Patients not adhering to treatment

[meow1985]

Arguably, this is one of the hardest parts of our job. Specifically, right now I'm talking about not following parts of the treatment plan such as timing of follow up and getting labs such as drug levels.

I'd like to know what other people do, because I've sought supervision in my residency about this, but the almost unilateral answer our medical director has is "have them sign a treatment plan." That tends to go over like a lead balloon, as it's hard for people not to see that as punitive or a precursor to getting fired as a patient. I've had success having people sign treatment plans in telling them that it goes back to the amount of liability the *institution* will allow me to accept, but what if the institution doesn't have a position on the matter, or there is no institution because you're it (in private practice)?

Some resolutions I've made for when I start my first attending job:
1. Have people sign a treatment contract when I first meet them, based on institutional policies on treatment adherence (if any), as well as my own comfort level.
2. Start discussions about potential barriers to adherence and how to deal with them early in the course of my work with someone.

If patients still don't do their part, I've been advised to do the following. Tell them that if they don't do x by y date, you will not be able to provide them with meds, and then follow through. Indicate that it's not safe and not good care to keep prescribing if they don't do the thing.

But I have an ethical problem with that. I mean, let's say someone is on Lithium, you're prescribing to them, and they go toxic - that's your fault, especially if you're not enforcing proper follow up and lab monitoring. On the other hand, let's say you stop prescribing to them because they won't come into clinic/get labs despite multiple reminders and they go manic - that's your fault too, arguably, because you made the decision to stop the meds. It's a catch-22, though legally the second one is more defensible because the patient was first to not uphold their end of treatment plan.

And then I'm also likely to have the Axis II's of world yelling at me and telling me that it's not good care to stop meds, and that I am being insensitive to their complicated life circumstances. And technically there would be truth to that.

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PS: I don't think accepting only the highly motivated, highly resourced patients in cash only private practice is a solution. A good psychiatrist, I think, is able to do the right thing when the bio, the psycho, and the social pieces of things are going to ****, and vetting your patients to those who are highly motivated, not personality disordered, physically healthy enough to make it to appointments/labs/etc and can solve problems with money is just avoiding the issue. And even a highly motivated patient can change to being willful and care-rejecting.

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[SourceOfDenial]

I think part of the issue is the frame ‘patient won’t do what I tell them to do’. I conceptualize my work with patients much more along the lines of taking a journey with them, and the decision making is mutual and aligned, as opposed to in opposition. Similar to the Jobes CAMS suicide model. Or sometimes I think of myself more as a guide than physician.

Medicine has done a terrible disservice to clinicians in leading them to think that everything can be fixed, that humans are complicated machines and if only you can figure out what’s wrong....

One of the most liberating moments of my training was when I realized I had far less control than I thought I had. Both humbling and empowering.

I’m just along for the ride, man.

 

[meow1985]

I think part of the issue is the frame ‘patient won’t do what I tell them to do’. I conceptualize my work with patients much more along the lines of taking a journey with them, and the decision making is mutual and aligned, as opposed to in opposition. Similar to the Jobes CAMS suicide model. Or sometimes I think of myself more as a guide than physician.

Medicine has done a terrible disservice to clinicians in leading them to think that everything can be fixed, that humans are complicated machines and if only you can figure out what’s wrong....

One of the most liberating moments of my training was when I realized I had far less control than I thought I had. Both humbling and empowering.

I’m just along for the ride, man.

Yeah, in many cases this can and does apply. I want to be fully collaborative with patients. I do not want to be the disciplinarian. In fact, I am probably the most pro-patient autonomy of all my co-residents and attendings at my institution.

The difficulty is when the patient needs to be and *chooses to be* on high-risk medications such as lithium, depakote, stimulants, and the like, but is unwilling or unable to engage in the required monitoring. Yet they still want the medication. It doesn't work that way.

There are leadership entities that define what standard of care is, there are peer reviewer and practice audits, and there is the legal system. They'd hit the roof if someone was being prescribed lithium but there wasn't a level in 2 years - and no one would be open to hearing, "but don't worry, the patient is totally legit, and their reasons for not being able to make it to clinic or lab for months on end are totally legit too, and lithium is better than no lithium because it's all that keeps them stable."

 

[VA Hopeful Dr]

Our job, generally speaking, is to offer our advice to patients. If they choose not to take it, that's on them.

Obviously this is somewhat different of the realm of psychiatry with things like involuntary commitment, but in patients that are coming to you of their own free will it applies.

 

[meow1985]

Our job, generally speaking, is to offer our advice to patients. If they choose not to take it, that's on them.

Obviously this is somewhat different of the realm of psychiatry with things like involuntary commitment, but in patients that are coming to you of their own free will it applies.

I think our job goes beyond advice. We prescribe -- or don't. Sometimes we prescribe contingent on certain actions of the patient, such as getting drug tested, getting drug levels or other labs (i.e. clozapine CBC with diff or lithium levels). When the patients won't or can't do the required actions but still want the meds, that's where it gets dicey. Getting a CBC or a lithium level is not advice, it's a requirement.

 

[TexasPhysician]

It’s all in how you document. Simple example below, but obviously the medication used and other factors adapt my plan. Continuing to prescribe potentially toxic doses of Lithium is a larger concern legally than stopping it from non-compliance.

Initial eval - labs ordered for .....

Follow-up 1 - Labs have not been obtained. Re-discussed the importance of labs including medical necessity.....

Follow-up 2 - Labs have not been obtained as repeatedly advised. Educated on the importance of labs and that not obtaining labs within 3 weeks will result in discontinuing medication due to ....... Referrals provided for alternative treatment options including CBT.....if patient continues to be non-compliant.

Follow-up 3 - Hard stop on meds. Advised that alternative meds requiring less frequent labs may be indicated after completion of current labs. Alternatively, referrals for treatment have been provided at......

 

[meow1985]

It’s all in how you document. Simple example below, but obviously the medication used and other factors adapt my plan. Continuing to prescribe potentially toxic doses of Lithium is a larger concern legally than stopping it from non-compliance.

Initial eval - labs ordered for .....

Follow-up 1 - Labs have not been obtained. Re-discussed the importance of labs including medical necessity.....

Follow-up 2 - Labs have not been obtained as repeatedly advised. Educated on the importance of labs and that not obtaining labs within 3 weeks will result in discontinuing medication due to ....... Referrals provided for alternative treatment options including CBT.....if patient continues to be non-compliant.

Follow-up 3 - Hard stop on meds. Advised that alternative meds requiring less frequent labs may be indicated after completion of current labs. Alternatively, referrals for treatment have been provided at......

And if they don't show up and keep cancelling, particularly at the last minute?

My residency institution has the stipulation that we are supposed to assess for barriers to care. However, financial issues aside (let's assume the MD is salaried), this sort of thing sends me the message that care is not being prioritized, whatever objective barriers there may be.

 

[calvnandhobbs68]

Yeah, in many cases this can and does apply. I want to be fully collaborative with patients. I do not want to be the disciplinarian. In fact, I am probably the most pro-patient autonomy of all my co-residents and attendings at my institution.

The difficulty is when the patient needs to be and *chooses to be* on high-risk medications such as lithium, depakote, stimulants, and the like, but is unwilling or unable to engage in the required monitoring. Yet they still want the medication. It doesn't work that way.

There are leadership entities that define what standard of care is, there are peer reviewer and practice audits, and there is the legal system. They'd hit the roof if someone was being prescribed lithium but there wasn't a level in 2 years - and no one would be open to hearing, "but don't worry, the patient is totally legit, and their reasons for not being able to make it to clinic or lab for months on end are totally legit too, and lithium is better than no lithium because it's all that keeps them stable."

First of all, how are you framing a stimulant as high risk medication in terms of labs or monitoring?

Second, I think you can make this argument most for lithium or clozapine. A lot of the other stuff is really not as serious as people make it out to be. Are Depakote levels nice? Sure mostly for toxicity purposes and people can always go to the ED if they’re having signs of that. I’ve seen neuro keep people on it for years as an outpatient without being able to get a level but the patient is doing fine. How many people you think have 100 percent daily compliance with their lamictal and run the risk of SJS by stopping and starting it? Hint, a lot, but best you can do is tell them not to do it.

I’m with the poster above. I’m just along for the ride man. I can ask the patients to do these things, document that we’ve discussed it, try to figure out what the barriers are. You can even go so far as give them a call before their next appointment and say hey remember that lab I told you to get, I need you to get that, here’s the closest lab to your address, I’m sending the order over there and I need that done in the next day.

 

[TexasPhysician]

And if they don't show up and keep cancelling, particularly at the last minute?

Terminate. There is only so much we can do.

 

[calvnandhobbs68]

And if they don't show up and keep cancelling, particularly at the last minute?

My residency institution has the stipulation that we are supposed to assess for barriers to care. However, financial issues aside (let's assume the MD is salaried), this sort of thing sends me the message that care is not being prioritized, whatever objective barriers there may be.

This is a totally different issue. I’m sure your institution has a no show policy. Ours is 3 no shows (generally cancellations less than 24hrs ahead of time although we have some leeway with that) and you’re given a termination letter, the policy of which is clearly laid out in the intake documents. I’d say after the first no show, I’d go over the no show policy with the patient.

Arent you supposed to be graduating soon? And you haven’t figured out how to deal with no shows?

 

[meow1985]

First of all, how are you framing a stimulant as high risk medication in terms of labs or monitoring?

Concurrent substance use, vitals checks due to cardiac risk. Said things have been drummed into me in residency. Maybe they're not as high risk as lithium, but still high risk.

 

[meow1985]

This is a totally different issue. I’m sure your institution has a no show policy. Ours is 3 no shows (generally cancellations less than 24hrs ahead of time although we have some leeway with that) and you’re given a termination letter, the policy of which is clearly laid out in the intake documents. I’d say after the first no show, I’d go over the no show policy with the patient.

Arent you supposed to be graduating soon? And you haven’t figured out how to deal with no shows?

I am graduating soon, and we have a policy just like yours. But technically you have flexibility in enforcing it ("may" instead of "will"), and many people don't follow it. There's also the whole "provider responsibility to assess for barriers" clause that we have. So in practice it's a lot more of a grey area. And then you inherit patients whose prior providers let things slide and you have to deal with that.

 

[calvnandhobbs68]

Concurrent substance use, vitals checks due to cardiac risk. Said things have been drummed into me in residency. Maybe they're not as high risk as lithium, but still high risk.

As long as they’re showing up for appointments you should be able to grab a blood pressure. If they aren’t showing up for appointments you shouldn’t be giving them controlled substances (and usually can’t give more than 3 months at a time anyway in most places). Same thing with drug abuse unless you have very special circumstances with very close monitoring.

I think you’re making this more complicated than it needs to be.

 

[meow1985]

As long as they’re showing up for appointments you should be able to grab a blood pressure. If they aren’t showing up for appointments you shouldn’t be giving them controlled substances (and usually can’t give more than 3 months at a time anyway in most places). Same thing with drug abuse unless you have very special circumstances with very close monitoring.

I think you’re making this more complicated than it needs to be.

Yeah, I am. I just have ethical difficulty with firing patients, and being yelled at when you bring up concerns about non-attendance of appointments is not fun either.

When it comes to substance use, people aren't going to always be honest, so regular UDS's are in order. Which means we're back to the lab monitoring issue.

 

[calvnandhobbs68]

Yeah, I am. I just have ethical difficulty with firing patients, and being yelled at when you bring up concerns about non-attendance of appointments is not fun either.

lol the kinds of patients who want controlled substances but don’t want to show up for appointments are going to yell at you 99% of the time when you cut them off or terminate them. Probably want to get used to that.

 

[meow1985]

lol the kinds of patients who want controlled substances but don’t want to show up for appointments are going to yell at you 99% of the time when you cut them off or terminate them. Probably want to get used to that.

I'm semi ok with firing those. But the ones with severe and persistent mental illness...

 

[SourceOfDenial]

Yeah, I am. I just have ethical difficulty with firing patients, and being yelled at when you bring up concerns about non-attendance of appointments is not fun either.

When it comes to substance use, people aren't going to always be honest, so regular UDS's are in order. Which means we're back to the lab monitoring issue.

It might be helpful to think about this not as ‘firing’ (which frames you as in a person of power and the patient seemingly without) but as a relationship. There are boundaries and a mutuality in all relationships—and they allow both people to feel safe. It’s not ‘firing’ a patient when youve described how you run a practice and have had conversations about what you are and aren’t comfortable with. It’s practicing in such a way that you feel you are safe.

If there are access issues then that warrants another somewhat different conversation.

 

[MBBSMOM]

Yeah, I am. I just have ethical difficulty with firing patients, and being yelled at when you bring up concerns about non-attendance of appointments is not fun either.

When it comes to substance use, people aren't going to always be honest, so regular UDS's are in order. Which means we're back to the lab monitoring issue.

I mean if they're not being compliant essentially they are wasting their time and yours. If you drop them as pts you can take on pts who will be compliant.

 

[meow1985]

It might be helpful to think about this not as ‘firing’ (which frames you as in a person of power and the patient seemingly without) but as a relationship. There are boundaries and a mutuality in all relationships—and they allow both people to feel safe. It’s not ‘firing’ a patient when youve described how you run a practice and have had conversations about what you are and aren’t comfortable with. It’s practicing in such a way that you feel you are safe.

If there are access issues then that warrants another somewhat different conversation.

Thank you. I agree. It's just hard because sometimes in residency you have to figure all this out as you go along, so having the ground rules/expectations conversation sometimes doesn't happen until and unless problems come up. I hope I can address some of this next year when I discuss boundaries and expectations when I first assume care of someone.

 

[SourceOfDenial]

Thank you. I agree. It's just hard because sometimes in residency you have to figure all this out as you go along, so having the ground rules/expectations conversation sometimes doesn't happen until and unless problems come up. I hope I can address some of this next year when I discuss boundaries and expectations when I first assume care of someone.

This is the role of supervision too—these are all things to consider before assuming care of someone. If this aspect of supervision is lacking, hiring your own supervision may be a good option (or asking for another supervisor).

 

[meow1985]

This is the role of supervision too—these are all things to consider before assuming care of someone. If this aspect of supervision is lacking, hiring your own supervision may be a good option (or asking for another supervisor).

It's not so much lacking as fragmented. Different supervisors do things differently, may work at different clinical sites, and may have different philosophies. The medical director of university outpatient services has worked to standardize some practice management protocols, but there's more work to be done.

 

[meow1985]

If there are access issues then that warrants another somewhat different conversation.

Yeah, and one thing I've noticed in clinics that care for the underserved who have few other options (i.e. rural areas, IHS) is that they don't like to fire people precisely because the no shows quite likely have weighty reasons for them, but said reasons are hard to address.

 

[nitemagi]

Look up "Psychodynamic Psychopharmacology."

Their adherence to medication is directly correlated to their relationship to you. Improve the relationship, and their adherence improves.

Will it reach 100%? Probably not. But cutting bait is shortsighted and misses the tremendous wealth of knowledge we have about therapeutic relationships and therapeutic alliance.

 

[VA Hopeful Dr]

I think our job goes beyond advice. We prescribe -- or don't. Sometimes we prescribe contingent on certain actions of the patient, such as getting drug tested, getting drug levels or other labs (i.e. clozapine CBC with diff or lithium levels). When the patients won't or can't do the required actions but still want the meds, that's where it gets dicey. Getting a CBC or a lithium level is not advice, it's a requirement.

Yes but you can't force them to take what you prescribe. You are suggesting that they take what you prescribe, that's your advice to them.

Now requiring labs to obtain said prescription is easy - no labs, no drugs. For lower risk meds, they get 1 freebie. For higher risk, none.

Whenever you make any kind of rule, you're going to have patients upset at you. You need to get used to that.

 

[clausewitz2]

Yeah, and one thing I've noticed in clinics that care for the underserved who have few other options (i.e. rural areas, IHS) is that they don't like to fire people precisely because the no shows quite likely have weighty reasons for them, but said reasons are hard to address.

That is certainly coming from a humane place, but it's worth looking at it like this: in places where access is so limited, it is almost guaranteed that someone else is on a waiting list for that appointment slot they're no showing, so someone else is also negatively impacted by this. And at the end of the day, simply having an appointment recorded somewhere is not the same as accessing or receiving care, so the identified patient may not be benefiting much either.

I am fully in support of identifying barriers to care and doing what you can to address them, but some barriers are not going to be surmountable and sometimes you have to recognize the reality of "we can't make this work right now."

 

[Candidate2017]

Arguably, this is one of the hardest parts of our job. Specifically, right now I'm talking about not following parts of the treatment plan such as timing of follow up and getting labs such as drug levels.

I'd like to know what other people do, because I've sought supervision in my residency about this, but the almost unilateral answer our medical director has is "have them sign a treatment plan." That tends to go over like a lead balloon, as it's hard for people not to see that as punitive or a precursor to getting fired as a patient. I've had success having people sign treatment plans in telling them that it goes back to the amount of liability the *institution* will allow me to accept, but what if the institution doesn't have a position on the matter, or there is no institution because you're it (in private practice)?

Some resolutions I've made for when I start my first attending job:
1. Have people sign a treatment contract when I first meet them, based on institutional policies on treatment adherence (if any), as well as my own comfort level.
2. Start discussions about potential barriers to adherence and how to deal with them early in the course of my work with someone.

If patients still don't do their part, I've been advised to do the following. Tell them that if they don't do x by y date, you will not be able to provide them with meds, and then follow through. Indicate that it's not safe and not good care to keep prescribing if they don't do the thing.

My attendings love treatment contracts. But I prefer to speak to patients about why they need to do certain things, risks of noncompliance, why I can't continue to prescribe if they won't work with me. I continue to explore barriers, nag & escalate over subsequent visits and ultimately give them a deadline for termination. All documented. On some level, if they continue to come to appointments, they want to work with you.

I feel "problems" with termination exist solely in residency because residents are given responsibility with zero authority. There's always the double bind: if you terminate the patient, your program will blame you for not being patient-friendly/lack of therapeutic alliance; if you don't terminate, your program will blame you for not enforcing boundaries. This is on top of being beholden to many different masters, including the patient.

Whereas after training you can say, "Yeah sorry it's obviously not working out, no hard feelings."

 

[keolu hills]

Terminate. There is only so much we can do.

Exactly what I was going to suggest.

 

[keolu hills]

I've noticed many patients that don't follow up have transportation and financial issues. So, a referral to case management would be necessary if not appropriate.