Physicians Can't Help Patients Who Can't Help Themselves

“So why are you here?”

I have found that this question leads to better patient compliance than any lecture I could give.

My typical visit consists of me taking a history, doing a physical exam, explaining the patient’s diagnosis and prognosis to them, and detailing the plan with them. The majority of the time, that works. The patient says OK, they fill their prescription, they get their tests done, and they come back. Granted, most of them don’t do so well with the lifestyle modification part of the plan, but most of them have good intentions.

On the other hand, I have some patients who really make me wonder why they even bother coming. They stop their meds, they go back on old ones (sometimes expired ones), they change their dose, they don’t get their tests done; all that in addition to the usual lack of lifestyle modification. I will usually conduct a typical visit anyway: history, physical, plan. I explain the whys and wherefores, I discuss the potential consequences of non-adherence to the plan. And I do take the time to explain to patients why they need to take certain drugs, what side effects to look for, why they need to get tests done, etc.

But at some point in this doctor-patient relationship, when the typical modus operandus fails, I stop entering things on the computer, fold my hands in my lap, lean back in my chair, and say, “So why are you here?” Sometimes it’s followed by, “How do you want me to help you?” or “What would you like me to do for you?” or “What would you like to happen now?”

I have found that making it their decision, based on their desire to get better (or not) puts the onus on them, thereby making them feel like owners of the plan. Case in point, I have a patient who at his last two appointments, came to me on different regimens than I had prescribed for him. He stopped one because he didn’t think it was helping so he went back on the old med he was on (you know, the one that was stopped the last time because it wasn’t helping), and he was started on something by an in-law who is a doctor. I told him he should follow up with his in-law but he doesn’t want to.

Then after that visit, he never started the new prescription I gave him, and he stopped another med.

 “So why are you here?”

“Because my diabetes is out of control.”

“What do you want?”

“I want you to tell me how to fix it.”

 “I did that last time, and you didn’t follow my advice. So what do you want to do now?”

“I want to get better.”

“How?”

This went around for a few minutes, but I think he finally understood that if he really wants to do better, to be better, that he needs to adhere to the plan, the plan that we agreed on together.

Now mind you, asking “What do you want me do for you now?” is not always followed by choirs singing Hallelujah. I had one patient reply, “All I want you to do is write prescriptions.” He did not want me to ask about his blood sugars (he wasn’t checking), he didn’t want to talk about his diet or his smoking, and he did not want me to change his doses. This, by the way, was the same ray of sunshine from an earlier post that called all angry because I allegedly did not call in his prescription and he had waited until he was completely out before he chewed me out about it.

But by and large, I do find that patient finally “get it” when I throw up my hands and admit I don’t know how else to help them without them helping themselves.