Sunday, August 2, 2015

Pulling My Hair Out…A Doctor’s Struggles with Patient Noncompliance and Managing Unrealistic Expectations

Several days a month, I come home from a long day at work feeling exasperated, frustrated, mentally dilapidated, and just plain tired.  Oftentimes, I feel like pulling my hair out…and for a middle-aged already balding physician, this presents a big problem.  The actual physical work varies by the day, but I have found that certain patient interactions can take a toll on me way more than the actual bodily stress does.  

Patient noncompliance seems to be one of my biggest stressors and it can take various forms.  It can be as simple as grandpa not caring to take his medications, grandma not being able to afford her meds, or crazy cousin Eddie not keeping his appointments.  I cannot tell you how many patients come into my office weekly and tell my nurses that he/she just ran out of meds and did not think to get them refilled.  Some patients truly think that one (or the last) bottle of meds “cured” their high blood pressure, others are just lazy and tell me that they never got around to going by the pharmacy again even though they clearly dropped in somewhere to pick up the pack of cigarettes in their front pocket.  Cost is a huge issue and with the exorbitant prices of some non-generic pharmaceuticals added to the fixed cost co-pays and outrageous deductibles, the price of healthcare can strangle some poor patients.  I have empathy for patients most times, however it is striking to see a poorly controlled diabetic walk into clinic with a McDonald’s bag and an iPhone (and iPad) then tell you that he/she cannot afford generic meds.  

The issue of noncompliance with medical appointments deserves special attention as there are days in which I have 1 out of 5 patients no-show.  This reckless and avoidable habit wreaks havoc on clinics nationwide.  Not only do no-shows mean lost revenue, but they also take away a spot that an otherwise sick person could have had.  Add to it, the patient who no-shows then has be rescheduled (assuming they want to be seen in the future) at their convenience which then bogs down the already tight schedule even more.  Some clinics and doctors have put in place policies to dissuade patients from no-showing like forcing the patient to pay a fixed cost if no cancellation within 24 or 48 hours of the appointment.  My office does not currently use this policy, however I suspect we will see more like-scenarios in the future to counteract this situation. 

The most glaring evidence of noncompliance seems to be rooted in local cultures.  My urban dwelling patients who are middle to upper class seem to have very little noncompliance.   Occasionally patients will return to my clinic earlier than scheduled to tell me that they have stopped a medication or therapy due to a misunderstanding or side effect.  My lower socioeconomic class patients, especially those who are illiterate, understandably seem to have the hardest time.  Most troublesome, however, are the rural patients who seem to march to a different drum beat.  When I go to an outreach clinic for a full day (and the patients know that I am in the clinic in their community all day), I often have late afternoon patients show up early in the morning and vice versa.   When asked by my nurses about their early or late arrival, they mostly say that they just thought that they could show up early (or late) and be seen.  I also have a tremendous amount of no-show/rescheduling, and I have patients who do not seem to be interested in their care/health/treatment/medications.  The Humpty Dumpty approach to medicine is strong in these locales.  

I have now grown accustomed to patient noncompliance and the ensuing disasters. Despite thorough education by multiple medical personnel, I have had multiple episodes in which a stent patient will stop his/her Plavix one month after a heart stent (and 11 months earlier than ordered).  This puts them at risk for clotting of the stent which can be life-threatening.  Cessation of blood pressure medications can also cause a similar emergency in which patients will develop chest pain, stroke symptoms, or have a heart attack due to lack of vital meds.  My patients with atrial fibrillation (a heart arrhythmia that can cause strokes unless treated with a blood thinner) often will stop their blood thinner due to a simple nosebleed, hemorrhoidal bleed, or trivial laceration/scratch on the arm or leg.  As expected, they then come into the ER with a large stroke from the AFib and wonder why.  

The other scenario that regularly causes me to want to pull my already scant hair out involves patient and family expectations.  As with the noncompliance section, I cannot give you a complete list of unrealistic patient expectations, rather I will just mention a couple of good examples.  Let me start by saying that all patients and families should have high expectations of doctors, nurses, staff, and their medical care.  The most common cause of trouble with these expectations in my experience has occurred AFTER a patient (and/or family) is educated about a disease process and told how to expect the course to go.

Cancer diagnoses and treatment plans often lead to incongruent patient-doctor expectations and thus can be frustrating for both sides.  Oncologists often have to balance the diagnosis/treatment of a metastatic cancer (which is almost always fatal and treatment plans are usually meant to prolong life while reducing pain and suffering) with the mental/psychological burden that has been placed on the patient.  Crushing the spirit of a patient too soon after diagnosis can  be extremely troublesome to the doctor-patient relationship.  

Emergency room patients and doctors often have a difference of expectations when it comes to being seen in a timely manner.  The patient often thinks solely about his/her presentation and symptoms, usually pain/trauma/etc.  The doctor must be tasked primarily with triaging patients from most sick to least sick and then endeavoring to see all patients as quickly as possible.  Most lay people do not understand the triage process and wonder why a patient who is having chest pain but appears comfortable is seen before the patient with a non-life threatening trauma.  ER doctors suffer quite a bit of stress from patient and family complaints due to the triage process which, for the most part, is out of their control.  

The above two examples are not everyday occurrences for me as a cardiologist.  My dealings with unrealistic expectations leading to frustration seem to be related to three situations:  post-heart attack or stroke apathy with repeat event, medication noncompliance leading to an unexpected event, and denial causing a false sense of well-being despite uncontrolled risk factors.  The second example has already been discussed above but is worth a repeat mention as a large percentage of patient events occurs due to medication noncompliance.  If insurers are ever able to capture this cause/effect in action, they are likely to try to unload the financial ramifications onto the patient.  

Certain patients take an apathetic approach to their life after an event like a heart attack or stroke.  They give up, or at least they stop caring about the healthy side of life.  They then set themselves up for a repeat event.  The family rather than the patient is usually the side who has unrealistic expectations when this event happens.  I often hear from them:  “how could you let Daddy have another heart attack when he just had one two years ago?  Don’t you think you should have treated him more aggressively?”  Unfortunately, this approach then pushes the physician to throw the patient under the bus by examining the reasons why Daddy had another event:  usually smoking, eating poorly, not taking meds, etc.  No matter the approach, the doctor-patient relationship is stressed.  

Finally, I bang my head against the wall and rip the hair from my scalp on a regular basis due to the patients who come into my clinic with diabetes, high blood pressure, high cholesterol, family history of heart disease, and tobacco abuse yet refuse to do anything about any of these disease processes.  These patients clearly expect not to have events despite overwhelming evidence to the contrary.  I have no answer for these unrealistic expectations nor do I hope to discover a cure for noncompliance.  

We can only hope that there is a culture shift and/or a new approach to educating patients and families which will alter compliance and expectations. 

David Jones, MD is the owner of, a healthcare ratings website dedicated to physician peer ratings, and a practicing adult cardiologist.  

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