Jarrod Shapiro, DPM
Practice Perfect Editor
Mountain View
Medical &
Surgical Associates,
Madras, Oregon
|
Blackmailed by Our Patients
Reading Dr Tamler’s last post about patients blackmailing their doctors provoked some of my own thoughts on the subject. I started thinking increasingly about this idea of patients blackmailing their doctors — and then thought some more — and some more still. I thought about trusting patients, how patients trust their doctors, and doing what’s right, despite the pressure to do what’s easy. I’d like to take a few minutes and expand these ideas.
First, my response to Dr Tamler’s conundrum. Plain and simple: if the patient demanded this blood testing unit even after I’d explained the clear lack of necessity and of any clinically beneficial use, I’d have to say, “If this isn’t good enough for you, then I’d recommend you see someone else.” I know; we don’t want to alienate patients, and in today’s economy, it’s hard enough to afford to practice and still satisfy our patients. But you really can’t compromise your knowledge, training, and experience just because it pleases your patient. Pandering to patient's requests can be a slippery slope that we don't want to slide down. Of course, this issue isn't purely black and white, and just like raising children, we must carefully choose which battles we wish to engage in, and when it's best to give in and move on.
Practice Perfect now features brand new lectures on podiatry.com – viewable for CME Credit. Take advantage of our FREE $60 CME Credit Introductory Offer, where you get $$$ that you
can apply
to
CME Credit on the site. Details are provided at the conclusion of the eZine. |
|
It’s sickening to think (even though it exists) that there are patients out there with their own agendas who don’t care to listen to what an expert in his field like Dr Tamler recommends. This is a different issue from the pain medication-seeking patient who’ll try to get his next fix any way possible. Rather, this is the patient that will attempt to manipulate the medical system for his or her own personal gain, whether emotional, physical, or monetary. Just think about that disability patient each of us has dealt with – many times a low back pain patient - who managed to convince someone they are permanently disabled and now milks the system for free money. Unfortunately, they’re out there in abundance. These are the patients we are talking about here.
Doctors Trusting patients - Where I Draw the Line
During my first two years in practice, I worked at a wound care clinic on Wednesdays. On one particular day, I was treating a notoriously noncompliant diabetic with a plantar heel neuropathic ulcer. Despite my best efforts to convince him otherwise, this patient continued to ambulate on his ulcer. I tried to explain to him the damage he was doing and the reason his wound was not healing. I had previously suggested multiple off-weighting options, all of which he refused. It seemed for a moment that I had finally gotten through, suggesting a total contact cast, at which point he said, OK you can put this on me, but if anything happens you’ll be hearing from my lawyer. Whoa! My response was, “I refuse to treat my patients under threat. I will not see you any longer, and I’ll refer you to one of the other doctors at the wound clinic.” I documented the incident in his chart and didn’t see him again. I refuse to be blackmailed. I may not have the ability to cherry pick my patients (nor do I want it), but that doesn’t mean the patient is in complete control either.
Now having said that, it’s crazy to think we ever are 100% in control of our patients. When I advise a patient to be nonweightbearing after surgery, for example, I’m relying on them to understand the importance of my advice and actually listen. But when they leave my office, they’re on their own. If they want to walk all over that fresh flatfoot reconstruction, that’s their option. There’s really nothing I can do about it once the surgery is complete. I can only try my best to screen patients preoperatively and avoid surgery on those patients I don’t trust.
This is also true for nonsurgical care. The most common reason patients see a doctor is because of pain, an unarguably subjective complaint, and for many pathological entities our success is determined by our patients’ subjectively reporting a decrease in pain. Take plantar fasciitis, for example. We may see associated pathology, such as midstance pronation and equinus, but we first think of this diagnosis when our patient describes first step pain. Whatever treatment then chosen, whether orthotics, splints, injections, or surgery, our success is determined by the patient’s statement of pain resolution. With all of our technical skills, modern procedures, and technology, we’re still reliant on our patients to truthfully tell us if their pain has resolved. We’re forced to trust our patients – at least to a certain extent.
Patients Trusting Doctors
Perhaps this is appropriate because the majority of our patients put their complete trust in their doctors. Take surgery as an example. Not only do our patients put their trust in us by accepting the surgical procedure we choose for them, but they literally put their lives in our hands when they go under anesthesia. There’s a chance they won’t wake up. How much more trust do you need?
On the other hand many patients choose when to trust their doctors. I have a patient with a talar dome lesion and lateral ankle instability who is an amateur competitive walker. After attempting a course of nonsurgical therapy, which was unsuccessful, I had her obtain a second opinion from one of my colleagues. He recommended surgical correction, but the patient chose to continue to observe the area while she continued to compete. Several months later she followed up with me, reporting continued pain and readiness for surgery. What I found interesting about this was she related to me that she wanted to follow-up with me instead of the other doctor, because she liked that I was more permissive in my advice – I had recommended she continue to walk unless it became too painful, while the other doctor suggested she completely stop due to the risk of AVN of the talus. She basically did what she wanted and used my advice as an excuse to do so. This is a patient who trusts her doctors only when it’s convenient for her.
Doing What’s Right
So, with physicians’ inability to never truly know their patients’ motivations and perhaps never fully trust them, and many patients’ lack of trust of their doctors, how do we come to a reasonable compromise?
I’m not sure there is a compromise. In practice, I try to follow two rules. One, maximize my patients’ trustworthiness, and two, do what’s right, not what’s easy. Maximizing trustworthiness includes knowing your patient, looking for signs of concern (the obvious example is that patient that asks you for pain meds right off the bat), providing clear and easy to follow instructions, appropriate documentation (to protect yourself), preoperative tests of compliance, and limiting patients’ abilities to harm your good work (for example, using casts instead of cam walkers).
| How to Maximize your Patients' Trustworthiness |
| 1. Get to know your patients |
| 2. Look for warning signs |
| 3. Provide clear and easy to follow instructions |
| 4. Document everything that you observe |
| 5. Assess how compliant patient is pre-op |
| 6. Use insurance, like a cast walker instead of a removable cam walker |
|
It’s completely in the doctor’s control to do what’s right rather than what’s easy. If nothing else is controllable, this is. The doctor has to trust his/her instincts. If a red flag goes up, then he/she must adjust their treatment accordingly. If the patient is noncompliant with presurgical instructions or he continually no-shows his appointments, then cancel their surgery. It’s often easier to do the wrong thing – doing that procedure despite your reservations, or letting that postop patient start weightbearing prematurely, simply because they ask for it. But the complications are never easy. That below knee amputation that occurred as a result of your failure to obtain arterial studies prior to that nail procedure will not be easy. Do what’s right, don’t cut corners, and trust your instincts. Let the trust issues work themselves out.
What do you think? Share you thoughts and experiences regarding blackmail and developing patient trust.
Keep writing in with your thoughts and comments or our eTalk discussion forum on PRESENT Podiatry and start or get in on the discussion. We'll see you next week. Best wishes!
Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]
|
