Virtual Mentor. April 2003, Volume 5, Number 4.
When a Nonadherent Patient Needs Your Care
Argues that non-adherence on a patient's part does not erase physician responsibility and examines how best to provide care for a non-adherent patient.
Commentary by David A. Bennahum, MD
Dr. Jefferson, an OB/GYN in private practice, first took care of Ms Carr when her mother brought the 15 year-old girl in for a pregnancy evaluation. The test was positive, and Ms Carr's mother accompanied her daughter on every prenatal visit. After a successful delivery, Dr. Jefferson brought up the topic of birth control. Ms Carr, partly on the insistence of her mother, wanted to take birth control pills because she had heard that they improved one's complexion and didn't cause much weight gain. Concerned about the 15-year-old's ability to stick with a contraceptive that required daily vigilance, Dr. Jefferson suggested taking a longer acting contraceptive, but Ms Carr insisted that birth control pills were the only kind of contraceptive she wanted.
Over the next 3 years, Dr. Jefferson saw Ms Carr for routine care, including renewing her prescription for birth control pills, always accompanied by her mother. One day, she came in without her mother; and Dr. Jefferson learned that the 2 had had a falling out and Ms Carr had moved in with her boyfriend.
Ms Carr missed a scheduled appointment, and when Dr. Jefferson saw her again, she was several weeks pregnant. When asked why she had missed her appointments, Ms Carr replied that she couldn't make it at the scheduled time and didn't think that missing an appointment was such a big deal–she wanted to get pregnant. During the visit, Dr. Jefferson stressed the importance of prenatal care for the health of both Ms Carr and her baby and the need for Ms Carr to come to all her scheduled appointments.
Ms Carr made her next appointment before she left the office but she failed to keep it. She did not respond to several calls prompted by Dr. Jefferson's tickler file for women receiving prenatal care. Four months into her pregnancy, Ms Carr appeared without an appointment. When asked about the missed appointment, Ms Carr apologized. "I know I should have come, but I have a job and another child to take care of and now that I live with my boyfriend, your office is much farther away than when I lived with my mother. I can't take off work without being docked and I can't leave the 3-year-old after I get home. I knew you needed to see me." Dr. Jefferson was worried about how Ms Carr looked; she had gained too much weight. Dr. Jefferson went ahead and saw her at the unscheduled time. She did an exam and got blood work. She sent Ms Carr away with a printed diet that called for less salt, decreased carbohydrates, and fewer calories in general.
The lab work showed that Ms Carr's blood sugar was elevated, so Dr. Jefferson had the office secretary call to schedule an urgent appointment because of concerns about gestational diabetes and its potential negative impact on the fetus.
Despite repeated attempts to contact her, Ms Carr didn't return to the doctor's office until 4 weeks later, now 5 months pregnant. She had gained more weight and had some swelling in her ankles. Dr. Jefferson informed her of the importance of closely monitoring and treating her diabetes, and that it might be better if Ms Carr found a physician closer to home or work whom she could get to more regularly. Dr. Jefferson said that Ms Carr's last trimester should be monitored carefully and that she, Dr. Jefferson, would help Ms Carr find another physician. Two weeks later, Dr. Jefferson was happy to receive a request from a colleague for Ms Carr's medical records.
One month later, Dr. Jefferson received a call from labor and delivery at a hospital where she attends. A nurse's aide said that Ms Carr had showed up at the ER in premature labor and had been admitted. When asked who her doctor was, Ms Carr promptly gave Dr. Jefferson's name.
Acts of Caring and Fidelity
In this case a young girl, Ms Carr, who had her first child at 15, was compliant with her physician, Dr. Jefferson's, recommendations as long as she lived with her mother. At 18 she had a falling out with her mother, claimed her independence, got a job, and taking her child with her moved in with her boyfriend.
Dr. Jefferson learns all this when the patient returns for a visit without her mother. Her next appointment is missed, however, and when she next turns up she is found to be several weeks pregnant, a pregnancy that she insists she wants. Her physician is troubled, perhaps annoyed, by Ms Carr's nonchalant attitude and possibly even by the pregnancy which the doctor tried to prevent by offering long-acting contraceptives after the first baby was born. Claiming that her job, the needs of her first-born, and the distance she has to travel to reach the doctor's office are all impediments, Ms Carr misses a number of appointments. When she does turn up again she is found to have gestational diabetes. The doctor at first urges her to keep her appointments, follow medical advice, and then suggests that she find a physician nearer to her home. She does that, but then unexpectedly she shows up at the hospital in premature labor and claims Dr. Jefferson as her obstetrician.
What should Dr. Jefferson do? Should she accept Ms Carr as her patient or refer her back to the colleague whom Ms Carr recently saw? Does the physician have a duty to care for this patient? Apparently Ms Carr, realizing that she was in trouble, perhaps in premature labor, rushed to the hospital. After all Dr. Jefferson had been Ms Carr's physician since she was 15, had seen her through her first pregnancy and continued to see her from time to time. Is Dr. Jefferson bound by a fiduciary duty to now care for Ms Carr? And if this premature baby does badly will she, Dr. Jefferson, be blamed and possibly sued? She would certainly be within her rights to think that she had not abandoned Ms Carr. On the contrary she arranged for Ms Carr to see a colleague. But what of the patient? She must now be scared, certainly no longer nonchalant, and immature, and now desperate to have the doctor she trusts and knows take care of her.
We can see at least 2 values Dr. Jefferson might consider here. The first is fidelity. Granted Dr. Jefferson has been the more faithful of the 2 in this patient-physician relationship. The second is the value of caring. The patient desperately wants a physician she knows and trusts not only to cure her but also to care for her. Will Dr. Jefferson see that trust as a gift, that Ms Carr is reaching out to her in her moment of need, rather than that Ms Carr has been careless and immature and is not worthy of further attention?
We can reject patients for so many reasons, and we are so easily put off when in the course of a busy day, someone does not follow our best advice. How we frame and name situations is very important. What do we really mean by non-compliant? Comply means to bend, and few of us wish to bend and bow before another. When a patient doesn't follow our advice, is it only because she was irresponsible? Do we ask ourselves if we were clear in our explanation? Did we ask the patients to articulate what we think we have just explained? Can the patient afford the treatment? Are there logistical problems such as Ms Carr had? Where to leave the baby? How to get a ride or money for gas? Will she lose her job if she takes too much time off? Do we really know our patients' lives their troubles and their joys? To what extent do our own values warp our judgment?
I would argue that Ms Carr's return is an act of fidelity on the part of the patient. Fidelity implies trust, and when a patient entrusts herself to a physician she brings a gift. If the physician can respond with gratitude and empathy to a patient's need, a bond will be established that will benefit both patient and physician.
David A. Bennahum, MD, is a professor of medicine at the University of New Mexico.
The people and events in this case are fictional. Resemblance to real events or to names of people, living or dead, is entirely coincidental. The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.
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