for the sake of money, a new treatment advancement, etc. So once your patient becomes comfortable with you, they can begin to trust what you have to say. Also it comes to being ready to face that you have a medical condition/problem. I was not overweight, but dealing with an internal issue that was out of my control. But being i denial and thinking if I ignored it long enough and prayed hard enough that it would go away, but of course it didn't. it resulted in my physician at school and the doctors in my hometown collaborating together to get me into the hospital which resulted in me having surgery the next day because they all knew that once I left the hospital I wasn't coming back. Yes I knew it was a serious issue and at any moment I could have died, but I wasn't yet comfortable with dealing with it and I didn't think my doctors cred enough about me to be telling me the truth. I did not have weight issue or something that would result in instant gratification, etc, but I did have a serious problem that could have possibly killed me and I just couldn't deal with it or handle it until I was ready to face it. Just some things to think about from a patient perspective. Please don't use what I have typed here for some kind of publication, etc. It's a personal story for here and here only, not to sound like a prick or anything, but it is very touching.

  13. Check-out this blog for real life strugle with difficult situations in out-patient clinic. Its written with light-heart and humor


    My teaching attending used`to say "We are physicians. We are not God" It just sometimes feels like you are expected to be..

  14. I agree wholeheartedly with the Motivational Interviewing suggestion.


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