Non-Compliance in DPC

I made this Empire Strikes Back meme today when I was struck by the statement of a patient, who insisted that my request that he cut down on carbohydrates was “impossible.”  Completely reminded me of the immature Luke Skywalker whining to Yoda.

It often occurs to me that in DPC, we are not only physicians in the medical industry(or our free-market, parallel economy version of it), we’re also, to some extent, in the service industry. People pay us to take care of them, and that’s what we do. Consider the waitress at most restaurants who, when introducing herself, says “Hi, I’m Ambreckyghnn*, and I’ll be taking care of you tonight.” Notice the “Taking care of you” there. In a manner of speaking, we’re also in the service industry. However, in the service industry, the customer is always right (although any Waffle House brawl video will instantly demonstrate that they’re obviously not). But the “customer is always right” mentality doesn’t and shouldn’t fly with us and when it’s expected, it makes our lives more difficult. The prudent DPC doctor is not a narcotic dealer for hire, won’t be told when to dispense/prescribe antibiotics for a cold, and so on.

This causes an inevitable clash from time to time with entitled patients who expect us to behave in such a way.  I made another meme about this years ago for Doctors Forbush and Harader for their fantastic “The Dark Side of DPC” Lecture:

The way I deal with this is to prevent it. I set up realistic expectations immediately, and tell patients “The only kind of medical service/advice I sell is the kind you need, not necessarily the kind you want.”  Sometimes the two are not the same, and when they’re not, you won’t be happy.”  I may give an example or two, and most respond well to this.

However, non-compliance is a little different. This is not the patient demanding much of you other than you accept their bad decisions. Here, I choose to let my inner Libertarian shine. You want to make bad decisions?  Go for it. I make my fair share of them too, and I’m not better than you. Bad decision-making isn’t just part of the human experience, it’s probably the genesis of 80% or more of what we do; indeed I suspect we’d be out of business without bad decision making.

A colleague of ours recently asked his patient to start increasing activity by shooting for 5,000 steps a day. His patient replied: “I’m not training for a marathon.” You just can’t make this stuff up.

When my patient says it’s “impossible” for them to cut carbs or take a walk, I just say “That’s fine with me, do what you want.”  But I also make sure they are acutely aware of the consequences of these decisions, what they should expect from that decision, roughly when they should expect it, and that the responsibility of fixing those consequences does not fall on my shoulders and may be impossible anyway. “I can’t unsmoke all those cigarettes for you” is one statement I’m fond of making, usually followed by some version of: “so don’t go blaming me for putting you on the wrong antibiotics or some crap like that when you can’t breathe in a few years”. It sounds weird and mean when typed, but rest assured I’ve found a way to say all of this lovingly, supportively, and non-judgmentally. My patients know I want the best for them, even if they don’t want to take the steps that will result in their best. Patients seem to like my direct approach, and one of two outcomes usually happens, both of which are acceptable to me:  1) They change (yay)  2) They don’t change, but also don’t blame me or bother me to try to fix the stuff they broke (yay).

Thinking about it, this approach to non-compliance is one place where my practice style hasn’t changed much since I was on the inside. I suppose now I have more time to talk about barriers to behavior change and so on, and conceivably have a better chance at helping them to change, but if they refuse, there’s not much special about DPC other than seeing them regularly and reminding them about how much better their life (or future life) will be with some changes.

I have seen some DPC docs really lament this kind of non-compliance, and even threaten to fire such patients. I get that it sucks to lead a horse to water and watch it refuse to drink, and slowly die of completely unnecessary dehydration. But if the horse paid you to lead them to water, you’ve done your job and earned your money justly. Once in residency, I was particularly frustrated by a horribly unhealthy diabetic deteriorating rapidly before my eyes, despite all the fantastic advice I was giving him that he ignored. An attending wisely said, to reduce my completely irrational guilt: “Vance, if you care more about patients than they care about themselves, you’ll just be banging your head on the wall.”  Such good advice.  So no, I don’t dismiss such patients. I stick with them through thick and thicker (see what I did there?) and respect their autonomy, always making my recommendations known. Often I’m rewarded with a surprise behavior change that makes it all worthwhile.

*  Ambreckyghnn can be replaced with Averee,Teegan, Keegynn, Kartyrr, Quayae, Navie, Madysen, Reminyss, Nyasia, Delainee, Emmarie, Fina, Jorryn or a hundred other late-generation names invented by uncreative parents who feel that it’s of extreme importance that their children be “unique” right out of the womb, rather than actually do something at some point in their lives to stand out. This, despite the fact that the poor child will have to spell out his or her idiotic name infinite times for strangers until the end of time, probably to carve onto participation trophies. (Sadly, Ambreckyghnn is the only name on this list that I made up.)