Physicians Can't Help Patients Who Can't Help Themselves

The author:

On the other hand, I have some patients who really make me wonder why they even bother coming. They stop their meds, they go back on old ones (sometimes expired ones), they change their dose, they don’t get their tests done; all that in addition to the usual lack of lifestyle modification. I will usually conduct a typical visit anyway: history, physical, plan. I explain the whys and wherefores, I discuss the potential consequences of non-adherence to the plan. And I do take the time to explain to patients why they need to take certain drugs, what side effects to look for, why they need to get tests done, etc.

But at some point in this doctor-patient relationship, when the typical modus operandus fails, I stop entering things on the computer, fold my hands in my lap, lean back in my chair, and say, “So why are you here?” Sometimes it’s followed by, “How do you want me to help you?” or “What would you like me to do for you?” or “What would you like to happen now?” http://www.physicianspractice.com/bl...s?CID=p2widget

Final comment:

But by and large, I do find that patient finally “get it” when I throw up my hands and admit I don’t know how else to help them without them helping themselves.

Oftentimes the doctor gets the patient they deserve. If they keep saying everything but the most common side effects is in your head, if they have no time to listen, if they don't understand how to approach sensitive things (like weight) but just walk all over the patient's feelings and if they touch you without respect, they will not get a patient who trusts them. If on top of that they get ANGRY if the patient does wrong to his own body and the doc treats the patient's body like it is the doc's PROPERTY, all is lost.

I know one of those non-compliant patients. Yea, he takes meds as he is told to, but he won't make lifestyle changes. Why? The doc hasn't even asked or tried to understand why he comforts himself with food, he hasn't asked how much he knows about nutrition (he doesn't know anything), friend has never had the doc say it can be fixed but it is hard. Doc just says fix this it's easy, forgets about his emotional baggage and doesn't get that he doesn't actually know what a carb is.

I know the doc is probably frustrated, but it is partially the doc's own fault for upsetting my friend instead of adapting the message.

Myself I have been told I should not be treated because I have "autism" and the doc needs to treat everyone alike and I can come back when I stopped having autism. All I asked was for a warning before being physically touched.... so I got stressed and couldn't do what was asked of me. Yea bad bad me!

10 Qualities a Therapist Recognizes in a Good Client, part 1
http://discussingdissociation.wordpr...client-part-1/

10 Qualities Therapists Recognize in Good Clients, part 2
http://discussingdissociation.wordpr...lients-part-2/

How to Engage in Meaningful, Successful Psychotherapy
http://www.wellsphere.com/mental-hea...therapy/782440

Psychotherapy
http://psychcentral.com/psychotherapy/

Well maybe the doctor ought to look into why they stop their meds, are the side effects unbearable? maybe its simply not helping and the patient has to choose between food and an ineffective drug that month, in fact maybe they can't afford the drugs or enough food even.

Also maybe the tests cost money the patient doesn't have, maybe they don't know how to make the lifestyle changes or maybe they simply can't. I had a therapist who admitted he didn't think there was anything else he could really do for me after quite a few therapy appointments because he wasn't qualified...and was of the opinion i needed more than therapy. I was ok with that, but that is because he didn't twist it around and act like I was simply refusing to let it help for no reason it just wasn't helping.

And he didn't even here half of my problems so yeah, it goes pretty deep not even sure if most psychiatrists can dig that deep without going insane themselves. Its intresting the first time a mental health professional seems perplexed and overwhelmed when you barely describe whats going on.....but after a few times it starts to make things look rather grim as far as mental health goes its certainly not re-assuring but maybe I am seeing it too negatively.

The simplest is figure out if the patient falls into 1 of the 3 groups: 1) non-compliant for bizarre reasons, 2) non-compliant for logic reasons (i.e. cannot afford new medications, side-effects, etc...), or 3) a combination of 1 and 2. I can definitely understand their frustration given they see many patients per day. I don't approve of the doctor simply twiddling their thumbs the moment a patient doesn't comply as that doesn't help either party.

If the reason is either 2 or 3, there are other factors affecting the patient that the doctor doesn't know about but should try and figure out. When a doctor just gives up, the patient probably feels pretty bad about themselves, may view their medical case as unbelievably difficult for the doctor or may wonder what they did wrong.

If the reasons is 1 or 3, bizarre reasoning can be very frustrating to deal with. I don't approve psychiatrists tossing their hands up because their specialization involves mental illness, it's the topic they studied. Giving up just suggests they don't care for their practice and it's unfortunate a patient has to be on the receiving end.

Hmmm perhaps there is to much empathis on 'compliance' I mean typically that term is used to indicate that one should obey an authority figure. Just does not seem appropriate. For instance say a mom asks their kid to check the mail on the way home, well before the kid makes it to the mail box they step on a large shard of glass and are bleeding so bad they have to go to the hospital........Did the child not comply by being unable to check the mail?

Point being sometimes there is a very valid reason as to why the patient isn't following the treatment plan or making the expected lifestyle changes or improvements. And it can be very dis-validating when the psychologist, therapist or whatever treats it as though the patient could have just done it and simply refused out of blatant disrespect or just because. Even if its a flawed reason chances are it is quite convincing and real to the patient experiencing it.

Also I just noticed something....'physicans cannot help patients who don't help themselves.' well I thought in the case of mental health people seeked out the help of mental health professionals because they cannot help themselves and need help. So isn't it sort of in the job description?

But there's no cure also...

When depression treatment isn't working
http://www.mayoclinic.com/health/dep...atment/MY00751

When people say their depression treatment isn't working, lots of things come to mind.

Be honest with yourself and your health care provider in trying to figure out why. Ask yourself these questions:

Are you taking your medication exactly as prescribed?
Are you attending to your basics needs, such as sleeping at least eight hours and eating regular, healthy meals?
Are you using alcohol or other drugs?
If in recovery for drugs or alcohol, are you following your sobriety plan?
Are you taking pain medications (prescribed or over the counter)?
Are you going to therapy on a regular basis as prescribed (if applicable)?
Are you balancing work and leisure activities?
Are you surrounding yourself with positive, supportive people?
Are you dedicating some "you only" time, such as meditating, listening to music, or shopping?
Are you trying something new to boost your mood and self-esteem (music, short concert, walk, church, coffee shop, etc.)?
Are you keeping your mind active? You may try crosswords, sodoku, video games, or reading.

Getting better means taking care of yourself and doing things that help you feel better. You likely won't feel like it, so start slow and work up. You can do it and it will pay off by improving your depression. Share with others if you have any tips on things that help get you through the rough spots.

This thread is not intended to be judgmental. It is intended as a reminder that we have a role in the process.

Thank you di meliora,

My T told me that I am one of his hardest working patients and I really try hard to "self improve". He told me that he has had patients that come to him to be "spoon fed" and they don't take on an "active" role. And there are also those that are "cynical" and so much so that they just assume that "nothing" will help them.

I feel that it is important to understand that "learning and keeping and open mind" is the path to healing. If someone is just going to conclude the "I am" attitude of just assuming that "I am a waste or bad person or loser" then that person has a poor chance of "overcoming". While none of us can "change" our personal history or life failures, we can take the time to look back and "learn" some of the whys. The pathway to "opening up the troubled mind" is "knowledge and understanding" along with "self forgiveness". Mental illness can truely "humble us" and we "can" learn "much" from it. However first we have to be willing to let go of the "self hate" and "self blame" that often accompanies depression as well as other mental illnesses that have depression as a symptom.

The other "disruptive and damaging" symptom is "anger" that also accompanies many mental illnesses. Again, developing and "open mind" in a way that commits to "embracing knowledge and self forgiveness" give those that struggle a pathway to letting go of "anger and frustrations".

It is, however, important to have a therapist that is a good match for the patient.
Often it is better to have a therapist that is either the same age or a bit older so that therapist will also have a better understanding of a patient's age challenges and piers.
If you are a person who doen't typically get along with "males" then it is probably better that you seek a female therapist, and visa versa.

Open Eyes

I have an overwhelming anxiety and fear, often to the point of panic, regarding doctors. Therefore, I rarely go. I have a standing joke that when my pain is greater than the fear I will drag myself on in there.

I'm getting older now, and realize this isn't the best way to tend to my overall health and wellbeing as I know some things are not quite right, but damn if I can overcome my fear.

All I can do is keep working on it and do the best I can ... Thankfully, I have a PCP who totally understands it and is very patient, gentle and kind with me whenever I do eventually show up.

IMO a world like compliance should not be used. If a doc said that about me I would not go back. For me this is very very negative word. When I had my ADHD testing I had a really cool psych doing the tests and she seemed happy that I was quite verbal and quite smart so I could actually easily say what I meant as an answer to her questions and that stuff. But never did she use that ugly world. When we had finished 2 intense days, I thanked her and said she was fun to work with (because she was, smart, listened, not patronizing and VERY interested in her work), and she thanked me back and said I was fun working with as well. Like as we were a TEAM. THAT is the way it should be!

Right now when I think of it I'm one of those bad patients. I STILL fight with anemia despite treatment the last months. I was totally able to do the mix of meds for a month I was asked to. After the month it comes out I can stop the other thing but my iron levels are still bad. Yea no crap. I'm white as a ghost an every little thing makes me feel like I'm suffocating. I suffer. I WANT to get better.

So I'm put on a mega dose of iron, twice what I had before. Which was much to begin with. I try it and my stomach completely flips. I realize this is not doable. I can fight to be a good patient all I want but my body has its say and it says no. So I have a quick word with doc who says I can do 3 tabs instead of 4. That is also hard so I alternate between 2 and 3 and it goes soso. I'm glad she didn't just slam me and said Well be that way if you don't want to get better!!!

I've had docs that did that. Telling me basically I should take the med or stop complaining.

This doc knows and I know with my current dosage I will probably have to do the iron 1-2 months longer than the now planned 2 months. I don't like it and I'm sure she would want it faster but we both understand you do what you can do.

I think this doc is a keeper.

Yea! Do away with the docs! That doc just told us she wasn't needed! I can handle a prescription pad! And now pay me for treating myself too!

Here psych docs often ask what the patient wants the doc to DO. The patient of course rarely knows. Which creates tension from the start. But that is how they do it here.... So DUMB.

My doctor could not help me, so I helped myself. All he offered was medication, it didn't help. I am not being non compliant, I am getting well. I was not a bad patient.. and I am no longer a patient. Maybe they need to leave the med compliance out of it. With bipolar, and after about 40 or so meds that made things worse, no I was not compliant by their definition. Doesn't seem wise to be labeling people as non compliant.

We will see. When this course is over and if my iron still is low it might be an option. I think I'm getting tested in a month or 6 weeks or so. I'm sure if I'm not radically better she will suggest it but I hope it won't be necessary.

Hmm that's weird it dissappered..

Jimi I hope you will see an improvement and start feeling a bit better, sure makes you feel pretty awful. I am in need of more at the moment too. Yup, my skin colour is matching the snow right now. Feeling pretty drained of any life force right now.

Someone was hungry and ate your post... I swear it wasn't me!!

Working with the Noncompliant Patient
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2912714/

The initial article treated NCB* as an aberration in the physician–patient alliance. In the few years since the publication of that article, there has been increased attention in the medical literature to this problem. The publications on this topic largely fall into two groups: articles on medication noncompliance, often dealing with related issues such as causes of noncompliance, and articles on disease-specific noncompliance, such as noncompliance in chronic pulmonary obstructive disease or asthma2 or noncompliance in patients with diabetes.3 What is apparent in most of these articles is that NCB is much more widespread than it was thought to be and that it has a serious, deleterious effect on health outcomes and medical costs.

Osterberg and Blaschke4 wrote that “even clinical trials report average adherence rates of only 43 to 78 percent among patients receiving medication for chronic conditions” and that of “all medication-related hospital admissions in the United States, 33 to 69 percent are due to poor medication adherence, with a resultant cost of approximately $100 billion per year.” Cramer et al, reporting5 on a meta-analysis of compliance in diabetes, hypertension, and dyslipidemia, noted that “only 59% of patients [take] medication for more than 80% of the [prescribed doses] in a year.” Even in the case of serious and symptomatic disorders, such as acute myocardial infarction, a study6 has shown that as many as one in eight patients discontinue all three medications of the commonly prescribed combination of ß-blocker plus aspirin plus statin within one month of hospital discharge. These patients have an 80% higher chance of dying within the first year after discharge compared with patients taking all three classes of medication.

It is apparent from these studies that NCB is epidemic and not just an aberration. NCB is likely one of the most common causes of treatment failure for chronic conditions, though this is not widely or consistently recognized.

*NCB: Noncompliant Behavior

I am one of those difficult patients that are at times non-compliant for bizarre reasons. I am hoping therapy can help me with these.

Perhaps these articles may provide some useful insights:

What Is Psychotherapy, Part 1
What is Psychotherapy: Part 2
What is psychotherapy: Part 3
What is Psychotherapy: Part 4, here
Getting the Most Out of Psychotherapy
The Healing Power of the Therapeutic Relationship
http://www.goodtherapy.org/blog/pers...erian-therapy/
When does therapy end?
Termination: 10 Tips When Ending Psychotherapy

Di meloria,

You'r article on non-compliance was interesting to me. I wonder how much non-compliance, is caused by the cost of meds. As we all know without insurance, these can be a killer.

splitimage

This is so true. It takes a lot of personal work to feel better. Whether it is walking every day, meditating, giving up alcohol or so many other things that have been shown to improve a persons mood. I know how hard it is to do what is good for you when getting up to pee takes more energy than you have but it is the only way to heal. It is not easy but it is worth it.

The cost of medications is cause for concern. There are, however, ways to obtain free and low-price prescriptions. See here: http://forums.psychcentral.com/showthread.php?t=153805

This Google search brought up more programs (I did not look to see if there were duplications of the ones Ygrec23 found.) https://www.google.com/#hl=en&tbo=d&...w=1920&bih=933

What you've said is so true! I was paying good money at a campus clinic to go to try and get help for my learning disabilities, but after two semesters the SLP (speech language pathologist) told for me to come back when I had my OCPD fixed, because until then he could not help me. I asked him to talk to my therapist on campus s that he would understand my OCPD and how he could structure his lessons around it, but I guess that was too much work for him. I know that when I finally get my degree and become a special education teacher, I will be sure to listen to the needs of my students, and make necessary accommodations to help them succeed.

...stop having Autism; do they think there is a magic wand or something? What a stupid suggestion for them to give you!

If therapy is only for "good" clients, then what about the rest of us? As far as I know, there aren't other alternatives. And it's not my fault that my meds won't make me stable. I take the meds, as prescribed, even though I doubt I even have the right diagnosis.

How can I ever go to a therapist again, knowing that immediately they'll dislike me because I'm a "bad" patient?

And if someone is completely stable etc., why do they need therapy? If someone fits all the criteria of a "good" patient, I don't see why they'd need or want therapy.