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clinical casebook - Non-compliant patient says you are uncaring

Mrs Smith didn't turn up for her appointment, arrives later and insists on being seen because she is breathless.

You see from her records that she smokes and is being treated for raised blood pressure, but has not been collecting her prescriptions. Her blood pressure, not surprisingly, is high and you advise her to restart her medication, stop smoking and lose weight.

She bursts into tears, says she had trouble getting out of work, gets panic attacks and is fed up with doctors going on at her about smoking. She insists her blood pressure is only up because she is stressed, and she doesn't want pills because they upset her. What she does want is some of those diazepam tablets her last doctor used to give her.

When you refuse, she accuses you of being uncaring and negligent.

Dr Melanie Wynne-Jones advises.

Would it have been better to have asked Mrs Smith to make another appointment?

Wasted appointments lead to pressure on the system which makes life more difficult for doctors, receptionists and other patients. Some would feel it is unfair to reward selfish behaviour; others would take the view that Mrs Smith will have to be seen eventually, and it may be easier (or avoid a complaint) to see her now.

You may feel irritated at her late appearance and inclined to go light on the empathy, or to do only the absolute minimum. But if you do agree to see her (and it's difficult to refuse to see someone who is claiming to be breathless), it's vital to put negative and angry thoughts deliberately to one side, as they could cloud your judgment or antagonise Mrs Smith, turning the consultation into a confrontation.

If a patient seems to be misusing the service, it is usually safest to address the medical problem first, and attempt to modify their health-seeking behaviour afterwards.

Given her lifestyle and lack of compliance surely you have a duty to 'go on at her'?

As her doctor it would be negligent not to point out the dangers of smoking, obesity and high blood pressure, but getting this right can be tricky. Doctors sometimes appear either to blame patients, to condone unhealthy lifestyles or non-compliance or to share the patients' feelings of helplessness; none of these are effective ways of helping them to change. An awareness of your own prejudices is important ­ patients are often quick to spot these.

You may also be aware of pressures to achieve clinical targets for the patients in your care ­ pressures that under the new contract will include financial gain.

Why shouldn't just telling Mrs Smith the risks she is taking make her realise the dangers?

Simply reiterating the risks may not have much effect if what you say doesn't square with her beliefs or willingness to give up unhealthy habits; you may even spark hostility.

Mrs Smith may be a fatalist who thinks that her life is pre-ordained, an optimist who thinks it will never happen to her, or in denial, so frightened by the potentially awful consequences that it's easier to pretend they don't exist.

She probably knows someone who dropped dead at 40 despite their healthy lifestyle, someone else who smoked and drank into their 90s, and someone whose life was made unbearable by antihypertensive medication.

If you are going to make a difference, you will need to understand 'where she is coming from', acknowledge the obstacles she faces, and pitch your discussion at the correct educational level.

You will also need to convince her

that reducing her personal risk is both beneficial and possible.

Whose agenda is more important?

Mrs Smith wants immediate help with her distress, but prescribing regular benzodiazepines is not in her best interests, and something you will probably not be happy to consider. You are entitled to stick to your principles; she will feel equally entitled to stick to hers.

You might avoid confrontation by:

 · Actively listening to her concerns

 · Summarising them (to show you have understood)

 · Signalling that you respect her autonomy ­ and that you expect the same courtesy

 · Negotiating what you both can realistically expect to achieve from this consultation

 · Exploring wider implications and 'what if' scenarios

 · Suggesting options, including taking a first step, and then reviewing the position

 · Giving her time to think things over before coming to see you again

 · Offering a short-term anxiolytic if indicated.

What do you need to achieve today?

This is not an isolated consultation; some things will not yet be clear, and not everything needs to be done today.

Your two most important tasks are to ensure that Mrs Smith is not at immediate risk (from too high a blood pressure or a serious cause for her breathlessness) and to try to establish a working rapport for the future. However, you may not be able to achieve this ­ and she may even refuse to consult you again.

Talk this one over with your trainer or a colleague ­ dysfunctional consultations are often the most enlightening.

Key points

 · Put negative thoughts to one


 · Point out the dangers of smoking, obesity and high blood pressure

 · Try to establish a rapport

 · Explain that reducing her personal risk would be beneficial

 · Offer a short-term anxiolytic if indicated

 · Stick to your principles

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