How many of the 50k applicants a year are just flat-out delusional?

[Ace Khalifa]

---

Members do not see this ad.

Oh darn, you got me, guess their system is all nonsense!

You know what I meant, smart***

It's the same thing for our undergrad.

"Oh look, there's free food and stuff at this event!"

"It's not free when we are paying higher tuition and fees..."

 

[mathnerd88]

Oh darn, you got me, guess their system is all nonsense!

You know what I meant, smart***

Well, the Europeans are used to that kind of tax rate and the benefits of what it comes with.

In America, we usually have very low tax rates but pay for things we need/want. It all depends on which system you prefer more. For example, I rarely ever go see a physician and I would prefer it if I didn't have to pay a lot for health insurance I don't need. I'm sure the $5500 I spent on health insurance last year paid for someone else's healthcare because I did not touch one cent of it.

I believe in Obama's intentions for healthcare for everyone, but I don't believe that his system works for America.

 

[efle]

Well, the Europeans are used to that kind of tax rate and the benefits of what it comes with.

In America, we usually have very low tax rates but pay for things we need/want. It all depends on which system you prefer more. For example, I rarely ever go see a physician and I would prefer it if I didn't have to pay a lot for health insurance I don't need. I'm sure the $5500 I spent on health insurance last year paid for someone else's healthcare because I did not touch one cent of it.

I believe in Obama's intentions for healthcare for everyone, but I don't believe that his system works for America.

It's inevitable. It works too damn well all over Europe. And, throughout history...the conservatives just don't win, eventually the left becomes center becomes common sense. But to each their own!

 

[efle]

It's the same thing for our undergrad.

"Oh look, there's free food and stuff at this event!"

"It's not free when we are paying higher tuition and fees..."

It's free if you don't pay tuition and fees 😉

 

[mathnerd88]

It's inevitable. It works too damn well all over Europe. And, throughout history...the conservatives just don't win, eventually the left becomes center becomes common sense. But to each their own!

In terms of healthcare, the European system makes sense but medical school there is extremely cheap and heavily subsidized by the government. In America, most institutions are private and tuition costs on average $50k per year.

If hospitals and medical schools are privatized, so should healthcare. I believe it doesn't work one way or the other.

 

[efle]

In terms of healthcare, the European system makes sense but medical school there is extremely cheap and heavily subsidized by the government. In America, most institutions are private and tuition costs on average $50k per year.

Oh for sure you'd have to adopt their education financed by taxes system too

 

[BGMayagi]

I was really into the discussion about delusional applicants...

 

[twerktastic]

There's no law that says we can't judge our patients as long as we still give them optimal patient care. But don't expect me to feel bad for you if I tell you, "You need to fill this Rx otherwise your chronic condition will get worse and you might die," and then you come back with major complications because you didn't fill it due to the bullsh** reason, "I didn't fill it because I didn't want to, even tho you told me I should..."

I think what @Lucca is trying to get at is simply that a physician should aim to increase the compliance of the patient and not become jaded as a doctor. Noncompliance could be the fault of the patient, the physician, or society itself; however, what is troubling in this case is that you are not willing to empathize with your patient. While you keep saying it's fine for doctors to become jaded or how you plan to not care whether your patient's follow your Rx orders, because that's how most doctors really are in the world, is this really what you want to do as a doctor... i.e. not care about the patient's health outcome? It's easier to not care because then you won't be emotionally invested and won't get frustrated, but you probably won't be able to provide optimal care as you said. Being a doctor doesn't require you to be some Good Samaritan with some philosophical moral high-ground; however, at the very least you should empathize with your patients, realize that their limitations could possibly be your own if you were influenced by other circumstances, and show compassion to your patients.

 

[mathnerd88]

I think what @Lucca is trying to get at is simply that a physician should aim to increase the compliance of the patient and not become jaded as a doctor. Noncompliance could be the fault of the patient, the physician, or society itself; however, what is troubling in this case is that you are not willing to empathize with your patient. While you keep saying it's fine for doctors to become jaded or how you plan to not care whether your patient's follow your Rx orders, because that's how most doctors really are in the world, is this really what you want to do as a doctor... i.e. not care about the patient's health outcome? It's easier to not care because then you won't be emotionally invested and won't get frustrated, but you probably won't be able to provide optimal care as you defined. Being a doctor doesn't require you to be some Good Samaritan with some philosophical moral high-ground; however, at the very least you should empathize with your patients, realize that their limitations could possibly be your own if you were influenced by other circumstances, and show compassion to your patients.

So, let's say you only have time for 15 minutes a patient, how do you expect to increase the compliance of the patient who is forgetful and refusing to follow your optimal health plan for the patient for several months and has not followed up on their treatment plan for at least three visits? Realistically, this isn't completely possible.

I've shadowed doctors for a while and have repeatedly seen patients who still don't follow their treatment plan even after different strategies suggested by the physician. Some people just don't care about their health at all.

Also, I've noticed that some geriatric patients become even more stubborn, and it may be difficult to convince them otherwise of what health plan they should follow.

 

[twerktastic]

So, let's say you only have time for 15 minutes a patient, how do you expect to increase the compliance of the patient who is forgetful and refusing to follow your optimal health plan for the patient for several months and has not followed up on their treatment plan for at least three visits? Realistically, this isn't completely possible.

I've shadowed doctors for a while and have repeatedly seen patients who still don't follow their treatment plan even after different strategies suggested by the physician. Some people just don't care about their health at all.

Also, I've noticed that some older patients become even more stubborn, and it may be difficult to convince them otherwise of what health plan they should follow.

Specifically I'm not arguing that noncompliance is the doctor's fault, it could be the patient's, the doctor's, or society's (e.g. poverty).... this would require societal reform. However; I'm simply pointing out that a physician should at least care about what his patient's health outcome is.

 

[genericpremedstudent]

Idk, I don't have an MD.

I didn't read most of the bickering in this thread, but all I know is that Lucca is talking out of their ass, and everything they are saying can be backed up by this one statement.

 

[mathnerd88]

Specifically I'm not arguing that noncompliance is the doctor's fault, it could be the patient's, the doctor's, or society's (e.g. poverty).... this would require societal reform. However; I'm simply pointing out that a physician should at least care about what his patient's health outcome is.

Oh, I'm sure almost all, if not all doctors care about what the patient's health outcome is. I believe doctors always do what they can to make the patient have better health, regardless of what the patient does. You work with what you have in the present situation.

 

[twerktastic]

Oh, I'm sure almost all, if not all doctors care about what the patient's health outcome is. I believe doctors always do what they can to make the patient have better health, regardless of what the patient does. You work with what you have in the present situation.

Literally I just quoted Ace saying he would not feel bad if his patient had major complications / died because of noncompliance.

 

[mathnerd88]

Literally I just quoted Ace saying he would not feel bad if his patient had major complications / died because of noncompliance.

Ahh..gotcha. I missed the whole previous conversation.

 

[Ace Khalifa]

Literally I just quoted Ace saying he would not feel bad if his patient had major complications / died because of noncompliance.

And why should I feel bad? If a physician did everything right, by the book, followed all standard protocol, educated the patient of all risks/benefits/alternatives for multiple treatment options before suggesting the final one, and believed the patient understood everything......why should the doctor feel bad if the outcome isn't good due to patient noncompliance? The patient was expertly counseled, but they CHOSE not to take the medical advice, whatever that may have been. They brought it upon themselves, period.

It's this kind of sh** that makes primary care repulsive to me. That's why I will not pursue it as a career. Ortho or some other procedural, interventional specialty is the way to go.

Okay, I'm tired of arguing with naive premeds. Go get some real clinical experience, and get accepted to med school, then maybe we'll talk. I will always defer to authority (aka listen to med students, residents, and attending physicians over premeds), so don't try to argue out of your ass when you don't know sh** (*cough* @Lucca *cough*).

 

[Grace184]

Idk, I don't have an MD. If the patient failed to follow their treatment, or you failed the patient...does it make a difference what the response should be? I don't understand what you are saying here.

You were saying that it's not patients that fail, it's the providers

 

[Grace184]

What's your point here? Nobody doubts that patients are idiots a lot. This is no different than someone continuing to smoke despite knowing how terrible it is for you.

I was Reiterating the noncompliance is the fault of the physician nonsense

 

[Grace184]

No

I kindly submit that your statement is totally illogical to say that as a general statement. What's more, it's often enough out and out untrue. You can practically stand on your head teaching some people. You can get them every resource available, go the extra mile and then more than a few more. You can try different approaches or use other people to influence. Still, sometimes and with certain folks, more than sometimes, it just comes down to this: "That dog ain't gonna hunt."

I will say, however, that it often is easier to take the quick out of writing that the patient was/is noncompliant and attempt to demonstrate it with their statements and actions--or lack thereof. It takes a huge amount of patience to get some folks to change their behaviors--and even after you have done all you can to help them or after you have gotten others and different things for them in order to increase compliance. It gets beyond frustrating when you've done all that can be done, and guess what? That dog still doesn't hunt.

People have free agency, and thus they are allowed to be noncompliant.
No healthcare professional has the right to make anyone be compliant. They may be able to set certain boundaries; but they don't have the right to make them comply. One of the hardest things to face is that people have to want help. They have to want health and wellness. They have to accept accountability for what that entails in so much as they are able.[/QUOT

No, I think we agree, I was saying something to someone in particular who cited that noncompliance was failure on the providers end, not the patients end. I made that statement bc I do personally counsel patients on compliance and some won't take (aka dog won't hunt)

I made that statement in response to someone saying noncompliance was failure on the providers end. I do a lot of disease state and medication counseling, as well as nutritional, and as you say, that dog won't hunt sometimes. I think we agree

 

[jl lin]

No


I made that statement in response to someone saying noncompliance was failure on the providers end. I do a lot of disease state and medication counseling, as well as nutritional, and as you say, that dog won't hunt sometimes. I think we agree

Oh Grace184, completely sorry I took that the wrong way. Didn't see that you were quoting. My bad. 😳

Oh wait. I think I was quoting Lucca not you. I'll have to go back and check what went wrong there. 🙂

 

[Grace184]

Oh Grace184, completely sorry I took that the wrong way. Didn't see that you were quoting. My bad. 😳

Haha it's all good! This thread has been all over the place!

 

[jl lin]

Yea went back, don't know how I ended up quoting you instead of the other person. Drive by responding probably. LOL

 

[skooper]

Okay, I'm tired of arguing with naive premeds. Go get some real clinical experience, and get accepted to med school, then maybe we'll talk. I will always defer to authority (aka listen to med students, residents, and attending physicians over premeds), so don't try to argue out of your ass when you don't know sh** (*cough* @Lucca *cough*).

weren't you the guy rolling over like a dog and begging for acceptances off waitlists late in the cycle? quite a cocky tone there for someone who barely scraped into a med school of his choice. But now you're an authority on this stuff over every other premed who didn't write pathetic LOIs canoodling deans for acceptances just 'cause you've scribed for a year or so?

oh and P.S. before you start med school, you're a premed. which means you're still a naive premed. So stop asserting nonexistent authority over others

 

[jl lin]

weren't you the guy rolling over like a dog and begging for acceptances off waitlists late in the cycle? quite a cocky tone there for someone who barely scraped into a med school of his choice. But now you're an authority on this stuff over every other premed who didn't write pathetic LOIs canoodling deans for acceptances just 'cause you've scribed for a year or so?

oh and P.S. before you start med school, you're a premed. which means you're still a naive premed. So stop asserting nonexistent authority over others

I am sorry already that I am stepping into this dog pile. Your response seems extreme. YOU don't know this person's experiences, which may be more valid and reasonable that you realize.

I am tired of people jumping into other people's stuff just b/c they presume to know so much more than someone else--since they are X amount of steps ahead of someone else in the process of becoming or having become a physician. Going through certain steps in the process doesn't necessarily mean you corner the market on perspectives. No, it doesn't. It depends on the individual's experience and what they are trying to share, given a bigger picture. This attitude of shooting down someone else's perspective b/c you feel he or she hasn't been through all the steps is freakishly childish to me. People sharing perspectives here aren't making unfounded diagnoses w/o the proper credentials, etc., for God's sake. They are sharing from their own particular perspectives, and this is just what they are. It doesn't mean they are nothing or not relevant or that they are necessarily arrogant for having and sharing them.

God this kind of elitist mentality for general discussions on an anonymous discussion site smacks of HS and the seniors attempting to beat down the freshman. . .b/c they are freshman. There's an arrogance and emotional insecurity in that as well. The attitude is not necessarily justified, even though some may want to believe it is. But heck, I can't change the world and all the reasons why people get stuck in their hateful and resentful thinking.

BTW, I have not as yet spent a second in MS; but I can tell you that the view that non-compliance on the patient's part is necessarily the healthcare provider's fault is off. As an experienced healthcare provider, I can tell you, it's just not necessarily true.
OTOH, I have also seen where HCPs don't want to be as patient or reasonably persistent with helping noncompliant people move forward. It's a tough line to walk sometimes, and it takes experience and wisdom. You push some folks too hard, too fast, you've lost the power of effective influence. For other folks, they will string it along, and then you risk enabling them.

 

[skooper]

I am sorry already that I am stepping into this dog pile. Your response seems extreme. YOU don't know this person's experiences, which may be more valid and reasonable that you realize.

I am tired of people jumping into other people's stuff just b/c they presume to know so much more than someone else--since they are X amount of steps ahead of someone else in the process of becoming or having become a physician. Going through certain steps in the process doesn't necessarily mean you corner the market on perspectives. No, it doesn't. It depends on the individual's experience and what they are trying to share, given a bigger picture. This attitude of shooting down someone else's perspective b/c you feel he or she hasn't been through all the steps is freakishly childish to me. People sharing perspectives here aren't making unfounded diagnoses w/o the proper credentials, etc., for God's sake. They are sharing from their own particular perspectives, and this is just what they are. It doesn't mean they are nothing or not relevant or that they are necessarily arrogant for having and sharing them.

God this kind of elitist mentality for general discussions on an anonymous discussion site smacks of HS and the seniors attempting to beat down the freshman. . .b/c they are freshman. There's an arrogance and emotional insecurity in that as well. The attitude is not necessarily justified, even though some may want to believe it is. But heck, I can't change the world and all the reasons why people get stuck in their hateful and resentful thinking.

BTW, I have not as yet spent a second in MS; but I can tell you that the view that non-compliance on the patient's part is necessarily the healthcare provider's fault is off. As an experienced healthcare provider, I can tell you, it's just not necessarily true.
OTOH, I have also seen where HCPs don't want to be as patient or reasonably persistent with helping noncompliant people move forward. It's a tough line to walk sometimes, and it takes experience and wisdom. You push some folks too hard, too fast, you've lost the power of effective influence. For other folks, they will string it along, and then you risk enabling them.

Woah woah hey hey most of your post is suitable for ace, not me. I'm not the one asserting more knowledge just because I'm farther along the process (I'm only applying this cycle), he is. I'm also not against anything he said besides his "i [barely] got into med school so stfu all you dumb premeds" attitude. It is just ironic that someone who was begging for acceptances two months ago is now using those acceptances as a scepter of authority, which makes no sense as you pointed out

So I don't get your post and the anger directed at me

 

[mk04447]

Oh for sure you'd have to adopt their education financed by taxes system too

This is the problem with the solution you support. In one sentence you've committed us to paying for college too. The euro is nearly collapsed, America is 20T in debt and its promised to pay another 100T in social programs. I love how your simple solution is, just make everything free.

 

[HCHopeful]

This is the problem with the solution you support. In one sentence you've committed us to paying for college too. The euro is nearly collapsed, America is 20T in debt and its promised to pay another 100T in social programs. I love how your simple solution is, just make everything free.

No idea who you are, but I've happened to see many of your recent posts. None of them are even remotely constructive. They consist of telling the other person he or she is wrong and how dumb the idea is. If you disagree, please provide an alternative option or at least further give explanation to why you feel this way.

You're annoying 99% of the people on this forum. The worst one was this post from the Crying at an Interview thread: "I can't imagine where your parents sent you wrong and worse, how did you decide a post like this was your solution. Damn millennials."

Did you really just attack someone and suggest they were raised incorrectly because they have an emotional connection to a kid they helped? You may think you're being funny or whatever it is you're aiming for, but you're coming across as a ****face.

I enjoy a comment made in jest every now and again, but you're rubbing me the wrong way.

Not that I can do anything about it, but please try to add something constructive to your demeaning posts.

Note: inb4 mk04447's response to me will NOT be constructive.

 

[SlayD]

This reminds me of this one roommate I had who was convinced she was going to do law. Always bragged about her law frat, the awesome Harvard lawyers she gets to have drinks with, and the fancy socials she attends. Hated LSAT studying, switched her life goal to medicine, and tells people she should be fine because she's URM and they need more doctors like her. Btw, she's never set foot in patient care.
I'm not trying to start a URM discussion but watch she does get in.

 

[Lucca]

Okay, okay, okay. Obviously I have not made myself clear. I will try to make this really short and concise and I will also backtrack and admit defeat in some areas. First of all about the "no experience" thing on my part. Well, I don't need an MD to make value-based statements do I? I have values, the system either does or does not uphold them...it does not matter to me what the system actually looks like. I like to think I have a little more credibility than that but let's say I have zero and move on since it does not really mater. In other news, I'm very glad to be living up to the "insufferable" part of my description again, it's been a while.

When I wrote the statement "noncompliance is a failure of the healthcare provider not the patient" I was thinking of the majority of noncompliance scenarios where the patient 1) does not understand the treatment 2) does not believe the treatment will work or 3) does not trust the physician enough to continue with treatment.
[citation needed, will add in future]

First, I see people have been confusing "fault" with "responsibility". Normally these two go hand in hand but medicine is inherently paternalistic; that is, there is an authority (the provider) who passes down a plan and then an individual has the choice whether or not to follow it but does not possess the ability to create a plan on their own. In this kind of relationship fault and responsibility do not go hand in hand.

E.g.: A child is a parent's responsibility. The parent does not go with the child to the school. The child picks a fight at school. The fight is the child's fault. The child chose to fight. The child is still the parent's responsibility. The parent is responsible for failing to teach that violence is not the answer. The fight is still the child's fault. The child is autonomous.

E.g.: Your patient is your responsibility. Your patient chooses not to follow a treatment plan. Your patient dies. Secretly, the patient wanted to die anyways. It is the patient's fault that they are dead. The patient is still your responsibility. You are responsible for understanding your patient enough to notice whether they are or are not at risk.

Just like in any scenario with responsibility involved, however, you cannot always prevent something you are responsible for from going wrong. It is here that I concede that I was wrong. It would have been better to say that "noncompliance is not necessarily a failure of the healthcare provider but most of the time it is." What do I mean by this? Let me explain.

I'll use adherence from now on because it is faster to type. Furthermore, "provider" includes nurses, mid-levels, etc.

Second, I'll show you that adherence is a healthcare problem. If adherence is not at all the concern of the provider but rather completely dependent on the patient's cognitive process as some of you seem to claim then it is not, by definition, a healthcare problem but a personal problem. I do not believe this to be the case and if I am correct then the onus is on the healthcare provider to take responsibility for adherence.

From Brown, Marie T., and Jennifer K. Bussell. “Medication Adherence: WHO Cares?” Mayo Clinic Proceedings 86.4 (2011): 304–314. PMC. Web. 21 June 2015.

• Approximately 50% of patients do not take medications as prescribed
• Medication adherence is not exclusively the responsibility of the patient
• Increasing adherence may have a greater effect on health than improvements in specific medical therapy
• Medication-taking behavior is complex and involves patient, physician, and process components
• Identification of nonadherence is challenging and requires specific interviewing skills
• Solutions include encouraging a “blame-free” environment, opting for less frequent dosing, improving patient education, assessing health literacy, and paying attention to rational nonadherence
• Many helpful Web-based resources are available

Those are some highlights from that review study. There are more like it from earlier years but this is the most recent review.

Look at bullet three. You can look at the article for supporting evidence, I'm just trying to be brief. If bullet points 1,3, and 6 are correct then adherence is definitely a healthcare problem as it affects 1) a significant portion of the patient population, ruling out exclusively unique, one-off, or personal factors as being deterministic of adherence/non-adherence, 2) improving adherence would - quite obviously - have a positive effect on healthcare outcomes which are the primary concern of the health provider and 3) of the proposed solutions some of the options include strategies that explicitly involve the healthcare provider as the active player (namely, education, paying attention, assessing literacy and developing interviewing skills).

So adherence is a healthcare problem. So what? We probably agreed on that to begin with. It doesn't change the fact that it is not a doctor's responsibility if someone chooses out of their own free, rational will to not give a **** about their health.

I concede this point to you but now I put this forth:

Which attitude is better for healthcare outcomes? If healthcare outcomes are the primary concern of the provider then should the attitude the provider holds not agree with the provider's goals?

Option A: Treatment adherence is entirely the responsibility of the patient.

This means that when you walk into the room you do your patient education bit, you explain what is going on to the best of your ability and then you just move on without addressing their concerns about their treatment or providing any sort of extra assessment of how likely they are to be adherent/non-adherent. If the patient adheres or not to the solution you have provided is totally on them.

Option B: Treatment adherence is entirely the responsibility of the healthcare provider.

The same as Option A is done but an assessment is also done by someone on the team to determine adherence likelihood and measures are taken to correct any concerning patterns that are found in the assessment (such as not believing in medicine to begin with, being suicidal, depression, addiction, etc.). If you do this and adherence outcomes do not improve for your practice then the onus is on you to continually improve your practice until adherence outcomes do improve.

In this option you are continually improving as a provider based on new information, in option A you have already given up and let go of the responsibility. In other words you admit to yourself: "Yah, around 30-50% of the people I spent hundreds of thousands of dollars and years of my life to help are just idiots who don't care about themselves and that is that. Oh well, time to go home and not think about it again."

There is no reason to "feel bad" for having a non-adherent patient in either scenario. I don't even know how this got inserted into the conversation. I imagine it has something to do with "fault" and "guilt" and "responsibility" somehow being twisted. Should you feel bad for getting into your car every morning if you know the exhaust fumes are doing damage to the environment? The environment is, after all, our responsibility. If your car is absolutely necessary and it is a reasonable car I don't think you have any reason to feel bad even though you are still, technically, failing in your responsibility to the environment. If no other alternatives exist, what are you going to do? Feel bad all day? That doesn't make any sense whatsoever. Taking responsibility (as I said before) means that you acknowledge that you have a duty to something and then continually working towards that goal in spite of the challenges. Not taking responsibility is simply throwing your hands up and saying "Well, he hit me first" or "Well, I did everything I could" or "Well, I had no choice, I would've lost my job." That is acting in bad faith; i.e, acting as if there were no alternative or no path to an alternative when there always is. Acting in bad faith is a failure of the moral imagination to conceive of a better state of affairs.

Ok, so maybe taking responsibility is a better attitude for professional development and healthcare outcomes but just because it may be better, ethical or nice-sounding does not mean that it is true!

Fair enough. Consider this, again from the article:

Several patient-related factors, including lack of understanding of their disease,46 lack of involvement in the treatment decision–making process,47 and suboptimal medical literacy,48 contribute to medication nonadherence. In the United States alone, an estimated 90 million adults have inadequate health literacy,49 placing them at risk for increased rates of hospitalization and poorer clinical outcomes.50,51 The patient's health beliefs and attitudes concerning the effectiveness of the treatment, their previous experiences with pharmacological therapies, and lack of motivation also affect the degree of medication adherence.3,52,53 Medication adherence continues to decline even after a catastrophic event such as a stroke (Figure 1)12; thus, it is not surprising that treating asymptomatic conditions to prevent the possible occurrence of adverse events years later presents an even greater challenge. Specific factors identified as barriers to medication adherence among inner city patients with low socioeconomic status were high medication costs, lack of transportation, poor understanding of medication instructions, and long wait times at the pharmacy.55 A lack of family or social support is also predictive of nonadherence,52,56,57 as is poor mental health.3,53,58 These findings are clinically relevant for patients with CVD because studies have shown that depression and anxiety are common in patients with coronary artery disease or stroke.59-61 Indeed, the poorer outcomes experienced by patients with depression and CVD may be due, at least in part, to poorer medication adherence by depressed patients.62,63

Of the patient-related factors or, in other words, the factors that we do not expect have anything to do with the physician, the bolded are clearly factors that are either implicit or explicit responsibilities of the provider and the healthcare system.

Thus, while it is true that medical adherence is mostly in the control of the patient it is the responsibility of the provider and the system to ensure that this control is exercised in the best manner possible - again, because of the paternalistic relationship - given that patient education and communication is intrinsically linked with likelihood of adherence.


So there you have it. While adherence is not necessarily the responsibility of the provider, assuming it is is a better approach for healthcare outcomes and, in all likelihood, the provider contribution to the complex problem of treatment adherence is significant enough in a given situation for this assumption to be correct.

 

[altblue]

Okay, okay, okay. Obviously I have not made myself clear. I will try to make this really short and concise and I will also backtrack and admit defeat in some areas. First of all about the "no experience" thing on my part. Well, I don't need an MD to make value-based statements do I? I have values, the system either does or does not uphold them...it does not matter to me what the system actually looks like. I like to think I have a little more credibility than that but let's say I have zero and move on since it does not really mater. In other news, I'm very glad to be living up to the "insufferable" part of my description again, it's been a while.

When I wrote the statement "noncompliance is a failure of the healthcare provider not the patient" I was thinking of the majority of noncompliance scenarios where the patient 1) does not understand the treatment 2) does not believe the treatment will work or 3) does not trust the physician enough to continue with treatment.
[citation needed, will add in future]

First, I see people have been confusing "fault" with "responsibility". Normally these two go hand in hand but medicine is inherently paternalistic; that is, there is an authority (the provider) who passes down a plan and then an individual has the choice whether or not to follow it but does not possess the ability to create a plan on their own. In this kind of relationship fault and responsibility do not go hand in hand.

E.g.: A child is a parent's responsibility. The parent does not go with the child to the school. The child picks a fight at school. The fight is the child's fault. The child chose to fight. The child is still the parent's responsibility. The parent is responsible for failing to teach that violence is not the answer. The fight is still the child's fault. The child is autonomous.

E.g.: Your patient is your responsibility. Your patient chooses not to follow a treatment plan. Your patient dies. Secretly, the patient wanted to die anyways. It is the patient's fault that they are dead. The patient is still your responsibility. You are responsible for understanding your patient enough to notice whether they are or are not at risk.

Just like in any scenario with responsibility involved, however, you cannot always prevent something you are responsible for from going wrong. It is here that I concede that I was wrong. It would have been better to say that "noncompliance is not necessarily a failure of the healthcare provider but most of the time it is." What do I mean by this? Let me explain.

I'll use adherence from now on because it is faster to type. Furthermore, "provider" includes nurses, mid-levels, etc.

Second, I'll show you that adherence is a healthcare problem. If adherence is not at all the concern of the provider but rather completely dependent on the patient's cognitive process as some of you seem to claim then it is not, by definition, a healthcare problem but a personal problem. I do not believe this to be the case and if I am correct then the onus is on the healthcare provider to take responsibility for adherence.

From Brown, Marie T., and Jennifer K. Bussell. “Medication Adherence: WHO Cares?” Mayo Clinic Proceedings 86.4 (2011): 304–314. PMC. Web. 21 June 2015.

• Approximately 50% of patients do not take medications as prescribed
• Medication adherence is not exclusively the responsibility of the patient
• Increasing adherence may have a greater effect on health than improvements in specific medical therapy
• Medication-taking behavior is complex and involves patient, physician, and process components
• Identification of nonadherence is challenging and requires specific interviewing skills
• Solutions include encouraging a “blame-free” environment, opting for less frequent dosing, improving patient education, assessing health literacy, and paying attention to rational nonadherence
• Many helpful Web-based resources are available

Those are some highlights from that review study. There are more like it from earlier years but this is the most recent review.

Look at bullet three. You can look at the article for supporting evidence, I'm just trying to be brief. If bullet points 1,3, and 6 are correct then adherence is definitely a healthcare problem as it affects 1) a significant portion of the patient population, ruling out exclusively unique, one-off, or personal factors as being deterministic of adherence/non-adherence, 2) improving adherence would - quite obviously - have a positive effect on healthcare outcomes which are the primary concern of the health provider and 3) of the proposed solutions some of the options include strategies that explicitly involve the healthcare provider as the active player (namely, education, paying attention, assessing literacy and developing interviewing skills).

So adherence is a healthcare problem. So what? We probably agreed on that to begin with. It doesn't change the fact that it is not a doctor's responsibility if someone chooses out of their own free, rational will to not give a **** about their health.

I concede this point to you but now I put this forth:

Which attitude is better for healthcare outcomes? If healthcare outcomes are the primary concern of the provider then should the attitude the provider holds not agree with the provider's goals?

Option A: Treatment adherence is entirely the responsibility of the patient.

This means that when you walk into the room you do your patient education bit, you explain what is going on to the best of your ability and then you just move on without addressing their concerns about their treatment or providing any sort of extra assessment of how likely they are to be adherent/non-adherent. If the patient adheres or not to the solution you have provided is totally on them.

Option B: Treatment adherence is entirely the responsibility of the healthcare provider.

The same as Option A is done but an assessment is also done by someone on the team to determine adherence likelihood and measures are taken to correct any concerning patterns that are found in the assessment (such as not believing in medicine to begin with, being suicidal, depression, addiction, etc.). If you do this and adherence outcomes do not improve for your practice then the onus is on you to continually improve your practice until adherence outcomes do improve.

In this option you are continually improving as a provider based on new information, in option A you have already given up and let go of the responsibility. In other words you admit to yourself: "Yah, around 30-50% of the people I spent hundreds of thousands of dollars and years of my life to help are just idiots who don't care about themselves and that is that. Oh well, time to go home and not think about it again."

There is no reason to "feel bad" for having a non-adherent patient in either scenario. I don't even know how this got inserted into the conversation. I imagine it has something to do with "fault" and "guilt" and "responsibility" somehow being twisted. Should you feel bad for getting into your car every morning if you know the exhaust fumes are doing damage to the environment? The environment is, after all, our responsibility. If your car is absolutely necessary and it is a reasonable car I don't think you have any reason to feel bad even though you are still, technically, failing in your responsibility to the environment. If no other alternatives exist, what are you going to do? Feel bad all day? That doesn't make any sense whatsoever. Taking responsibility (as I said before) means that you acknowledge that you have a duty to something and then continually working towards that goal in spite of the challenges. Not taking responsibility is simply throwing your hands up and saying "Well, he hit me first" or "Well, I did everything I could" or "Well, I had no choice, I would've lost my job." That is acting in bad faith; i.e, acting as if there were no alternative or no path to an alternative when there always is. Acting in bad faith is a failure of the moral imagination to conceive of a better state of affairs.

Ok, so maybe taking responsibility is a better attitude for professional development and healthcare outcomes but just because it may be better, ethical or nice-sounding does not mean that it is true!

Fair enough. Consider this, again from the article:

Several patient-related factors, including lack of understanding of their disease,46 lack of involvement in the treatment decision–making process,47 and suboptimal medical literacy,48 contribute to medication nonadherence. In the United States alone, an estimated 90 million adults have inadequate health literacy,49 placing them at risk for increased rates of hospitalization and poorer clinical outcomes.50,51 The patient's health beliefs and attitudes concerning the effectiveness of the treatment, their previous experiences with pharmacological therapies, and lack of motivation also affect the degree of medication adherence.3,52,53 Medication adherence continues to decline even after a catastrophic event such as a stroke (Figure 1)12; thus, it is not surprising that treating asymptomatic conditions to prevent the possible occurrence of adverse events years later presents an even greater challenge. Specific factors identified as barriers to medication adherence among inner city patients with low socioeconomic status were high medication costs, lack of transportation, poor understanding of medication instructions, and long wait times at the pharmacy.55 A lack of family or social support is also predictive of nonadherence,52,56,57 as is poor mental health.3,53,58 These findings are clinically relevant for patients with CVD because studies have shown that depression and anxiety are common in patients with coronary artery disease or stroke.59-61 Indeed, the poorer outcomes experienced by patients with depression and CVD may be due, at least in part, to poorer medication adherence by depressed patients.62,63

Of the patient-related factors or, in other words, the factors that we do not expect have anything to do with the physician, the bolded are clearly factors that are either implicit or explicit responsibilities of the provider and the healthcare system.

Thus, while it is true that medical adherence is mostly in the control of the patient it is the responsibility of the provider and the system to ensure that this control is exercised in the best manner possible - again, because of the paternalistic relationship - given that patient education and communication is intrinsically linked with likelihood of adherence.


So there you have it. While adherence is not necessarily the responsibility of the provider, assuming it is is a better approach for healthcare outcomes and, in all likelihood, the provider contribution to the complex problem of treatment adherence is significant enough in a given situation for this assumption to be correct.

Brevity is wit. 😛

 

[Lannister]

I will try to make this really short and concise

*Proceeds to write longest post ever written on SDN*

 

[Lucca]

Brevity is wit. 😛

I tried, I swear.

*Proceeds to write longest post ever written on SDN*

Actually, I think I did that elsewhere. My very first post on SDN was insanely long and the first reply to it was "This post just gave me cancer".

 

[altblue]

I tried, I swear.

I overshot every word limit ever when I was a humanities major, so I understand that. Lol

 

[mathnerd88]

I tried, I swear.

Actually, I think I did that elsewhere. My very first post on SDN was insanely long and the first reply to it was "This post just gave me cancer".

Lucca, I completely agree with you. If the healthcare community is perfect, then you would be completely correct. What makes this system not work when you start making it the responsibility of the physician. In your comparison, you ascribed the child as the parents' responsibility. This is so because the child is not competent enough to make rational choices.

With patients who are adults, they are/should be mentally competent to make rational choices, unless they have some sort of mental disease or defect. The problem comes along is when doctors bear the responsibility of the patient outside of their own clinic. Do you know how many lawsuits that would occur if that responsibility is shifted to the doctor?

I understand that medical adherence is a problem, especially for many patients, but doctors cannot continue to babysit patients who will not care for themselves, especially when they are mentally competent to make their own choices. Doctors will try to make it as easy for the patient as possible, but in the end, it is up to the patient to follow through.

 

[Lucca]

Lucca, I completely agree with you. If the healthcare community is perfect, then you would be completely correct. What makes this system not work when you start making it the responsibility of the physician. In your comparison, you ascribed the child as the parents' responsibility. This is so because the child is not competent enough to make rational choices.

With patients who are adults, they are/should be mentally competent to make rational choices, unless they have some sort of mental disease or defect. The problem comes along is when doctors bear the responsibility of the patient outside of their own clinic. Do you know how many lawsuits that would occur if that responsibility is shifted to the doctor?

I understand that medical adherence is a problem, especially for many patients, but doctors cannot continue to babysit patients who will not care for themselves, especially when they are mentally competent to make their own choices. Doctors will try to make it as easy for the patient as possible, but in the end, it is up to the patient to follow through.

I do not propose that the decision making portion of adherence be taken away from the patient. Quite the contrary, that is precisely where it should stay. A physician should give their patient as much power as possible.

However, even though patients are adults they are still children in the healthcare setting. They do not have the knowledge or understanding to make the best decision without the education of the physician. This is why patient education is such an important part of delivering care. Effective patient education will make the patient the autonomous adult they should be in the healthcare setting. The responsibility for treatment adherence is not so much the physical application of treatment as it is the onus to improve in such a way that treatment adherence improves when faced with challenges to adherence. Is this clear? I hope it is because it is my only and central argument.

There is a fine line between being responsible for a patient not taking their pill at 10pm and instead doing it at 10am and being responsible instead for providing a plan where it is very, very clear what the correct time should be.

 

[mathnerd88]

I do not propose that the decision making portion of adherence be taken away from the patient. Quite the contrary, that is precisely where it should stay. A physician should give their patient as much power as possible.

However, even though patients are adults they are still children in the healthcare setting. They do not have the knowledge or understanding to make the best decision without the education of the physician. This is why patient education is such an important part of delivering care. Effective patient education will make the patient the autonomous adult they should be in the healthcare setting. The responsibility for treatment adherence is not so much the physical application of treatment as it is the onus to improve in such a way that treatment adherence improves when faced with challenges to adherence. Is this clear? I hope it is because it is my only and central argument.

There is a fine line between being responsible for a patient not taking their pill at 10pm and instead doing it at 10am and being responsible instead for providing a plan where it is very, very clear what the correct time should be.

Ahh, gotcha. I completely agree with you. I think myself and others were more concerned about your point that it is completely (or mostly) the fault of the healthcare system. While that may be true in some cases, it is the combination of everything. Healthcare systems will always continually try to improve and give a more patient-centered approach, because not everything is the patients' fault. Doctors should be doing what they can to minimize this type of problem for the patient.

In my shadowing experiences in primary care, however, I have seen countless patients who come into the office and say "I didn't take my medication because I feel better already!" or worse, "I know I was supposed to take this medication but I didn't feel like it." The doctor would always keep repeating herself explaining the risks of not taking the proper dosages at the correct intervals, but yet, they continue to not follow.

In this case, the doctor made it very clear the risks and benefits but the patient still forgets/doesn't take the medication as prescribed. Who's fault is that? Doctors cannot always be checking up on their patient to see if they take the right medication. I believe this problem is systemic, and for effective treatment, both the provider and the patient should be on the same playing field.

 

[mk04447]

No idea who you are, but I've happened to see many of your recent posts. None of them are even remotely constructive. They consist of telling the other person he or she is wrong and how dumb the idea is. If you disagree, please provide an alternative option or at least further give explanation to why you feel this way.

You're annoying 99% of the people on this forum. The worst one was this post from the Crying at an Interview thread: "I can't imagine where your parents sent you wrong and worse, how did you decide a post like this was your solution. Damn millennials."

Did you really just attack someone and suggest they were raised incorrectly because they have an emotional connection to a kid they helped? You may think you're being funny or whatever it is you're aiming for, but you're coming across as a ****face.

I enjoy a comment made in jest every now and again, but you're rubbing me the wrong way.

Not that I can do anything about it, but please try to add something constructive to your demeaning posts.

Note: inb4 mk04447's response to me will NOT be constructive.

Thin skin and overly sensitive. Do you paint your fingernails black and write poetry?

Lets be clear, liberals like you are the ones who suggest giving everything to everyone without providing any way to pay for it. As if taxes meant some bottomless pit filled with money. Have you even held a job more than a semester or two?

As for rubbing you the wrong way, ok. I think I'm fairly consistent, granted I won't ever write something as inexperience and naive as your posts, but I'm sensing thats the real problem here. You don't think what I'm saying is constructive because you're a child who's used to being pampered and likes to be surrounded by like minded dreamers. In the event you're older and still think anyone cares about your rant, that's just pathetic.

Think before you emotionally vomit.

 

[Goro]

or URM or MD vs DO or Carib schools or....


Alright kids, pay attention:

Godwin's Law of SDN - as the number of pages in any thread increases, so does the probability that the discussion will turn to health care reform.

 

[skooper]

@Lucca still trying too hard. downgrade to 1/10, do not buy

 

[NeuResurgens]

No need to be provocative y'all.

 

[HarryH00d]

tl dr

 

[HCHopeful]

Thin skin and overly sensitive. Do you paint your fingernails black and write poetry?

Lets be clear, liberals like you are the ones who suggest giving everything to everyone without providing any way to pay for it. As if taxes meant some bottomless pit filled with money. Have you even held a job more than a semester or two?

As for rubbing you the wrong way, ok. I think I'm fairly consistent, granted I won't ever write something as inexperience and naive as your posts, but I'm sensing thats the real problem here. You don't think what I'm saying is constructive because you're a child who's used to being pampered and likes to be surrounded by like minded dreamers. In the event you're older and still think anyone cares about your rant, that's just pathetic.

Think before you emotionally vomit.

I never commented about taxes in any form, nor am I a liberal.

I simply wanted to point out the simple truth of your posts not aiding anyone in any way, and I believe you've successfully validated this point with your response.

Regarding working, I have independently operated two business, and I've worked steadily since high school. Don't presume to know my situation.

Please keep attacking others and using arguments with no basis. It only serves to prove my point.

Talking down to younger people with different views doesn't have any purpose other than to make you feel nice. If that's what you enjoy, go ahead. Just know that it's not beneficial to anyone.

 

[Cotterpin]

In the event you're older and still think anyone cares about your rant, that's just pathetic.

Projecting.

 

[Ace Khalifa]

weren't you the guy rolling over like a dog and begging for acceptances off waitlists late in the cycle? quite a cocky tone there for someone who barely scraped into a med school of his choice. But now you're an authority on this stuff over every other premed who didn't write pathetic LOIs canoodling deans for acceptances just 'cause you've scribed for a year or so?

oh and P.S. before you start med school, you're a premed. which means you're still a naive premed. So stop asserting nonexistent authority over others

Nice try, but nope. Everything you said is completely off-base. Oh, look the ignore button is right there.

 

[mathnerd88]

People really need the read the forum rules or risk getting banned. Just a friendly reminder.

http://www.studentdoctor.net/online-service-agreement/?reload=1&r=1434911283387

1. Protect anonymity.
2. Be courteous and contribute positively. If you’re not contributing to the forums in a positive manner, you may receive a warning or have your account temporarily or permanently closed.
3. Use the search functions.
4. Stay on topic. Our membership encourages open discussion and debate as long as it relates to the topic of the thread at hand. Posts that do not relate to the original purpose or topic of the thread may be moved to a more appropriate location.
5. Don’t advertise (SPAM).
6. Don’t cross-post on the forums.
7. Use the “Report Bad Post” button to report inappropriate posts.
8. Respect copyrighted information.
9. Harassment and Flame-Wars burn everyone. Be courteous. Just ignore those members that can’t discuss topics professionally. Remember, the academic healthcare community is relatively small; don’t behave in a manner which might get you into trouble now or in the future.
10. Positive interactions between medical communities.
11. Images / Videos / Medical Images
12. Kill Trolls Quickly.
13. TROLLS AND SPAMMERS BEWARE.
14. Once you’ve posted on the site, it’s there forever.
15. Don’t delete mail with the SPAM button.
16. Don’t be a poser.
17. No Sockpuppeting.
18. Be sure to have fun!

 

[skooper]

Nice try, but nope. Everything you said is completely off-base. Oh, look the ignore button is right there. Guess I'll just stoop down to @differentiating's level.

how so? honey your post history is public. it clearly shows that you hated EVMS and then pandered to get of WLs to your dream school on the beach to hang out with your ortho bros. you barely scraped into med school and now you have the temerity to use your admitted student status to silence other people's views? I actually agree with your views, but it's an ironic turnaround and ego you have now. You are not better than anyone else here because of your accepted med student status or how much "clinical experience" you have. you have no right telling people to "come back when you're a med student" as if you are already one and know so much more. pls stop

that being said i shouldn't be surprised at your behavior at all since you still won't shut up about the fact that you went to washU where everyone was really smart, etc. etc.

 

[Ace Khalifa]

how so? honey your post history is public. it clearly shows that you hated EVMS and then pandered to get of WLs to your dream school on the beach to hang out with your ortho bros. you barely scraped into med school and now you have the temerity to use your admitted student status to silence other people's views? I actually agree with your views, but it's an ironic turnaround and ego you have now. You are not better than anyone else here because of your accepted med student status or how much "clinical experience" you have. you have no right telling people to "come back when you're a med student" as if you are already one and know so much more. pls stop

that being said i shouldn't be surprised at your behavior at all since you still won't shut up about the fact that you went to washU where everyone was really smart, etc. etc.

Am I being mooped right now? If so, then lol. If not, then okay, my bad. I'll just stay out of pre-allo and go to allo where I now belong.

 

[jl lin]

Woah woah hey hey most of your post is suitable for ace, not me. I'm not the one asserting more knowledge just because I'm farther along the process (I'm only applying this cycle), he is. I'm also not against anything he said besides his "i [barely] got into med school so stfu all you dumb premeds" attitude. It is just ironic that someone who was begging for acceptances two months ago is now using those acceptances as a scepter of authority, which makes no sense as you pointed out

So I don't get your post and the anger directed at me

I am not anger so much as I am frustrated by certain mentalities that come here at SDN at times. It's nothing against you. It's just silly crap that lends to that whole god complex thing that patients and people get annoyed with from physicians at times. I have seen so much of this quick to shoot someone's perspective down b/c "How dare you give me a treatise or your knowledge is so terribly limited--when in fact, no one really knows and neither can fully assess my experience and knowledge. God you give a perspective that differs from someone else's here, next thing you know they are nicely telling you to shut up b/c you are a know nothing idiot. Their "authority," position, and notoriety somehow makes it OK for them to assault w/ the equivalent of ad hominem attacks. But as I said, I can't change the world and everyone in it. Let people give their perspectives; b/c they are just that--their perspectives. There indeed may be something worthy of consideration. The world doesn't always function by way of stringent absolutes.
So know skooper, I didn't mean to direct anything to you. It's just an idiotic mentality that pops up here and by virtue of clout and some sense of authority, people bulldoze others over w/o really giving fair consideration to the other person/s' point/s of view.
All I am saying. It's an ignorant way for educated people to function. It's also a lazy way to make an argument.

 

[Ace Khalifa]

I am not anger so much as I am frustrated by certain mentalities that come here at SDN at times. It's nothing against you. It's just silly crap that lends to that whole god complex thing that patients and people get annoyed with from physicians at times. I have seen so much of this quick to shoot someone's perspective down b/c "How dare you give me a treatise or your knowledge is so terribly limited--when in fact, no one really knows and neither can fully assess my experience and knowledge. God you give a perspective that differs from someone else's here, next thing you know they are nicely telling you to shut up b/c you are a know nothing idiot. Their "authority," position, and notoriety somehow makes it OK for them to assault w/ the equivalent of ad hominem attacks. But as I said, I can't change the world and everyone in it. Let people give their perspectives; b/c they are just that--their perspectives. There indeed may be something worthy of consideration. The world doesn't always function by way of stringent absolutes.
So know skooper, I didn't mean to direct anything to you. It's just an idiotic mentality that pops up here and by virtue of clout and some sense of authority, people bulldoze others over w/o really giving fair consideration to the other person/s' point/s of view.
All I am saying. It's an ignorant way for educated people to function. It's also a lazy way to make an argument.

You do realize that medical training is a hierarchy, right? Deference to authority is the only option most of the time.

 

[skooper]

Am I being mooped right now? If so, then lol. If not, then okay, my bad. I'll just stay out of pre-allo and go to allo where I now belong.

huh? yea do that. Bai felicia

 

[jl lin]

Lucca,

There is such a thing indeed as due diligence. No one is saying that anyone should skirt around that as a HCP. The reality, however, is that a number of folks will be noncompliant no matter what you or anyone else does.

Ultimately it is somewhat of a partnership, where both parties have to take on their own level of due diligence. I can't make anyone do anything. We can put down boundaries and ascribe consequences; but we must also face the reality and even respect the reality of free agencies. This is important from an ethical perspective as well.