Last-Ditch Efforts with Non-Compliant Patients

There are days I really wonder why certain patients bother coming for their visits.  Earlier this month, I had one of those days. 

I had 3 patients back to back who have diabetes and insulin pumps, and don’t really seem to participate in their own care. They had not had labs done in the last 9 months or so, even though I give them lab slips at every visit. They check their glucose once, maybe twice a day. They bolus for some meals, but not all, sometimes not at all for an entire day (or weekend). 

We’ve had discussions on numerous occasions about the consequences of their actions (or inactions). We’ve spoken in the past about the complications of uncontrolled diabetes.  I’ve explained that I can’t adjust their pump settings if they’re not using the ones they’ve got. I went through discussing barriers to self care – depression, time limitations, etc. 

On this particular day, I was out of lectures, out of tips, and out of suggestions. I pushed my computer tablet aside and just asked, “what do you want to happen?” All three seemed confused by the question, so I went further. “What is your goal? Are you satisfied with where you are? If you think this is good enough and you accept the consequences, then I will stop pushing you to make it better.” 

They all said they want to prevent complications and that they want better glycemic control. I told them that I can’t do it for them. I can only work with what they give me, and if they give me nothing, they will get nothing in return.

I have colleagues whose policy it is to dismiss non-compliant patients from their practices. They feel it is a waste of time and energy, and in the face of pending pay-for-performance, these patients are a liability. I can definitely understand that. If I am going to be penalized because I have patients whose HbA1c are above goal, it will be tempting to get rid of patients who won’t even make an effort to improve their own care. But then, where will these patients go? Who will care for them? What will the burden on the health system be, if patients such as these are deprived care?

I am hoping that our little discussions prod my patients into better self-management. Otherwise, it seems like a waste of their time and mine, a waste of a copay, and a waste of a slot that could otherwise be saved for someone I can actually help.