Do non-compliant patients really sue their doctors?

The non-compliant patient who sues his physician for an adverse clinical outcome is a storied malpractice bogeyman. After failing to follow a screening regimen, show for appointments, undergo recommended tests, make health-related lifestyle changes, or take their medications, these patients (now plaintiffs) have the audacity to blame the doctors and nurses for not being adequately clear or assertive.

Are they real?

Yes and no. Not every “difficult” patient is a potential claimant, but some patients do put themselves at risk for irreparable harm and expose their caregivers to greater risk for allegations of negligence.

Five percent of 8,500 malpractice cases analyzed via CRICO’s national database cite patient non-compliance as a contributing factor. Most commonly, such cases allege harm due to diagnostic errors. About one-third (36 percent) of cases with non-compliance issues result in payment to the plaintiff; payments average $496,000.

Of course, more than five percent of patients are non-compliant with their physician’s recommendations and care plans, reflecting both willful and circumstantial discordance. Understanding when a recalcitrant patient poses a liability risk requires some delineation.

Difficult patients who demand extra attention, who challenge your clinical aptitude, who want superfluous tests or treatment can, indeed, be irksome. Yet patients who aggressively contest standard care recommendations are not necessarily non-compliant. Their assertiveness does, however, signal the need be vigilant in maintaining trust and documenting the rationale behind areas of disagreement.

Non-compliant patients are those who seemingly agree to follow your recommendations (i.e., referrals, medications, follow-up appointments, lifestyle changes) then don’t—without telling you. Behavior that is apparent to the care giving team (e.g., missed tests or appointments) identifies that patient as being at additional risk, and reinforces the importance of clinician follow up, pursuit, and documentation. But unseen non-compliance (e.g., unused medications, substance abuse, unreported symptoms) exposes physicians to the risk of practicing in the dark. Subsequent care based upon an assumption of compliance with previous instructions piles risk on top of unresolved issues for both patient and provider. One option physicians might consider to reduce this type of exposure—especially for high-risk or chronic care patients—is an assessment to guide their level of vigilance in confirming treatment plan adherence.

Clinicians at the sharp end of health care need to be blunt with those patients who are inclined to sidestep their recommendations. Patients need to know 1) your advice is personal, not generic; 2) you are adamant, not ambivalent; 3) the long-term risks of non-compliance; and 4) resources available to help them comply with your treatment plan. In turn, providers need to know (and document) the patient’s perception of his or her recommendations and the patient’s ultimate preference for care.

If you still sense (or have evidence) that compliance is unlikely, stratify the underlying risk. For those patients who you worry will end up in the morgue—or in the courtroom—develop a protocol that enables you to extract the reasons for non-compliance. If your patient can tell you why he or she is reluctant to take your advice, you have a second opportunity to find a mutually agreeable alternate plan. Documentation of those discussions and, if necessary, the patient’s expressed (informed) refusal is essential. Without it, their decision not to comply becomes your risk, too.

Jock Hoffman is the Patient Safety Education Program Director for CRICO, the malpractice insurance provider for physicians and hospitals affiliated with Harvard Medical School. Follow on Twitter @cricotweet.

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  • Michelle

    Compliance.

    Are doctors still using that word?

    • MassachusettsPCP

      Hahaha.

      Good point Michelle. In one conference I distinctly recall the speakers telling us there is no such thing as “noncompliance” and to stop using it. They dispensed advice that is obvious to any rational PCP (does patient understand your advice? Any underlying fears such as news reports relatives or friends with stories of adverse outcomes due to procedures tests or drugs similar to what doc is proposing, financial barriers, transportation barriers, cultural barriers, etc?) and then reframed the preferred nom to “physician/patient dissonance”, all the time and at the end summarizing it as a failure in most cases of the doctor to properly communicate to the patient. It was implied that nearly all such patients — fearful, embarassed, or even the “empowered patients” — are rational despite exploring the aforementioned barriers and that usually it is a DOCTOR/patient breakdown in communication (notice where I put the caps). Gravy to the plaintiff’s bar or those that like to throw rotten online fruit at even those doctors who do sit down and take time to explain things, patiently exploring the patient’s beliefs and limitations, to still shift the blame to the person in this dance as having the “disproportionate power and knowledge” in the patient/physician relationship. Funny how people bemoan the supposed lack of mutual collaboration between doctors and their patients in medical decision making, but when things go wrong the paradigm on the academic and speaking tours shifts from “noncompliance” to “doctor/patient dyscommunication”.

      • ninguem

        Proper word is “adherence” these days?

    • http://paynehertz.blogspot.com Payne Hertz

      Unfortunately, the word implies that patients are under some kind of obligation to do what they’re told, rather than having the right to exercise their own judgment about what they will and will not put in their own bodies.

      I know a few people who have paid with their lives for failing to question their doctors or insist on further testing. “Noncompliance” assumes doctors are always right, even when their treatment decisions are in error or based more on protecting their self-interests than those of the patient.

      Patients get labeled noncompliant for refusing to take drugs that cause them intolerable side effects, yet doctors often fail to document the reasons for the patient’s refusal to follow instructions. or even acknowledge the reality of adverse events.

      Doctors should perhaps be a little more concerned with finding a treatment plan that works for the patient than psychopathologizing the patient as “noncompliant” and refusing to document the reasons for noncompliance for fear that it might make the patient’s refusal seem reasonable and their own refusal to try and formulate an alternate solution seem suspect.

      Attempting to negotiate with doctors who are in denial or refuse to work around adverse drug reactions or make something remotely resembling an informed diagnosis based on objective evidence tends to fall heavily on the “difficult” and “irksome” scale as well. I should think a genuine concern over liability as well as the well-being of the patient should make this common practice, which is why I am so surprised that it isn’t.

      Please provide some evidence of the number of doctors who have actually been sued because their patients failed to follow a treatment plan. Correlation is not causation.

      • Kevin

        They’re isn’t a lot of negotiating room for treatment of may chronic ailments, given that a physician can be help accountable for his/her adherence to guidelines (and in some cases, have his/her “performance” determined by said adherence).

        • ninguem

          Good point. In addition to litigation, there is the matter in insurance “performance”. Failure to follow medical guidelines and recommendations. impacts the physician even absent a bad outcome.

        • Diora

          Kevin – people can always choose to take a risk of dying earlier (maybe) instead of taking a drug that causes them side effects.

          Additionally, in these days risk factors are often labeled as chronic diseases often when the absolute risk of certain bad things happening is very small. Guidelines or no guidelines, patients have a right to decide whether a tiny reduction in risk is worth the risk of the side effects especially considering that there are doctors out there who don’t know the difference between absolute risk and relative risk.

        • http://paynehertz.blogspot.com Payne Hertz

          When it comes to comes to adverse reactions, there is often quite a bit of room to negotiate. The patient can try other drugs, other therapies or take no drugs at all. The idea that there is but one way or the highway based on guidelines is dangerous and uninformed.

          Let me give some real world examples: I had a friend whose husband died as the result of combining statins with an anti-inflammatory both of which were prescribed simultaneously by his doctor. The combination of these drugs was known to be potentially fatal. “Noncompliance” in this case would have saved his life.

          As for my friend, she later died of lung cancer. She had been complaining of chest pain for years, and her doctor kept blowing her off, telling her that the pain was the result of her age and fibromyalgia. Finally, she insisted on getting a referral to PT to deal with the pain, and the PT insisted on a chest X-ray as a precondition for admittance to the program, at which time the cancer was finally detected. By this point, it was already Stage IV.

          In both these cases, the patient failed to question the doctor, or become “difficult” or “irksome” enough to insist on further testing, and the result was fatal. They are not alone. Hundreds of thousands of Americans are killed and injured every year as the result of doing exactly what their doctors ordered, yet we don’t see a comparable number of lawsuits occurring as the results of this.

          I find it highly unlikely that a patient’s documented refusal to follow a particular treatment protocol would result in a lawsuit, as any such case would necessitate both proving negligence on the part of the doctor and that the absence of a particular treatment is what led to the injury in question, two things which are near impossible to prove.

          I doubt that “failure to take prescribed medications” has ever been listed as a cause of death by any coroner anywhere.

          This is why I’d like someone to present me with some hard evidence rather than the usual anti-malpractice PR.

  • http://www.BocaConciergeDoc.com Steven Reznick MD

    Yes doctors still use that word. Their relatives and legal guardians sue all the time.

  • Sallie Weems

    Whether we use the word compliance or adherence, it’s still a problem that pits the healthcare provider against the patient and family. The four things that “patients need to know” outlined in this blog are critical, but still reflect the old model of the physician dictating the plan of treatment to the patient. If the physician included the patient in the discussion and decision-making, perhaps the issue of “non-compliance” would be lessened.

    • Family Medicine Doctor

      No, I think you misunderstand. In general, a vast majority of the time, we doctors DO include patients in the decision making. Oh, sure, it’s alot fun, quite popular, & all the rage to say “If the physician included the patient in the discussion and decision-making, perhaps the issue of “non-compliance” would be lessened”, but all I saw in residency were doctors EVERYWHERE trying to include patients in the discussion. The problem was patients NOT participating in the discussion, despite the physicians best efforts to get the patient involved. I did learn in residency to say “non-participation” rather that “non-compliant” . It does sound better. I also like to use the word “adherence” cuz it can describe the situation well at times. But I use adherence specifically to taking medication non-participation fir the overall treatment plan.

      But overall, patients who want to participate, can. Patients who want to adhere to the plan, do. The others, well don’t do as well. Which is sad.

      • Kevin

        Rather than rely on a label (i.e. noncompliance), I usually just document that the patient has ‘elected to forgo recommended treatment,’ followed by a quick blurb explaining my efforts to address possible barriers to patient following my guidance, blah, blah. I, for one, don’t lose a lot of sleep over patient noncompliance. Like any learned advisor (attorney, accountant, etc.), I am here to diagnose and recommend the most efficacious and safest treatment to my patients. They can choose to follow, or not. They are responsible for their health. I can only try to be a trusted guide in their treatment decisions.

  • Finn

    Obviously. The more important question is, why are nearly 2% of malpractice cases being won by patients who do not follow through on their doctors’ recommendations?

    • MedexRiskManagement

      As a risk manager, I have handled a bunch of these cases over the years. Usually, if they are delayed diagnosis cases, they boil down to ‘informed refusal’ situations: the patient alleges that the doctor never explained the seriousness of the underlying condition, or why getting the necessary workup was necessary. And if they had only known that getting the workup would have made the cancer diagnosis that much earlier, thus saving their life, of course they would have followed the doctor’s advice! They lacked the necessary information to make an informed choice to refuse to follow the clinical advice. A whole bunch of states recognize this as a cause of action.

      • ninguem

        And no matter how well you explained it, how forcefully you explained it, verbally, in writing, or hula dancing, it was not enough after the fact.

        • Vox Rusticus

          Exactly. If you said, “I really think this is serious and we really need to nail down this diagnosis, because among the possible causes is cancer, and if not treated, you could have a very bad outcome, even die” and the patient still did not follow recommendations and did badly, they still could say, the doctor told them they could die, but they really didn’t think he meant that.

          I write letters to resistant patients spelling out the bloody details and consequences. I send them by documented services. It doesn’t guarantee me anything except having in black letters exactly what I said if anyone questions anything later.

          • http://warmsocks.wordpress.com/ WarmSocks

            As the one-time recipient of one of those letters, I can explain my resistance to extra testing. I saw my PCP, who said, “I’m pretty sure it’s A, but it might be B. There are some home remedies you can try, and here’s a prescription. If it’s A it should resolve in two weeks; if not, I’ll refer you to a specialist.” In two weeks it hadn’t resolved, so I made an appointment with the specialist. It was two more weeks before I could be seen, and by then the problem had nearly resolved – guess it was just on a different timetable than my doctor expected. I almost cancelled the specialist’s appointment, but didn’t. My mistake. The specialist quite emphatically said, “That’s not B. It’s A.” He then explained that it was minor, and people can live their entire lives without any treatment. That was fine. At least I knew what I was dealing with and knew it was merely annoying, not something about which to be concerned.

            On his way out the door, the doctor changed his mind and said, “We should get an MRI just to make sure it’s not B.” Sounded like CYA medicine to me. A quick, simple $30 test “just to be sure” I might go along with. Not an inconvenient, time-consuming $3000 test. There needs to be a better reason for a test; not “just to be sure” – especially when the symptoms are already resolving. At least wait a week/month or so to see if the problem continues to improve, or gets worse and needs to be addressed.

            I would have happily signed a waiver that said I understood there was a chance it was B instead of A, and still preferred to take a wait-and-see approach.

          • http://warmsocks.wordpress.com/ WarmSocks

            As the one-time recipient of one of those letters, I can explain my resistance to extra testing. I saw my PCP, who said, “I’m pretty sure it’s A, but it might be B. Home treatments are…, and here’s a prescription. If it’s A it should resolve in two weeks; if not, I’ll refer you to a specialist.” In two weeks it hadn’t resolved, so I made an appointment with the specialist. It was two more weeks before I could be seen, and by then the problem had nearly resolved – guess it was just on a different timetable than my doctor expected. I almost cancelled the specialist’s appointment, but didn’t. My mistake. The specialist quite emphatically said, “That’s not B. It’s A.” He then explained that it was minor, and people can live their entire lives without any treatment. That was fine. At least I knew what I was dealing with and knew it was merely annoying, not something about which to be concerned.

            On his way out the door, the doctor changed his mind and said, “We should get an MRI just to make sure it’s not B.” Sounded like CYA medicine to me. A quick, simple $30 test “just to be sure” I might go along with – not so with an inconvenient, time-consuming $3000 test. There needs to be a better reason for a test; not “just to be sure” – especially when the symptoms are already resolving. At least wait a week/month or so to see if the problem continues to improve, or gets worse and needs to be addressed.

            I would have happily signed a waiver that said I understood there was a chance it was B instead of A and was happy with a wait-and-see approach.

  • Hexanchus

    Probably because the physician either didn’t provide adequate information to the patient regarding the proposed treatment in terms the patient could understand, or didn’t adequately document the patient’s informed refusal. Just assuming they understand is dangerous for both the patient and provider.

    Maybe they need to ask the patient some point blank questions directly and document their answers – such as:

    Do you understand what we have discussed and agree with the treatment plan?
    Are you going to be able to adhere to the treatment plan we have agreed on?

    A written copy of the treatment plan should always be given to the patient. You might even include some of the questions and have the patient sign it – make it essentially a treatment contract.

    Just some thoughts…..

    • Family Medicine Doctor

      “Do you understand what we have discussed and agree with the treatment plan?”
      Nope. Bad way to ask the question. Many pts will just say “yes” even if they don’t understand it.

      Better way is to ask “in your own words can describe the treatment plan?”

      You also suggested:
      “Are you going to be able to adhere to the treatment plan we have agreed on?”
      Also big nope. Better to ask, “what problems or obstacles do you see getting in the way of you being able to do what decided on?”
      Makes them get into the conversation. Don’t ask questions w yes or no answers.

      “A written copy of the treatment plan should always be given to the patient. You might even include some of the questions and have the patient sign it – make it essentially a treatment contract.”
      Now, that is excellent!

      • Hexanchus

        Agree with you from the standpoint of making sure the patient really understands the proposed treatment and has the intent to adhere to it.

        I was looking at it more from a standpoint of limiting potential future liability – make it more like a formal consent process, just like you would for a surgical procedure. If you can document that the patient was provided with the risk information of not following the recommended test or treatment, and have them sign a statement acknowledging that, it goes a long way towards limiting any future liability. I think there’s a need to do both…..

      • Jeanja

        Great rephrasing of yes/no questions into participatory questions that lead to conversations!

  • Ernie G

    I fire non-compliant patients. A young woman on TNF blocker who misses/no shows for appointments/labs is almost always fired. I find this whole conversation troubling. A patient is there for advice on diagnosis and treatment- if they don’t want to do what I recommend it is their responsibility to tell me, my job to explore why, or their job to seek other’s advice. In the era of “patient autonomy” and “shared decisions” I see no reason why I need to keep non-compliant patients, and why they need to keep seeing physicians if they don’t listen to advice. I think alot of this would be adverted if patients had the opportunity to develop strong relationships with generalists who they could trust…Oops I was thinking of an era long gone, where insurances rule with their widget mentality, and Obama follows.

    • Theresa

      The era “long gone, where insurances rule…and Obama follows.” comment didn’t add to the discussion. The insurance take over of medical practice by financial means happened long before Obama. The present fiscal crisis in the world happened on another president’s watch. There is not going to be a political solution to the defective health care system because the policy makers lack the solution. Medicine itself lacks a solution to the dysfunctional healthcare system. It is a case of “physician heal thyself” but none of us really can fix the system. Medicine as a whole is noncompliant with what experts recommend for its better performance. It is not surprising that individual patients don’t follow their doctor’s recommendations either.

  • Michelle

    I wouldn’t even say that my doctor and I work together, or that I “participate” in decision making. It just works. He acts like more of an advisor like an attorney or car mechanic would. His ego is not in it. I’ve never felt like he talks down to me. We act more like friends who meet to talk out a problem. He gives me options and I consider them.

    Part of the problem with this issue is that patients do not take enough responsibility for their own health. There are a lot of good resources out there if you’d just look.

    People also wrongly assume they need a prescription or special access to all of this. Not true. Some of it is directly for sale or available to consumers.

  • Michelle

    p.s. My doctor has never once said “treatment plan” to me. He gives me prescriptions, etc. Gosh, “treatment plan” would be way too formal.

    I can’t stress enough how much success I have had with doctors who aren’t so formal about things. This isn’t pediatrics. We can have a conversation like normal functioning adults.

  • http://www.tedsmedicalthreads.com Ted

    Jock, your closing statements are so important for the practitioner to perform. “Documentation of those discussions and, if necessary, the patient’s expressed (informed) refusal is essential.”

  • http://www.healthecommunications.wordpress.com Steve Wilkins

    The leading cause of patient malpractice claims as I understand the data (see citations below) is poor physician communication with patients, followed by poor physician-patient interaction and poor care coordination.

    Coincidentally, poor physician-patient communication is also a leading cause of intentional patient non-adherence/non-compliance, e.g., . physician/patient dissonance as MassachusettsPCP puts it.

    Conversely, effective communication enhances patient satisfaction and health outcomes and mitigates malpractice risk and intentional non-adherence.

    Steve Wilkins
    http://www.healthecommunications.wordpress.com

    Roter, D. L.. The Patient-Physician Relationship and Itʼs Implications for Malpractice Litigation. Health Care Law & Policy. 2006:304-314.

    Rodriguez HP, et al. Relation of patientsʼ experiences with individual physicians to malpractice risk. International Journal for Quality in Health Care. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18055504.

  • Deborah

    The government’s move to publicly reported “report cards” are quite easily misunderstood/misinterpreted by the lay public and are influenced by factors out of providers’ control (statistically adjusted notwithstanding). Lack of compliance plays a huge role in the escalating amounts of Medicare/Medicaid reimbursement – patients cling to the entitlement issue, providers identify functional illiteracy and willful noncompliance as commonplace among the beneficiaries. Whether the patient is “non-compliant, non-adherent” or there is “dissonance” between health care provider and patient results in the same thing: unhappy parties with less than desired outcomes. Until some other methodology emerges to accurately assess outcomes without unduly penalizing providers for actions beyond their control i.e. patient compliance, providers will need to get creative in expressing what the patient needs to do as well as taking measures to protect themselves against frivolous lawsuits caused by the patient themselves who are either not completely following orders or purposely with-holding pertinent information that impacts clinical decisions.
    I’m in home health – even after thoroughly explaining what home care can/cannot do, what expectations are held for the patient/caregiver involvement, and getting their verbal buy-in, patients/caregivers still behave as though they have no responsibility in the process: medications are not procured or taken, MD visits not kept, diabetic pts eating whatever they want & then acting surprised at the A1C result, home exercises not done, etc. We use patient compliance contracts that spell out specific behaviors/action expectations on the part of the patient and/or caregiver, these are signed by the patient/caregiver and healthcare provider. It includes the consequences of not following through with the expected behaviors by outlining potential clinical complications as well as the consequence of discharge from service. Both parties have a copy and it is referred to frequently to remind patients of their expected participation behaviors. Lack of appropriate follow through from the patient/caregiver – after a limited number of opportunities to get on board the program – results in the patient being discharged. Providers need to identify in their own practice areas those patients that are high risk or higher risk for adverse outcomes (i.e. “frequent flyer” pts, known noncompliant pts, complicated wound care, etc) and perhaps refuse them outright or refer elsewhere.

  • http://www.healthecommunications.wordpress.com Steve Wilkins

    Deborah,

    Do those compliance contracts state that physicians agree to spend an adequate amount of time (greater than the average 57 seconds out of a 12-15 minute visit) telling the patient why they need the medication, how and when to take it, contraindications, when and how to stop taking the medications? Then assess whether the patient understood and has any questions?

    I think contracts are great if evenhanded….

  • Steven Markowitz

    I represent plaintiffs in matters involving medical (alleged) malpractice. I recently interviewed a young woman who had lost a full-term baby. She was an uncontrolled diabetic. She remembered the doctor told her that “noncompliance with blood sugar testing could cause fetal demise.” Yet she insisted that no one had ever told her that her high blood sugar “could kill my baby” I have no doubt that the Dr. warned her about the possibility of Fetal demise, or that she was sincere in her belief that no one had indicated the diabetes posed a danger to the unborn child.

  • aly

    As a pt diagnosed with gastroparesis, i wasn’t given many options to treat my condition, 2 meds available in US (one with harsh side effects, the second one aparently loses its effect after a while), 1 med only available in Canada that hasn’t been aproved in US by the FDA yet. So i tried Reglan (sp?) and after a couple weeks wen’t back to my gastro Dr because symptoms weren’t improving and the drowsiness was making to go class difficult. She changed the dosis and told me to continue taking it for 3 months “to start”. I was told about the harsh side effects and the fact that there haven’t make many studies yet on long term side effects (WHY do they make it available to the public if they don’t know for sure what the long side effects are like??). So after another month, symptoms didn’t improve, i kept worrying about the side effects known– such as involuntary movement of muscles–, and drowsiness continued around exams, so i stop taking Reglan, went back to my doctor, and asked for an alternative to that medication since i felt there were too many negative side effects and no improvements. Well my Dr made a scene, telling me i HAD to continue taking Reglan to see any improvement. Common sense told me that there were too many risks in following what my Dr was telling me and i didn’t want to wait for side effects to worsen to then switch to a different med or different treament. So i stop going to my gastroenterologist and started seeing a nutritionist to work on a specific diet and meal schedule to reduce my symptoms without any harsh medications.

    the following month i saw a comercial saying that Reglan had caused permanent damage in some patients, and they were no longer using it.

    How can we trust our physicians if they recommend us medications and treatments that they don’t know much about? My Dr seemed more concerned to give me a refill for my medication than listening to my concerns and symptoms.

    Btw I’m a gastro patient but I’m also pre-med student, i believe that there is a lot that needs to be changed to ensure the safety of the patients.I personally don’t think its fair to sue a physician who is doing all he/she can to help you improve your quality of life or to relieve your symptoms (it is like punishing someone for trying to do good) but clearly there are many physicians that have forgotten that patients are also people not just their way to make money.

    • JustADoc

      Studies on long-term side effects take *Who’d a thunk it* a long time to do.

      There are only 2 drugs for gastroparesis. One is Propulsid which is very rarely used(I’ve never actually seen a patient on it) because of some rare but serious cardiac adverse effects. The other is Reglan which has tardive dyskinesia as a rare but significant adverse effect. It is also sedating as you noted. I would wager large money that your gastroenterlogist knew about these adverse effects long before the lawyers did. The TV was also wrong. Reglan is still used.

      Diet(frequent small meals) can help but the truth is gastroparesis is a tough medical problem.

      You are a pre-med. Come back in 10 years when you’re thru your training and you’ll find you know the answers to most of the questions you asked.

  • Penny

    I myself am a “difficult” patient. Surely my doctor would love it if I were to leave but I don’t want to even if I often don’t listen because he’s the most capable physician around. I think doctors simply don’t understand why patients buck. There’s no time to explain either because the issue is so complex.

    For example, if doctors recommend a cancer operation and the patient refuses for a couple of years, the doctor often hasn’t got a clue of the thoughts that may be in that patient’s mind — things like,
    “I believe it has originated in a more painful part of my body, and since they can’t treat the painful part, why treat a part that doesn’t hurt at all so that it too will hurt for years?
    Or, “I really don’t know how I will care for myself after such an operation.”
    or, “I’m terribly traumatized by another patient’s experience and can’t bear the thought of going through that right now,”
    or, “this is such shell shock that my mind can’t work well so I want to try to recover it first”;
    or “I’ve already had one operation and don’t want to be cut repeatedly because that would be a horrid quality of life;”
    or, “my immune system has been so low for some time that I need to boost it up first so I won’t succumb the effects of the operation and/or treatment;”
    or, “if I change my diet now and drop all sugar and eat well, I’m I may be able to beat this on my own;”
    or, “I truly can’t afford treatment and can’t afford to stop working especially;
    or,”I desperately need to research options even if it takes a year or two, because I’m too scared to undergo such a serious operation without knowing much about it;”
    or, “cutting seems so brutal and old-world like — a thing of the past. I want to try alternative treatments first;”
    or, “life is pretty rough and we all have to go sometime so it doesn’t matter when people die because after death the years lived before are irrelevant anyway”;
    or, “I’m so tired that a permanent sleep sounds like such a beautiful rest now anyway;”
    or “I feel like a cow suddenly thrown on a conveying belt by a system that expects me to simply comply to butchery without question and I feel the system especially does this to women, more for profit than anything else;”
    or, “the prescribed medicine might harm me because, like many others I have been prescribed, this drug too is already lined up for an upcoming class-action lawsuit”;
    or, “most everyone is going to die from something painful anyway, so if it isn’t this, it will be something else”; ”
    or, “I’m getting older anyway, the world isn’t improving, and dying from this might be better than dying from Alzheimer’s;”
    or, “life is so costly I can’t really afford to live anyway;
    or, I have so much pain in another part of my body that death from cancer might be less painful than dying from the pain caused by the other thing;”
    or, “if the cancer has originated from another place which I believe, then simply removing a piece of the body elsewhere won’t do a single bit of good anyway;
    or “the preop procedures are so brutal already, let alone the operation; that this will probably just make cancer spread faster than it might have if left alone;”
    or “please, can’t I just die the natural way?
    Cutting hurts for years afterward;
    operations weaken the heart;
    chemo weakens the immune system and makes people sick, only to likely succumb in a few years anyway;
    I don’t want loss of hair and especially curly hair from chemo;
    and I have a super sensitivity to pain.”.

    It’s these types of thoughts that makes patients difficult, especially when they feel most vulnerable. The feeling of extra vulnerability at a dangerous time makes them crave even more strength and empowerment than usual.

    Doctors often detest such patients, never fully understanding them and likely always fearing and/or loathing them due to the fact that they appear to distrust their judgement or see them as uninformed. What they don’t understand is that these patients need their doctors badly.

    Women especially often want the advice of men even if they don’t listen. Don’t ask me why. Maybe it’s because I’m what many men might call “a typical woman.”

    Why can’t patients simply sign forms stating that they wish to empower themselves on this type of decision, agreeing that they won’t seek any legal action against their physicians? Very few patients want to make doctors feel bad and a form ensuring them of legal protection would be most welcomed by both patients and doctors.

    • Theresa

      Even if a patient did sign a form saying that he/she would not seek legal acton against their physician, such a form would be difficult to enforce. It can always be argued that the patient felt coerced into signing it. Those disclaimers of responsibility don’t work for roller skate rinks or other places of public amusement. People sue despite such signed waivers. People are much less likely to sue if they have some sort of bond with the doctor. That has to be accomplished by establishing some mutual respect and trust.

    • http://pulse.yahoo.com/_CQESWBUCW43R3XGOQIXZWGBWOY Salena

      Penny- you clearly have had a rough time with cancer and the option of surgery. I think you are wrong though in generalizing that MDs and other healthcare staff don’t understand the issues you’ve brought up. As an RN of almost 20 years I get it, I understand, and 98% of all the MDs I’ve ever worked with get it also. But what you are essentially saying in your letter above is ‘My doc is the most competent around and I won’t leave him/her BUT I also won’t follow his/her recommendations because I need to feel empowered.’ Be empowered- do a little research. Make a choice. Don’t want surgery? Ok then. Don’t have it. But no need to continue cycling on about the decision. If you choose to change your mind later and it still isn’t medically too late you’ll have that option.

      A frightened patient- which you sound like- is very different than a non-compliant patient. You are making a decision due to fear of pain and side effects from treatment options. The truly non-compliant patient ‘just’ decides to stop taking their meds or goes swimming in a duck infested lake three days after surgery. I’ve seen it. Patient had the meds, just decided she felt better. The operative patient just decided to go swimming because it was a hot day and oh by the way doc you told me not to soak in a bath tub didn’t say anything about swimming in a lake and now my infection is your fault. That is non compliance.

      The point here- if you continue to feel as though you have to defend your decisions with your doc, then it is time to either have a heart to heart with your doctor or find a new one.

  • Steve Wilkins

    Interesting article entitled: Medical errors as common in doctor’s offices as hospital settings  http://tiny.cc/lrmqm

  • Steve Wilkins

    Interesting article entitled: Medical errors as common in doctor’s offices as hospital settings  http://tiny.cc/lrmqm

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