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Who had the problem—my "problem" patient or me?

This young physician was stunned when she finally found out why a difficult patient was so noncompliant.

By Landi F. Halloran, MD
Internal Medicine and Pediatrics Resident/Flint, MI

I hated her.

I swore I would never feel that way about one of my patients, but there was no other way to describe my contempt for Ella Mae Simpson (not her real name). When my pager went off, my blood began to boil. I knew it would be her. She called me on this line more than any other patient. My fear would be borne out when I dialed the number and heard, "Hello, Doctor? It’s Ella Mae Simpson, do you remember me?"

She said this every time she called, even if it was only five minutes since her last call. The staff at my clinic smirked when they handed me messages from her. Even my fellow physicians knew her name and said, "What does she want this time?"

Ella Mae called me at the office, the hospital, and even at my home, until I finally got an unlisted number. I set limits. I made demands. But still, she came late or not at all for appointments. She never went to the specialists I referred her to. She had a list of prescription drugs and home medical devices a mile long–all of which she had before we ever met. One word sums up that list: "noncompliant."

Ella Mae first came to my practice after a hospital discharge. She apparently liked the practice so much that she wanted to be seen almost every week. She was clearly my problem patient. So what was I to do with her?

Finally, one afternoon, I’d had it. Ella Mae came 20 minutes late, dressed in her finest Sunday clothes. My medical assistant told me there were no letters from the last few specialists I’d referred her to, and no lab results either. In the past, we’d sent Ella Mae several letters making it clear that she was in jeopardy of being discharged from the practice if she didn’t keep her appointments with me or with the consultants I sent her to.

So now, I said to myself, "This is absolutely the last shot." I resolved to spend our clinic time together giving her my best effort without allowing my disdain for her to push her out the door. I flipped through the chart and noticed that I was dealing with Ella Mae’s immediate problems each visit, but I hadn’t even begun to care for her health. The chart showed no Pap exam, no mammogram, no documented diabetic foot exam, no documented lipid profiles, no recent glycosylated hemoglobin, and no success in lowering her blood pressure.

Ella Mae had failed me so many times. But I was failing her, too.

That day, we reviewed her problem list: hypertension, congestive heart failure, diabetes, angina, obesity, interstitial lung disease, hyperlipidemia, eczema, obstructive sleep apnea–it went on. We discussed my attempt to remedy these conditions with referrals to pulmonology and cardiology that she didn’t keep. We sorted through lab test requests that never produced any lab results. One by one, we listed her medications that weren’t helping because she wasn’t taking them. There I sat, frustrated.

Finally I said, "Ms. Simpson, I don’t think I’m helping you. Is there someone at home who can remind you of your medicines and appointments?" She replied, "I got no one to help me. A girl from the church tells me what day to go to the doctor. I give the bus driver my papers and he takes me to the hospital. But then when I get there, the lady at the desk don’t know where I go next."

Gradually, it dawned on me: Ella Mae couldn’t read. After she gave her referral slip to the bus driver, she didn’t know what to do once she got to the information desk at the hospital. My bitterness toward my "noncompliant" patient had blinded me to her needs.

We tried a very simple step. The next time I referred Ella Mae to a specialist, the medical assistant made six copies of the referral form and gave them to her. Afterward, we made six copies of absolutely everything we sent to her home.

Astonishingly, Ella Mae never missed another appointment, lab draw, or referral. She gave a copy of her referral form to anyone who could help point her in the direction of the specialist’s office, and, in that way, she was able to keep her appointments.

I realized Ella Mae had made this breakthrough when I saw her recently for a clinic visit. At first, seeing her name on my schedule raised my blood pressure somewhat. But then I looked at the chart to review the last clinic note and saw that it had been five months since I last saw her, and the purpose of this visit was for routine health maintenance. I was stunned.

Something as simple as making extra copies of my patient’s plan of care was all it took for her to get the help she needed so she could become the kind of patient both she and I wanted her to be.

My "problem" patient taught me a valuable lesson about who really had the problem.

Landi Halloran. Who had the problem--my "problem" patient or me?.

Medical Economics

2001;8.