Managing Patients Who Object To The Standard Of Care

Perhaps it is an active runner who is resistant to having surgery due to a potentially long post-op recovery and scaled back training. Another case may involve an older patient who is very anxious about a medication you have recommended due to polypharmacy concerns and being able to keep track of his or her current medications. In another situation, you may find yourself as the referee between a coach and a young athlete’s parents debating what the best treatment option is for getting the athlete back on the field more quickly.

Podiatric medicine is intriguing because it involves the treatment of patients from newborns to senior citizens. Under most circumstances, adults consent to their own procedures and are responsible for their own care. During the course of treatment, conflicts may occur and are often due to a breakdown in communication. Effective communication is vital in healthy doctor–patient relationships. In addition, establishing trust is also important for optimal outcomes. Mastering both of these skills may be difficult as communication can be highly variable from patient to patient, and takes both patience and practice.  

All doctors take the Hippocratic Oath, which is essentially a pledge to “do the right thing” in regard to treating all patients, and not cause harm. One of the most daunting duties as a medical professional is coping with patient opposition to the standard of care, especially in the case of urgent, life- or limb-threatening conditions. Numerous factors play a role in patient mistrust of a physician’s medical advice and management. The patient may have had personal experiences or know of others with negative outcomes from a certain intervention. Some patients are naturally more conscious and suspicious than others. The patient may not prefer or trust the treating physician. We can overcome many of these obstacles with the right skills and approach.  

It is typically best to allot yourself extra time to manage anxious patients. Make sure you and the patient are physically comfortable. Sitting down usually helps. You may need another healthcare professional to be present during the conversations. In the case of inpatients, if they have developed a positive rapport with their nurse, therapist or another provider, it may be beneficial to have one of those people available during treatment plan conversations. Always rely on your medical team. They know the patient well and usually spend the majority of time with them during the course of a day.

It is essential to be aware of, respectful and sensitive to any language or cultural barriers. Explaining yourself in multiple different ways helps and actively getting patients involved in the conversation by asking them questions and letting them intervene with concerns is important. Reinforce the fact to patients that the main objectives are their health, well being and safety.

Undergoing surgery or an invasive procedure is a major decision. With many decisions, especially difficult ones that can affect overall health, productivity and lifestyle, there is a cycle. This cycle may pertain to those in need of urgent to emergent care and is similar to the Kübler-Ross five stages of grief. The stages are denial, anger, bargaining, depression and acceptance. Patients who need urgent intervention in order to prevent sequela, such as possible amputation, must go through these stages in expedited fashion. As the surgeon of record, being cognizant of these stages, knowing where the patient is in the grief stages and aiding the patient through the process is beneficial to all parties involved.  

Podiatric medical school teaches future podiatric physicians the facts and fundamentals of practice, but schools cannot teach experience. Physicians can only acquire experience through more and more exposure to patients. Additionally, a solid understanding of human behavior and personality is beneficial in practice given the variety of people and personality types one will see every day in practice.

Real world practice scenarios often include negotiating and mediating. Perhaps schools should teach classes in these principles and emphasize them more significantly during school and/or residency curriculums. Ultimately, however, staying above the fray and being true to one’s convictions and the best evidence can guide us to achieving optimal outcomes for our patients.

Dr. Ryans is in private practice in St. Louis.

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