Contempt and compassion: The noncompliant patient

Source: Salvation Army

“After I had berated the patient for his obvious failure to comply with my recommendations to correct his ‘misbehavior,’ he said, ‘You know, doctor, there is more to life than good health.’ These words have helped me rein in my sometimes overzealous attempts to force patients into that glorious state of wellness and maintain a more realistic approach to the best possible state of health.” (Lewis E. Foxhall, M.D.)

Patients who fail to follow a doctor’s orders are labeled noncompliant. In the current national conversation on health care reform, noncompliant patients are one of many targets blamed for rising costs. If only everyone took their meds as directed, lost weight, exercised more, and used less cocaine, we wouldn’t be in such a mess.

Preventive care now to save expensive care later is a medical mantra, even though its truth (with the exception of not smoking) is tricky to prove. The recent story on “macho” men neglecting their health was about noncompliance. In all the news reports I read on this story, the unspoken assumption was that these men must be uninformed, unintelligent, pig-headed, or – at the very least – inconsiderate of the rest of us. Our insurance premiums rise because they’re too much of a “real man” to see a doctor.

Here’s another doctor discussing compliance from the perspective of the patient.

“Who made ‘health’ the central issue of our life?” they ask, when the physician is too heavy-handed about compliance or patient education. “The point of my life,” they’ll say, “is to be a rancher. I only want a doctor when I can’t break my bronco and my bronco breaks me.” Physicians are always thinking of longevity: “How can I help someone to live longer?” But for these ranchers and farmers in west Texas, medical care is not their first priority.

Over the last half century, medicine has been eased into the role of doing society’s dirty work: Controlling behaviors that need to comply with social values. Homosexuality, addiction, depression, reproduction, aging and death, obesity. Modern biomedicine considers itself successful when no one questions its overarching wisdom.

Noncompliance is about the misbehaviors of individuals. In the seventies, social critics tried to focus our attention on what was wrong with this perspective. When individuals are blamed for their noncompliance, the social environment in which individuals live gets a free ride. When we blame the overweight for their lack of will power, we ignore the relative cost of a Big Mac and two-dollar-a-pound apples.

Contempt: Blaming the patient

I was recently struck by the contrasting thoughts of two doctors I happened to read on the same day. The first one illustrates contempt for the noncompliant. The other tries to teach compassion.

From my perspective, there are people who really don’t deserve health care reform. … The “elephant in the room” is that some patients (rich and poor alike) do nothing to care for themselves, take no responsibility for their well-being, are never accountable for their actions and will happily bleed any system dry, public or private.

These folks don’t listen, won’t listen and are proud of it. They continue to smoke after bypass surgery, eat themselves into disability for obesity, and remain obese after lap-band surgeries or gastric bypass. … They don’t adjust their diets to care for their diabetes (even when they have access to physicians and supplies) and generally want someone else to take care of little details — like their life-and-death illnesses. …

How will the pending [health care] reforms handle repeat drunk drivers and the medical costs they incur and cause? How will it handle drug dealers and drug addiction recidivism? Will it even attempt to face those individuals who latch onto contrived and unsubstantiated somatic “diseases,” that require enormous pharmaceutical expenditures in order to maintain what really constitutes a narcotic addiction or depressive disorder?

While we reasonably debate the morality of universal coverage for the nation, will we ever debate the morality of lassitude and the abuse of social programs? Of persons who, given the opportunity, always take without giving? Will we crack down on families where one man fathers multiple children with different women, a thing which is very costly to our health care system in uninsured and underinsured poor children?

Will we censure or fine the promiscuous, gay or straight, who develop and then spread HIV, or the less deadly but also troublesome STDs that lead to pain, infertility and medical expenditures? Will we address the cost of gang violence? Will illegal aliens who use our health care resources be fined or deported?

The morality of health care reform is a question we must reasonably ask. But we have to be willing to address the morality of giving more of our tax dollars, with no personal expectations, to those who already cost us so very much.

Compassion for the “difficult” patient

Michael W. Kahn is a psychiatrist who guides students on their journey to becoming doctors. In a recent issue of The New England Journal of Medicine, he discusses a patient (her name has been changed) and what his students learned by interacting with her.

Homeless and addicted to drugs and alcohol, [Ms. Andrews] had terrible coping skills, a nasty temper, and a habit of leaving against medical advice after tormenting everyone for a few miserable days. Admitted – yet again – for pancreatitis, she was doing battle – as usual – over dilaudid and cigarettes. …

The first [task] was to allow patients to vent about being in the hospital – in Ms. Andrews case, about everyone’s colossal incompetence and stupidity. The second was to find answers to the following questions: Where do you live and with whom? Who are the important people in your life? How do you spend your time? What gives you pleasure?

Ms. Andrews told us about having been physically, psychologically, and sexually abused by her drug-addicted parents and in serial foster homes; how teenage prostitution and crime had helped support her own habit; and how much she missed her two children, who had been taken away by the state. She explained why some people prefer living on the streets to staying in shelters, that cocaine helped her mood more than sertraline, and that she loved horror movies and Stephen King novels. She seemed glad to be able to talk without fighting.

In discussing the patient after the interview, students realized that:

[I]f Ms. Andrews was allowed to curse like a drill sergeant for 30 seconds or so, the wind would leave the sails of her hostility and she could actually have a sharp sense of humor. … She seemed less the so-called classic borderline case than a person who came by her very difficult behavior honestly. …

Ms. Andrews’s impossible behavior had become more intelligible, and the students learned that there were ways to begin collaborating with patients who have trouble doing so. …

Ms. Andrews has continued in her difficult ways but with much less intensity. Since she now knew that her caregivers knew something about the hell her life had been (and still was), she could afford to curb her antagonism and allow others to feel some sympathy for her. …

[William] Osler wrote long ago that “it is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” To modern ears, this assertion can unfortunately sound like irrelevant high-mindedness from a vanished era rather than a principle that can tangibly improve patient care and professional satisfaction … [H]olding rounds on behaviorally difficult patients is one way to show the usefulness of his principle. These rounds can demonstrate the immediate payoff of knowing even a little bit about a patient’s life. Lose that knowledge, and we risk becoming more technician than clinician.

Thanks to KevinMD for the Ed Leap link.

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