Residency Rap

Last week in clinic, I saw one of our regular clinic patients. We’ve been seeing this non-compliant patient for quite some time for a chronic Charcot-induced plantar midfoot neuropathic ulceration. Just to make things interesting, besides his diabetes, he has severe peripheral vascular disease (deemed a non-surgical candidate by vascular surgery) and chronic renal failure, for which he receives hemodialysis three times per week. Oh yeah, did I mention his blood sugars average in the 300’s and had a BKA a couple of months ago on the contralateral limb secondary to worsening gangrene? This fella is the model of noncompliance, chronically incapable of keeping his blood sugars at even a semi-reasonable level, not to mention the animal hair we consistently find in his wound. In this patient’s case, the most difficult component to heal his wounds and save his remaining limb is his non-compliance.

In my opinion, this, next to insurance issues, is the most vexing part of patient care, whether in the diabetic population or our otherwise healthy patients. Trying to get patients to do exactly as you advise is a difficult task.

Often, “non-compliance” is not the patient’s fault, but our own failure to adequately communicate. Much of podiatric pathology is complex and may be difficult to verbalize clearly to the lay patient. I’ve seen many residents and attendings communicate to patients in medical jargon about their foot problems with patients just as confused after the discussion. I’m sure I’ve done this plenty of times myself. How can we expect patients to comply with our protocols when they don’t have a basic understanding of their disease? Additionally, many of our treatments are multifaceted and require our patients do perform several tasks after leaving our office. Take plantar fasciitis, for example. At our program, a new patient with this problem may receive 7 to 10 pieces of instruction, besides a discussion of the etiology of their problem. I don’t think they could possibly remember this deluge of information, much less comply with it.

Some patients just won’t listen to their physician. This brings up the medico-legal issue. You do everything you can to help these patients, yet they refuse to take your advise. I think the key to these patients is to figure out why they won’t comply. Perhaps they don’t understand, but are intimidated to let you know? Perhaps they’re incapable, due to some personal life issue? A person one step from homelessness is not going to concern themselves with appropriate shoegear. Some patients just don’t like doctors. In any case, it’s imperative to honestly and accurately document their non-compliance and what you’ve tried to do about it. Remember, in court, if you didn’t chart it, it didn’t happen.

A couple of obvious but rarely performed methods to improve patient compliance may include:

• Always speak to patients in lay terms. Keep the pod-speak out of the conversation.
• Dispense written pamphlets on patients’ diagnoses. The APMA has a series of useful ones covering the major foot and ankle pathologies.
• Give your patients a written “podiatric prescription” documenting in list form what you want them to do outside of the office. Make sure your patients are literate, first. Not everyone can read!
• Ask the open-ended question “do you have any questions” after your discussion, giving them time to think of questions.
• Some physicians ask their patients to repeat back to them their treatment regimen. As a spin off of this, I always have my patients demonstrate Achilles stretches when I first teach them and at follow-up visits. They often perform these incorrectly without some reinforcement.

Take time to know your patients and let them speak to you about their issues. Their comfort level with you will dictate their level of compliance.

How do you handle noncompliant patients? What tips and pearls have you learned that might benefit the resident community? Write in with your ideas.


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