When does Serving Become Enabling?


Get a group of Family Doctors together to talk about improving patient outcomes, any outcome, and one question is certain to come up, “What is the patient’s responsibility?”

Doctors are measured against a number of standards. Each month I get reports on the percentage of my patients who have had colon cancer screening, mammograms and pap smears. For diabetic patients the list is extensive and includes blood pressure control, cholesterol medications, blood sugar control and whether or not the patient has been screened for kidney disease.

In my office, staff members review the reports and make phone calls and send out electronic reminders to encourage patients to get the necessary tests and treatments. Every time I look over the list of names and review the charts I see that regardless of the test or screening all of the patients have something in common. Every one of them has been previously told what the tests were and been given the necessary orders and referrals to get them done. They just haven’t bothered to do it.

It is a source of unending frustration for doctors. We went to school to be doctors, to care for disease and provide treatment to patients under our care. None of us signed up to be patient care reminder professionals. Yet that is what we are becoming. My medical group recently announced a new quality measure that illustrates the absurdity of it all. We are now being measured according to how consistently our patients pick up their prescriptions at the pharmacy. Telling a patient to take a medication daily and sending the prescription to the pharmacy is not enough. If they don’t pick up their refills consistently we are held responsible!

Too many patients do not prioritize their health and instead expect their doctor to pick up the slack. Several months ago a diabetic patient came to our office for an initial visit. We started a new blood pressure medication, ordered the appropriate lab work and asked the patient to return in a month. Four months later the patient returned. The blood work had not been done, so the order was sent again to the lab.

Two months later, 6 months after the initial visit, the patient called the office requesting a refill of his medications. I checked the chart and saw that the patient still had not been to the labs. Reluctantly I decided I needed a firmer response. I left a voice mail and sent an electronic message saying that we wanted to partner with him in the care of his diabetes but that he had failed to follow our recommendations in spite of repeated calls from our office. I told him I would refill his medications for 5 days to allow him time to get his blood work done and be seen in the office and that no additional refills would be given until he was seen.

Nine days later on a Saturday I received a page from the patient. He had been to the lab that morning but he was out of his medications and he wanted an urgent refill. I was unable to hide my frustration when I returned his call. I reminded him that I had told him that he had to get his labs done and be seen in the office but that he had failed to follow my advice.

“So you are going to deny a diabetic his medication?” was his angry reply. My reminder that his lack of medication was a result of his personal choices did not go over well. He started to argue with me and I wondered what to do. I finally decided to offer a compromise.

“I’ll give you three days of medications and see you in the office Tuesday morning,” I said. He begrudgingly agreed. Before hanging up the phone I shared with him a truth that I often share with similar patients saying, “You know, If I care more about your diabetes than you do, there is something wrong.”

What was wrong with this patient is what is wrong with many patients. For a multitude of reasons, many of them understandable, patients fail to take care of themselves and to follow recommendations. Twenty years ago they alone suffered the consequences of their poor decisions. What few of them understand is how their poor decisions impact the physicians providing their care and how these consequences put a strain on the doctor/patient relationship.

As a physician who is committed to providing the very best care for his patients I find myself frequently wondering if I am enabling instead of serving, if there is a point when going the extra mile is actually a disservice to my patients, and how to determine when that point has been reached.

Although I think this patient may have reached it…

-          Bart

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