Apart from managing a patient’s glucose level, vascular and nutritional status, I have observed that patient compliance is a critical in the management of our diabetic patients.

For example: Just yesterday I had a patient in the clinic who was referred for "toe pain and persistent fevers" who presented with a significant right second digit infection. The toe demonstrated a distal ulceration with a sinus tract which was draining a foul smelling sero-purulent drainage and which probed to bone. X-rays demonstrated near complete erosion of the middle and distal phalanx of the 2nd digit, and concomitant vascular calcifications of the DP and PT and metatarsal arteries.

The patient is diabetic but does not check his blood sugar regularly, insisting instead that he simply 'knows' when his blood sugar is too high (incidentally, I checked his glucose level in the clinic it was >300). His past medical history was consistent for the usual suspects: PVD, HTN, CRI, etc...

I discussed with the patient how severe his condition was, and the likelihood that he would lose all or a portion of his toe to prevent further spread of the infection, describing the risk to him for doing nothing, and suggesting that, since he was already experiencing fevers, that it was likely that this infection would spread and become a significant threat.

He listened interestedly, nodded at all the appropriate moments, and expressed the desire to do everything necessary. However, when I told him that I wanted to admit him to the hospital to start antibiotics and establish a vascular workup prior to surgical intervention he simply said that he was willing to do that when he got back from Jamaica (he was leaving the following day for a week trip).

I hadn't gotten through. I reiterated the serious and potentially limb-threatening nature of his condition, but he was simply disinterested. He said he understood the risk, but would deal with it when he got back...

I am certain that we all have experienced just this scenario. You give your best spiel, but it doesn't seem to matter, and the patient through apathy, ignorance, or fear simply does not comply. While I recognize that you cannot save a person from themselves, yesterday's experience got me thinking about what other strategies practioners may have utilized in dealing with noncompliant patients to achieve more successful results.

Please share your suggestions!

In dealing with patient non-compliance, I think it is easy to overlook the many reasons why a patient may be acting that way. Besides not understanding the seriousness of his of her condition, the patient may also be dealing with other issues. The patient may not be able to afford the treatment, the pt may be angry at or depressed about his or her condition, or the patient may have specific religious or cultural beliefs. Furthermore, the patient may not feel comfortable with the physician. That is where the importance of trust enters the equation. We must learn to be active listeners. Once a trusting dialogue has been established between the doctor and the patient, then other issues may be clarified, goals may become one and the patients’ attitude, which was once thought to be one of non-comliance, may begin to take on a different light.

Your explanation of the evaluation was very good. It presented the situation in clear logical easy to understand terms.
But you were frustrated by the patient. Other than his mentioning of the trip, I did not see where you listened to him. I agree with the poster that the patient has issues, though money not likely as his trip to Jamaica would indicate.
The non compliance with medication was your indication that you had a patient that wanted a pill to magically solve their issue so they could continue to abuse their body.
To motivate such patients, some marketing courses may be in order. You can sell to a percentage of people that don't want something just to make you go away, but to get to the majority, you need to show them benefit to them. Keeping a toe may not be enough incentive. Maybe negotiating a later trip after surgery would result in a more enjoyable trip if the issue was resolved. Or avoiding being rushed to the island hospital where less care options exist.
Sometimes putting aside logic and reason is the only way to reach such a patient

I agree with everything you pretty much said.  Sometimes you have to really open the patient eyes to reality.  Asking them which is more important; a trip to Jamaica, losing a toe and still being alive, or dead from possible septicemia?  can really get their attention.  I do think that Ryan was listening to his patient but a patient telling me that they will handle a bad infection after their trip to Jamaica, you can't expect a logical doctor to say that is fine.

     Diabetics  seem to be the most noncompliant patients.  I tell them it is very important to keep your blood sugar within normal limits because if it stays high it make the cells in your body less effective in fighting infections.  So pretty much we have to just tell the patient your recommendation and the consequences of refusing treatment.  Start educating them from the moment they sit into that seat and make sure that they understand in simple terms what is going on.

Ryan,

Great story. It reminds me of a patient we were treating for a submet 2 ulcer. He insisted on going on a cruise to the Caribbean with an open soft tissue envelope. Despite our strictest warnings, he proceeded. On his trip, he encountered sand and hot tubs. By day 3 of the trip he was febrile and started on IV Abx in the infirmary by the ship doctor. He refused to be medivaced off the ship. Upon his return home, he presented to the E.D. pussed out. In fact his entire anterior compartment required fasciotomy as the infection spread all the way up his leg. Below you see the end result, anterior compartment fasciotomy with initial Lisfranc amp. This gentleman has since been been converted to a Choparts and is currently trying to granulate in the fasciotomy.

 

 

I like to take a military approach with these patients. I will often say to the patient "This IS what we are going to do. You ARE going to the hospital. You WILL be admitted."

 

 

If this Jedi-mind trick fails, and the patient threatens to leave AMA and is truly at risk for developing sepsis and dying, then an involuntary commitment is well within your rights and is in fact your responsibility as a physician.

 

I once brought a patient with wet gangrene to tears in the E.D. This was a grown man who was simply living in denial. He was febrile with elevated white count, nausea, vomiting, and chills. His blood cultures were pending. I truly had reason to believe he was septic or could become septic soon. He was very upset with me that night I forced him to be admitted to the hospital. It turned out his blood cultures were positive for MRSA. He underwent emergent debridement that night. This patient returned recently to the hospital to pay me a visit and thank me for saving his life and leg that night.

 

I think the biggest mistake one can make with the limb preservation patient is to try and be thier friend. This is NOT a patient population who you are trying to sell an elective procedure to. This is truly life and death stuff. In my practice with this population, I refuse to compromise my treatment plan for their convenience, because I've seen what can happen when you do.

 

Thanks for the stimulating topic!

 

 

 

 

 

 

I cringe when I hear my colleagues say, "Oh, he is a typical, non-compliant diabetic patient ..." or something along the line. 

I think it's insensitive to attach a label on any medical condition. I happen to know many diabetic patients (both type 1 and type 2) with excellent blood sugar control and keen awareness of their diseases.

If our diabetic patient is mis-bahaving so badly, isn't it our fault (as healthcare providers) for not educating the patient properly? 

FYI, According to the latest study from Dr. Larry Lavery, diabetic MALE had twice the leg amputation rates than diabetic FEMALE, as we probably tend to ignore medical problems and less likely to get appropriate medical care when we develop foot ulcers and gangrenous toes.  

Perhaps it is our Y chromosomes that needs to be labelled inherently "non-compliant"??! 

I have always been accused of being allergic to the word "non-compliant" and perhaps I am. I hate to label people. But in this case, perhaps it is appropriate! As to non-compliant, I believe that there are ways to reach people and teach them and that it is our failure to do so if they don't follow the rules. But Dr. Fitzgerald may have found the exception.

When this particular patient pulled out the excuse of going to Jamaica before seeking definitive treatment I first wondered if the trip was indeed true or just a convenient excuse to doctor shop for an answer he liked better. Or, if it was true, if he was just clueless.

In residency we called this type of response Diabetic Brain Syndrome only to learn later that there is also glycosylation of brain material and that the diabetes also causes narrowing of the arteries. This causes gradual damage and it has been noted that people with diabetes are more likely to be vulnerable to depression. The Franklin Institute also notes that diabetics "suffer a decline in mental ability as they age." Thus the Diabetic Brain Syndrome (DBS) that three irreverant podiatric interns labeled the condition all those years ago. 

My suggestion for the future? What I did many times, in a calm and gracious voice with a smile - "Sir, when you go to Jamaica (or wherever) please take out to the medical travel insurance before you leave the country. Before you leave our office today I will dictate instructions to the Medi-Vac physician and nurses instructing them on what will be required if you should go into septic shock from the infection in your foot. Make sure that the policy will also transport your body should you die while you are out of the country." 
 
That last sentence alone has kept several patients from traveling when they needed to stay and get an infection treated. Besides, who wants to be in a whirlpool onboard a ship with someone who has an infected foot? Not me!

I do not think it is just diabetics who are different, but I do know that those without "the gift of pain" are different.     Dr.Paul  Brand said it is impossible for those of us who can feel pain to understand the indifference of those who are insensate.  He compared the obese patient and smokers to this.  They do not feel pain when they overeat or smoke, or they would not do it.