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Lecture Hall Wound Care | Analysis

The Non-Compliant Wound Patient


Kathleen Satterfield
Kathleen Satterfield, DPM
Clinical Associate Professor
Dept. of Orthopaedics/Podiatry Service
University of Texas Health Science Center at San Antonio, TX
System Requirements Method of Participation Disclosure Information
Lecture Transcription




Hello! My name is Dr. Kathleen Satterfield and I am a Clinical Associate Professor in the Department of Orthopaedics/Podiatrist Service at the University of Texas Health Science Center at San Antonio and I will be talking to you today about noncompliant wound patient: Pitfalls, advice, and evidence.



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We are going to talk about several issues regarding noncompliance:

1. The reasons that exist for noncompliance.

2. The widespread impact of noncompliance.

3. How we can better detect problem before it affects us and our patients.

4. Ways to enhance compliance in our practices.



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Whether or not you believe that noncompliance really exists depends on what side of the exam room you are sitting on. If you are the patient you may be saying to the nurse or the doctor, “you know I know what is right for me and that is what I am doing.” In their mind’s eye, they are not noncompliant. They are just doing what they think is right.



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However, if you are the healthcare professional you want to protect the patient, you want to protect your career, you want to do the right thing, and you look at the actions and you think to yourself “well, of course the patient is being noncompliant. He is not doing what I told him to do and after all I am the one with the education and the training, I know what is best for him or her.”



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Sometimes the best thing is to break it down into smaller pieces, so that we can really see what is affecting our patients and why they are acting in the way that they are. There are some very common causes of what we call noncompliance. The first one is:

1. Physical limitations.

2. Memory problems and complexity.

3. Cultural and generational issues may be at play.

4. Issues of control, who is in power.

5. Financial concerns creep into it as well unfortunately.



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The patient may not be ready to comply with what you are asking of them. They may have educational limitations or there may be literacy issues. They may have a fear of effects of the treatment. Their motivational level may be very low. You may simply be miscommunicating with the patient and the one that may surprise you.



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If the patient perceives that you do not really care about them and that you do not really have their best interest in mind, they will not comply with what you are asking them to do. They will do what they think is best.



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Lets use some case studies to illustrate some of these etiologies for noncompliance. Take physical limitations for instance, especially in the wound patient, we may have a patient who not only has diabetic retinopathy and cannot see the wound well, but they also have neuropathy. They cannot even feel that they have a wound, some very difficult setup.



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Here is an example of a patient from our clinics at the University of Texas Health Science Center in San Antonio. This gentleman was only 47 years old and yet he already had a 12-year history of very uncontrolled type 2 diabetes. On one limb, he had a below knee amputation and on the contralateral limb, he had already had a transmetatarsal amputation and now he has a very deep infected neurotrophic ulcer that is putting his remaining limb at risk. When he is questioned about what he has been doing, he said he had to do some walking. he did not think it was very much but he had to do some work and there was just no other way around it. He wants miracle care at this point. He knows that he is in trouble but he cannot think logically about how he got there. What would you do with this patient? What is the next step that you would take? Probably the natural conclusion or the natural response that anyone would have would be the one of frustration and our natural response would be to want to go to anger when the patient does not listen and continues to throw up, “well, I had to, I had to,” and we would say, no you did not have to. I think the thing we will have to realize is:

1. The patient has retinopathy, he could not see that he was developing a new wound.

2. He certainly has neuropathy, he could not feel that he had the wound.

3. Very real in his mind is the fact that he had to provide for his family and that he really was less of a man because he was no longer able to properly provide for his family, so he was going to go out and he was going to do what little he could. So all of these emotions are bound up in his response and is one of defiance. He can still go out and he can do something. He can make up his mind to go and do something and he is pushing himself to the limit. There are lot of factors that work there but the wound is not his main focus right now. If you listen to him, what he is saying is he needs to find a way to provide for his family and this is what is pushing him to this response. The response for this patient, our response for this patient, was to get him completely off of his foot to have a wheelchair donated to him, so that his walking would be minimal and he could propel himself in a wheelchair. This provided a chance for this wound to heal and it did and then we could address some of the other issues in his life that needed attention by other health care providers and social workers so that he might have a chance.



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The patient with memory problems and difficulty in comprehending complex issues is a difficult one. They may be totally unfamiliar with the topic that we are trying to explain to them and they may also have depression. We certainly know that many patients who have diabetes and chronic illness also have concomitant depression, often undiagnosed. Dementia and Alzheimer are much more widely diagnosed in this day and age and we see patients dealing with those and now we have a patient with a wound who has the challenge of memory problems. We have a complex regiment to explain to them and it is a very difficult thing to tackle and to have a successful outcome for the patient. Let us look at a case study in this area.



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You have an 82-year-old woman. She has diabetes. She has a hammertoe that is going to be very problematic unless it is reduced. She has excellent vascular supply. Her blood sugars are good. She is otherwise healthy besides her diabetes and you make the decision that this is the one patient at this age with this disease that I think that I am going to do this prophylactic surgery on in order to give her a better life and at the end of the procedure, you give her oral postoperative instructions and you go on to your next patient. When she returns in a week, the nice clean dressing that you placed has been changed and replaced with a small bandaid and you say to her what in the world happened, why did not you call me and her response is well, you said to keep the bandage clean and the other one got dirty, so I had to change it, you told me to. What do you do? Well, again, you know the initial response is, I mean, you are frustrated, you know that you did not mean what she has taken your words to mean, it certainly will do no good to be angry. Well, the first think you do is examine the wound, of course, the surgical wound and make sure that everything is all right. Splint the toe, cleanse it, redress it and then you approach her from the standpoint of other methods of education. Either you give her written instructions, which I think everybody these days certainly would but also if you suspect a memory problem, if you suspect comprehension problem, the best thing to do is to incorporate the use of an additional caregiver, a family member, a friend, or perhaps you need to get home health care involved during the postoperative or during a treatment period if it is for an ongoing care of an ulcer. It is important another set of eyes and ears in this patient population will be very valuable.



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Cultural issues can be a very interesting source of noncompliance because the different cultures may have different expectations of the health care system and they may have entirely different belief systems and you have to appeal to them on their level and reach them on their level in order to facilitate a positive outcome.



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Using an illustration of a Hispanic family because I have practiced in San Antonio, Texas where the majority of our population is Hispanic but in your community it may be another cultural group and you must learn the ways of that group. This is a very common type of scenario in our clinics where in this case this was an actual patient of mine, a young Hispanic man who was a type 1 diabetic who had been extremely noncompliant with control of his disease as a teenager, which is certainly not uncommon and now he had presented with an infected ulcer, extremely neuropathic but he was accompanied to his appointments by his grandmother, “abuelita” and as many people in our community do, she believes in what we call botanicas. These are small shops in the neighborhood and they have wonderful selections of herbs and candles and different potions and lotions that are designed to do everything from you know get your girlfriend back to healing a diabetic ulcer and his little abuelita had a lot more faith in the Curandera who ran the botanica than she did in our modern prescription of antibiotics and she was quite resistant to him taking an antibiotic because she had heard rightfully so that there are a lot of side effects to modern medicines such as this one and we had given him the list of things to watch out and to not do while he was on this and so how in the world do we convince this wise little lady who loves her grandson very much that what we are asking him and her to do will help and not hurt him. What would you do? Well, the very first thing that I would always tell our students and residents is under no circumstances make fun of or put down these beliefs. This is an excellent opportunity to learn about another culture. I would always remind the residents in the case of botanica where do many of our modern medications come from? They come from plants and by talking to the people from neighborhood, you may learn something about the importance of this type of medicine and so in this type of situation and in this very situation, what I did was to sit and talk with the grandmother at length asking her questions. What did she recommend, how had she seen it used, how would it affect her grandson, had she used it already, why had it not worked, and in this case she had tried something and it had not worked. It was because it was a bad medicine and what she meant by that was not that the herbs were bad but that someone had put, for lack of better word in English, a bad spell on her grandson and wished him ill and so that was my opening. I said what if we combine powers here, what if you take your most powerful medicine from the botanica and I take my powerful medicine from the hospital and we will combine them and then the bad medicine will not be able to affect the combination. She pondered this for a while and pretty soon she pretty much thought it was her idea and that is what I am going for. You have to give the patient and their support team an opportunity to take ownership of what you are offering them. They will really have to sign on to the whole regimen and in this way we were able to combine forces. The one caution I would give you is this, if the treatment that the patient or their family is proposing or is doing is harmful, that is a difficult thing to have them stop immediately. I had a patient who placed tobacco in their wound and there was some very small wisdom to it. The tobacco was very acetic. It would affect the wound somewhat of antimicrobial because of this acetic environment but it was very toxic to the skin cells and no angiogenesis could take place and so we had to wean the patient away from that type of treatment introducing more and more of our traditional methods in replacing his traditional methods. It is a matter of gaining respect and keeping it.



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I think one of the hardest areas of noncompliance to deal with are those control issues because there are so many family dynamics that you may be stepping into and while this family may have had these dynamics for 50 or 60 years, and you are the new comer and you are trying to get them to do something that no one else has been able to do over decades and sometimes there is no matter what you call in different cultures, here we call it Machismo and that has to be very delicately addressed. Again, we will never make fun of, we will respect people, and people deserve respect. We have to talk with them, listen to them, and learn what those dynamics are. I may give an example.



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This was a patient at our clinics who swore that the shoes that we had issued to him for his diabetic neuropathy and a history of ulcerations were just way to loose. He had been fitted with wrong sized shoes. He had told this, he wore smaller size and now look now he had an ulcer because the shoes were too loose and they were moving around on his foot. In fact, they were so loose that he had had to put some pads inside them right at that big toe to keep it from rubbing. So what you will do? You know that the patient is neuropathic. The patient can only feel his shoes when he makes them so tight that it fires more proximal nerves. When that happens, they are very much too tight. You and I know that the shoes not being loose did not cause the ulcer but the pad that he placed there did. So what do you do? Here is a respected patriotic of a family. The rest of his family respects what he says, why do not we as a caregiver respect and believe what he says. This is a case where you have to show respect again as we always should and show him facts. This is the man who will believe in facts. It does not work with every patient but in this particular case, it would. Giving him a long discourse on why he only feels his shoes when they are very-very tight would not work, it did not work, I can tell you we tried. What would not work, however, is to put his shoes on him and put a slip of paper inside as he is putting the shoes on, have the piece of paper extending up out of the shoe. Now, these shoes he said were too tight. We laced them, we tied them, and then we had him lean over and tried to take the slip of paper out from the shoe and we said these shoes are very loose, and he said yes and he moved his foot around to show how would we go around on his foot and he truly felt that it was and we said all right and then the paper will then just slip right down. He said it has probably already gone and he reached down and he pulled on the paper and then he tugged on the paper, and then he looked at us and he was genuinely surprised that the paper was tight there and was very difficult to remove. Then, we did the old foot care trick of taking his shoe and measuring around it and then having him step out of it, having him put his foot down over that, and outlining his foot and showing him how it met the parameter of his shoe and then showing him the shoe that he thought fit, which he of course came in are an old pair of shoes and showing him how that shoe was much smaller than the shape of his foot and by seeing those things, he was able to comprehend and then he had a story to tell everybody in the waiting room. Pretty soon, he was correcting everybody else about the size of their shoes. He suddenly had a fund of new knowledge.



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Sometimes a patient is just not ready to hear the news that we have to give them, especially wound care patient when things have gone bad. We may be trying to give them too much information or the news is so bad that they cannot comprehend it.



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This is an example of the type of situation I am speaking of. In this case, we had a patient who was a construction worker with diabetes and he really had managed to do fairly well for most of his life. He had had a few close calls across the years but not many, but now he had a chronic ulcer over the past year that he had not been able to heal. He came in to our clinics and he gets an introduction to us and we send him for x-ray, we bring him back, we put the x-ray up and say, you know nice to meet you essentially and now let us show you, you have a bone infection and we are going to have to take off a part of your foot. Well,

1. He just met us.

2. He has been doing well for all these years. He cannot believe it is that bad and you know, he is ready to pick up and leave, which he tries to do. This is not the way to handle this. Certainly, if we have just met a patient, if they have just came into our care, we have to gain their trust first and foremost. What would you do in that kind of a situation? Ask yourself. The first thing to do is just to slow down, give them a little information about what is going on. This is not a life or limb threatening infection in most cases. Nothing will be improved or hurt by waiting a week, placing the patient on some antibiotics, and having them come back after they have heard the news and been able to absorb the news a bit. In this kind of case, we give them a little bit of information, try to educate them, and then bring them along as they are willing and ready to hear the news. It also helps us to explore different options for patient rather than just giving them the same line of well usually we would amputate this because in most cases the antibiotics are not effective in this extent of osteomyelitis. Well, may be we need to put the breaks on as well and do some additional investigation ourselves. It is a matter of deciding how much and how soon in order to gain the patient’s trust.



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There was a very interesting article in a 2001 issue of Hippocrates that said that it estimated that there are up to 90 million Americans who do not have the reading skills or the level of understanding sufficient enough to understand a prescription drug label, discharge instructions, a consent form, or even oral instructions about a treatment plan. If you think about this and think about your practices, that is kind of a frightening thought. It is sort of like giving someone a car without any instructions on how to drive but you are the person who has to pay for any damage that they do. It makes us realize that we have to inform our patients on a variety of levels; oral, visual and taking them through the steps because we may be dealing with one of these 90 million people who does not have the ability to understand what is presented to them in one form.



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Let us talk about one of these cases and I think this is kind of an embarrassing issue for a lot of people because you do not want to say to a person, are you able to read and write? It is not a question that we are comfortable with. Let’s say, you perform a nail avulsion on a patient and you hand them written instructions outlining the care that they are supposed to do at home and then you pick up the chart and you notice that on the patient’s history section, the patient did not fill out any of the information and you have just gotten a few other clues from talking with the patient that may be they have not gotten the benefit of a lot of education and you wonder, can they read and write?, do they know what I have presented to them? What are you going to do? Are you going to say, can you read or write? Well, there are several ways to handle this, not so abruptly as saying, can you read or write? Tackling it in a bit more polite manner and more effective manner.

1.Take the postop sheet and go over it step by step and ask the patient to repeat it to you; not as laborious as it sounds, but okay when you get home, Mr. Smith, what are you going to do tomorrow to your toe and have them repeat back to you the steps that you are asking them to do and even easier way to handle it is to simply have a postop sheet or any instruction sheet from your office and also include some visuals. These do not have to be great works of art, just some guidelines to show the patient in a different way what is necessary. If you hit them with a written word visually through photographs or pictures and you have them repeat spoken instructions, you have hit three key ways that people learn and you are liable to get the response that you want by doing those things.



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Sometimes we have to deal with patients who have very low motivation and that can affect their outcome greatly. You will be talking to a patient and explaining to them what you need them to do to have a better outcome and they just seem totally disinterested. It is a very difficult situation. You may also have a patient who is just depressed, something else is going on in their life, and they are anywhere except in that appointment room and they are just not with you mentally. A third category is the patient who is there for secondary gain. Their motivation to get better is very low and that is a whole different scenario.



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Let us look at a case study dealing with low motivation and trying to play this out in your mind thinking him as one of your patients and how you would deal with this same situation. You have a woman who comes in often. You are very familiar with her but you are very frustrated by her because she keeps coming in with complications. She has not followed any of your instructions. You are investing a great deal of your time and effort into her health and she does not seem interested in doing anything. She does not seem interested in a positive outcome at all. What are you going to do? Well, again the first response is a feeling of frustration and sometimes anger but it is so important to not let that show. You have to find out why the patient has low motivation. Are they truly just disinterested in their situation? That is not a common factor, especially if someone has come to the office for care, but they may be depressed. Listen to the patient. Find out if there is something else going on in their life. You may not be the caregiver to solve that problem but you certainly may be the caregiver who can refer them to someone to solve the problem and that is a very important role and we can find that out by simply listening to them and responding. If the issue is one for secondary gain, that may be more difficult thing to find out. Ask the patient if the injury or if the wound in this case came about as a work related incident. Certainly, not every patient who has a work related incident is there for secondary gain, the vast majority is not but it is something to keep in mind. You see that the common denominator in all of these solutions for these is listening to the patient. Frankly, if the patient is depressed, it may be very difficult to get them to talk and to elicit a conversation, a meaningful conversation from them. This is where you may want to involve other people in the office. They may feel more comfortable talking to the person who checks them in for that appointment or the person who put them in the chair, or the person who they check in with at the end of the appointment. Get everyone involved and try and find out what is the cause of low motivation. Yelling at a patient, putting them down for not carrying out your instructions will get you nowhere except more distressed and even more noncompliance.



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I think we have all asked ourselves this question. Is diabetic noncompliance different from other noncompliance and there were times when we would be so frustrated with patients and we would make reference to diabetic brain syndrome and then low and behold the literature caught up to that concept and found that yes, you know this glycosylation of proteins that is occurring elsewhere in the body is occurring in the nerves as well as we know now and it certainly can effect neural performance, it can effect memory, and it can effect many components of the diabetic. In this article out of the journal of Health Psychology, it was interesting to see the patients who failed to show for appointments at a diabetic clinic were found to be either:

a.A high fear group, meaning, they did not like to come because they did not want to hear that they were afraid of what they would hear, that they were going to go blind, that they were going to lose their limbs, that they were going to have to go on dialysis.

b.They knew more than the doctors. You know their aunts controlled her diabetes with cinnamon and little exercise in the afternoon and I think I know more than that group and then the other group, the low motivation group and this again is a very difficult group to deal with but they were really motivated to get there, to get to the appointments.



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So what do we care about noncompliance? Well, we care a lot because noncompliance has a big impact on many things. First of all, on our patients, it impacts their medical outcome almost to 100% negatively and then emotionally. Noncompliance leads to bad outcomes, which leads to depression, very emotional outcomes, and then the one that unfortunately affects some people in the healthcare field very badly and that is the litigiousness of society and legal outcomes can end a brilliant career. Noncompliance of just one patient can end a brilliant career and then financial noncompliance, and I am not talking about for the patient or for the physician or nurse or other healthcare provider but for the system as a whole. It is a very big impact.



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When it comes to the medical impact, this is a very interesting survey that was produced by the Committee on Practice and Ambulatory Medicine back in 2000. About 90% of the pediatricians who were surveyed believed that noncompliance with the prescription regimen that they had ordered for their patients was interfering with their ability to control the patient’s medical conditions. That is pretty astounding when you have 90% of group of physicians saying that their patients are being affected.



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Although this is a much smaller number, it is because of the effect of it, it is equally horrifying. About 6% of hospital admissions may be due to noncompliance. Think about the impact of that. Think in your history of patients that you have encountered. Have you had the patients who had to be admitted because they had noncompliance with whether it was prescription medications, completion of the use of antibiotics thus allowing an infection to return, their orders about being nonambulatory, nonweightbearing. I think we can all think about wound care patients who have certainly been admitted to hospitals because they have been noncompliant with our orders whether they were noncompliant by choice or they “had to” and why do I say that, because sometimes we do ask patients to do things that they are not capable of doing. I will just say that when it comes to financial issues; if we do not make sure that the patients have the ability to carry out the instructions that we give them from a financial basis, we are dooming ourselves for one of these admissions as well.



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Here are two very interesting studies done by two diverse groups pharmaceutical company, on the left Upjohn and AARP, Association of Retarded Persons on the right. In the pharmaceutical study, when they did a survey of patients, they found that 20% of the patients did not fill prescriptions that they were given by their doctors and when they went on to find out why they did not fill them, over half of them did not fill them because they did not believe that they really needed the medication; that is interesting. From our standpoint as healthcare providers, we would question why do not they believe me, why are they usurping my position of trying to take care of them, and it again may be one of those control issues from the pharmaceutical company standpoint that represents billions of dollars. The AARP found something, a little different, but what you might expect in their population. About 21% of the patients also believed that the medications would not help, 22% were concerned about the side effects, but sadly 14% of the patients could not afford the medications that they were prescribed and so again it is very important to speak with the patient, to listen to the patient, and nip these in the bud. These are all things that we could have found out by speaking with the patient and listening to the patient. Just ________ any feelings that they have about the fact that they thought they would not help, educate them better about that, educate them about potential side effects and if the patient could not afford it, either direct them to one of the plans that will help pay for prescription drugs for those of limited income, provide them with samples if that would be an option, or provide an alternative prescription that would be less expensive.



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Probably, no one listening to this lecture is surprised by this outcome, nonadherent patients have statistically and clinically worse outcomes than patients who adhere to instructions. We would certainly hope that patients who adhere to our instructions and treatment regimens would not have worse outcomes, certainly but it is important to see this in a scientific study, so that we have the ammunition and we have the ability to educate our patients. You know what, people have looked at this and we find that if our patients do not do these things that they are not as healthy, they do not have good outcomes, and sometimes that is all it takes.



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This study was generated at UT by David Armstrong and Lawrence Harkless and appeared in the journal for foot and ankle surgery in 1998 and they found that patients who were noncompliant and they identified that as patients who missed more than 50% of their clinic appointments during the year and if they fell into the UT Foot Classification of category 3, they were twenty times more likely to have an amputation than those who were in that same classification but were compliant and that speaks volumes. When you present that to a patient and say, look this is where your condition falls, you have the same condition. The patients who came to their appointments and who took their medicines had twenty times better chance of keeping their foot and their leg than those who did not and that is powerful.



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If you practice involves surgery, then this has been your pain as it has been mine over the years and that is availability of surgical OR time. It gets more scarce every year, it seems like, and then what you do you schedule a patient and they fail to show for their surgery and so you get bumped from the schedule. It reflects badly on you and your ability to schedule additional procedures is sorely affected. In this VA study, they found that patients who fail to show for scheduled surgery had a previous history of noncompliance with “other healthcare encounters” meaning their clinic schedules and so scheduling these people was interesting. If they had that history, they would schedule that at the end of the day in order to better optimize the operating room time; that really was an ingenious way. People love to be able to end early certainly but if you have a series of no shows at the beginning of the day, it throws the whole schedule off and starts to affect other people’s healthcare delivery as well.



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And then it starts to affect the pocketbook and it affects the pocketbook of everybody because a lot of noncompliance does not affect an individual’s financial situation, it affects society’s pocketbook if you will. In a study that was done in Florida, they looked at noncompliance with seatbelt use and if this resulted in worse injury and in fact it did and the study showed that it was driving up the economic burden at trauma hospitals and that there was a real need to either educate people regarding use of seatbelts or there has to be some kind of a penalty for noncompliance with seatbelt use or some extra benefit to the trauma center who would then take care of these people because they would just be disproportionate number of severe traumas from this population and these, of course, are the ones that are extremely expensive to care for and require longer hospitalization and utilization of more of the facilities, staff, procedures, medications, and therapies.



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We touched on this one a little bit and I will just say something brief about this again and that is the emotional impact and another slides is meeting the patient’s emotional needs and that is very difficult. First of all, a lot of times when you are dealing with depression, the patient has difficulty in opening up in order to really reveal that aspect of themselves, use your judgment; if you sense that there is an issue, this may be the patient who does well in a group setting with other patients at the University of Texas Health Science Center and we have been very successful in having an Amputee Support Group for instance. It is run by the patients, facilitated by the nurse case manager, and attended by the residents and by having this milieu, the patients have been able to open up and share much more honestly and deal with emotional aspects. It is interesting to see when we would as practitioners visit on occasion, they can get away with a lot more with each other than we certainly can as the professional dealing with the patient. They can chide them, they can tease them, they can say “you know I have been there” and they truly have walked in those shoes and usually we have not and so it is a setting that helps to deal with the emotional impact much more effectively.



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Then, there is the inevitable and terrible impact of litigation sometimes. Noncompliance may very well equal a lawsuit and in order to not go that direction and I do not think there is any tried and true 110% way to avoid that but a way to minimize that is to think of the interaction as a partnership rather than a dictatorship in order to avoid problems. Yes, the patient needs to take ownership of their disease and we need to take ownership along with them of their care but we cannot on their disease for them and the other thing that I would add in this regard is document, document, document. If you do not write it down, it did not happen and in this rushed world of 10 and 15 minute patient visits, it is difficult and that is why dictation is a wise way to go because it may give you the opportunity to expound upon issues of noncompliance with more description.



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You know, it is kind of interesting but we all want to believe, I think, in our patient’s best interest for themselves and we like to believe that our patients are really trying and so when I saw this study, I thought it was very interesting. It shows that clinicians’ personal assessments of the patient’s level of compliance were often very unreliable. What it showed was that the physicians and nurses were rating their patient’s compliance at a much higher level than what they were actually doing. So what they were saying once they were in that treatment room was what they thought that we wanted to hear them say rather than what they were actually doing and so you have to get attuned to that fact so you can do a little more digging for the facts.



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So how do you come up with those facts ? Well, you have to kind of be an investigative reported here. One method is claims-based measures for medication adherence, meaning look at what prescriptions they filled, look at what they filed. Another way is pill counts. People especially in pain clinics will do this often as well as blood levels of medication. I really hate to do this because it shows an inherent distrust. I understand why people in pain management practices will do so but essentially is not this what we are doing when we order a hemoglobin A1c. It certainly is showing us compliance over a 3-month period with the diabetes regimen and we have to look at this whole picture, and I would say you have to have a healthy dose of suspicion as well as respect for your patient and realize that they probably respect you very much as well and they do not want to disappoint you and so they are not always going to tell you the absolute truth because you might be disappointed in their response.



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Perhaps the best thing to do is to figure out how to enhance the patient’s compliance and figure out how to make it a better world and the number one thing is consider communication. How are we going to better communicate with that patient and I have _______ to this before but it is really not better two-way communication but one-way because we want to be able to better listen to what the patient has to say. If I am sending the patient home with a medication that needs to be refrigerated and I have not listened to the verbal clues that the patient has given to me that their living situation is not amenable to making that happen, i.e., I had a patient who was homeless and if I had not picked upon these clues, I would have sent him home with this medication that needed to be refrigerated and it would have been thrown away because there was no way and so that person needed some social services help in order to be able to be compliant but I had to listen to pick that up. She was embarrassed to say, “look, I am homeless. I do not have a refrigerator. I do not have a place to refrigerate this” but by listening I was able to pick up on that. Ask a few polite questions and get her to then open up to me.



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Another way is to use the facts to prove to patients what you are asking them to do is of value. We have spoken about that, certainly illustrating about the tightness of the shoes worked in that particular patient’s case. It would not work for every patient. Some will still think that they know best but you will be surprised when they come back. They often times will have incorporated that fact into what they now believe, do not give up. Explain what the patient can expect from treatments or medications. I think the biggest frustration is occasionally you will give a patient a sample and the doctor information slip will be on the inside of the closed package and they come back in and they say, well you did not tell me it could cause deaf, it could cause my liver to die, it could cause blindness, hair growth, migraine headache, whatever and although these things are very rare in the case of this hypothetical medication, you have to explain them; if heaven forbid that they find out from somewhere else and you have not explained the possibility of a side effect and heaven forbid that they experience a side effect and you have not explained it to them because at the least, they will discontinue the medication and you will not get the outcome that you had hoped for. Ask the patient to repeat the instructions at the end of the visit, particularly important if you have a patient who seems to have some memory problems. Bring them along slowly, have them repeat those instructions, and draw a picture if you have to. You want to be able to appeal to them in several forms of learning, so that they will better understand. Keep it simple that is the best advice about everything, is in it? Ask the family members and friends to assist the patient and if there are no family members or friends available and it is reasonable to do so, employ home healthcare for their care. Develop markers that the patient can use to track progress. If you have ever been on a diet, think about it that way. You looked forward to those milestones and when I lose that first five pounds, then I am going to treat myself to new pair of jeans. When I lose fifteen pounds, I am going to do this. Develop markers that the patient can use to track their progress in their situation. In terms of a wound patient, it may be that when your wound decreases to this point, we will be able to put you into a different kind of a shoe. You will go from having a total contact cast to wearing removable cam walker. Give them markers that they can look forward to, they can monitor, and that will enlist their active involvement.



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It is important to develop a policy regarding noncompliance. The steps that you want to take are to document all occurrences of noncompliance and what the outcomes were. You want to document all staff communications regarding the patient’s noncompliance that may be the front desks call from a patient stating, “you know I was walking barefoot out in the yard and I stepped on a nail.” Have them document it. That also includes the physician intervention and to document the actions that had to be taken as a result of the noncompliance. But you know what, if it continues to happen time and time again and it is putting you as a healthcare provider at risk, then you may need to fire the patient and they are certain legal steps that you need to go through in order to do that and they must be followed. Check with your malpractice carrier or your institution regarding the steps that you will be required to take. Although, it is a painful step to take, it can sometimes also be a wake up call for the patient who uses that as their moment of clarity when they realize they have got to stop messing up and start taking care.



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Thank you very much for your attention. I hope this helps you in your practices.



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The controversial topic of patient non-compliance is explored in-depth in this lecture. Many of the diverse etiologies that have been identified are discussed and the more common ones are explored in case-study format, based on actual cases. Methods for overcoming patient non-compliance are discussed as well as the significant impact that this activity has on the medical system. After viewing this lecture, the student will be able to identify non-compliance in his patients and implement methods to successfully overcome that destructive behavior.
Goals and Objectives
After participating in this activity, the viewer should be better able to:

1. To trouble shoot the reasons for patient noncompliance
2. To process the cultural issues of noncompliance
3. Assess the effects of noncompliance

Estimated time to complete this activity is 66 minutes.
Target Audience
Physicians, diabetes educators, and other health care professionals who treat patients with diabetes.
System Requirements
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A Pentium-III class computer with a minimum of 256MB of system RAM is required to view Online Internet lectures. While a 56Kbps dial-up connection is supported, a Cable or DSL broadband Internet is strongly recommended for optimal video playback. You will need an up-to-date web browser such as Internet Explorer, Mozilla Firefox, or the AOL browser with Java and JavaScript enabled. Some lectures require the use of Internet Explorer to run and will not run with other browsers. Lectures may require the use of helper applications or plug-ins to access the materials. For example, most online lectures/presentations require either Adobe Flash Player or Windows Media Player (both free). To be able to print completion certificates Adobe Acrobat Reader must be installed.
Method of Participation
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Complete the 4 steps to earn CE/CME credit:
  • Complete and submit the required pre-test
  • View Lecture
  • Complete and submit post-test and program evaluation. Credit will be issued with a passing score of 70% or better.
  • Click Print Certificate.
Disclosure Information
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It is the policy of PRESENT e-Learning Systems and it's accreditors to insure balance, independence, objectivity and scientific rigor in all individually sponsored or jointly sponsored educational programs. All faculty participating in any PRESENT e-Learning Systems programs are expected to disclose to the program audience any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker with a potential conflict of interest from making a presentation. It is merely intended that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts.
Kathleen Satterfield, DPM has nothing to disclose
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(i) We are accredited by the Accreditation Council for Continuing Medical Education ("ACCME") to provide continuing medical education for physicians, through a sponsorship agreement with the Mount Sinai School of Medicine. As an ACCME accredited entity, we are required periodically to submit aggregated data about CME participants and the CME activities we certify. We also provide personally identifiable information to other accredited CME/CE providers who certify CME/CE activities posted on our Web sites, as required by the ACCME and other accrediting bodies. These reports may include personally identifiable information about you and credits issued to you, for the purpose of maintaining records that you can request from the accredited provider for up to six (6) years;

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(iii) Our Editorial and Customer Support Staff will have internal access to files containing personally identifiable information, including evaluation forms and aggregated CME /CE participant information. These files can be accessed in order to respond to your questions or comments. Our staff may also use personally identifiable information, including registration information and evaluation data, in assessing educational needs and planning marketing activities; and we may use the information we collect as otherwise permitted in this Privacy Policy.

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Uses We Make of Information

In this section of our Privacy Policy, we identify the ways we may use information about you that we have collected.

Aggregate Data

We collect data about visitors to our Web sites for product development and improvement activities. We also use it for market analysis. We may provide information from our Web sites in aggregate form, with identifying information removed, to third parties. For example, we may tell a health care partner what percentage of our registered users are of a particular medical specialty or have certain credentials. Any third party that receives our data must agree not to attempt to re-identify the people it belongs to. For example, we may provide information to a potential advertiser of a product that would appeal to a diabetes patient about what percentage of our users have diabetes. Depending on our agreement with the third parties, we may or may not charge for this information.

Marketing and Advertising

We may target our advertising or marketing depending on information we have about you. For example, a user that is a healthcare professional who treats diabetes may receive advertising for new diabetes therapies (although in neither case will the advertiser have access to any individually identifiable information about you). We may also personalize our Web site based on your interests. For example, you may see different articles in different places on our Web site based on information you have shared with us, or information we have gained by observing your previous behavior, or information we may have gained from your interactions with a third party that shares information with us. We use information for our own internal marketing, research, and related purposes. Third Parties In addition to aggregate information (discussed previously), we may share some kinds of personally identifiable information with third parties as described below.

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Our Employees and Consultants: We contract with other companies and individuals to help us provide services. For example, we may host some of our Web sites on another company's computers, hire technical consultants to maintain our Web-based tools, or work with companies to remove repetitive information from customer lists, analyze data, provide marketing assistance, and provide customer service. In addition, if you are a healthcare professional, we may validate your licensure status and other information against available databases that list licensed health care professionals. In order to perform their jobs, these other companies may have limited access to some of the personal information we maintain about our users. We require all such companies to comply with the terms of our Privacy Policy, to limit their access to any personal information to the minimum necessary to perform their obligations, and not to use the information they may access for purposes other than fulfilling their responsibilities to us. We use our best efforts to limit the use of other companies in areas where personally identifiable information may be involved.

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Protection of Information

In this section of our Privacy Policy, we discuss the security measures we take to protect information that we have collected about you.

We have implemented technology and security policies, rules and other measures to protect the personal data that we have under our control from unauthorized access, improper use, alteration, unlawful or accidental destruction, and accidental loss. We also protect your information by requiring that all our employees and others who have access to or are associated with the processing of your data respect your confidentiality. We use security methods to determine the identity of its registered users, so that appropriate rights and restrictions can be enforced for that user. Reliable verification of user identity is called authentication. We use both passwords and usernames, as well as double opt-n verification, to authenticate users. Users are responsible for maintaining their own passwords.

Access to Information and Choices

In this section of our Privacy Policy, we tell you how to obtain and correct information we have about you, and how to choose what types of information you may share with us.

Correction of Information We Have About You

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Our Employees

Our employees are required to keep customer information private, as a condition of their employment with the company. Only selected, authorized employees are permitted to access personal information. Our employees with access to personally identifiable information are required to attend a confidentiality/privacy training class, and to sign a confidentiality agreement. All employees and contractors must abide by our Privacy Policy, and those who violate that policy are subject to disciplinary action, up to and including termination of their employment and legal action.
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