The Chronic Non-Compliant

You know him. I know him. In fact, everyone in the hospital knows this man. From the volunteer at the front desk to the lead hospitalist, we've all come into contact with this man. Let's call him Mike but really, he's one of many. Mike is your chronically non-compliant patient with CHF/diabetes/HTN or some other type of chronic disease. Mike comes into the hospital every 30 days due to non-compliance with recommendations for medication, diet, and/or exercise. He comes into the hospital every month for a "tune-up" and leaves a mark on whichever floor he's housed. By that, I mean that Mike doesn't seem to have a nice bone in his body. He complains about the care he receives to anyone in his room and dismisses the dietitian, therapists, and other medical staff attempting to help him control his condition. In short, Mike is the patient you dread to have and want to see discharged as quickly as possible.

Mike isn't a real person, per say, but I'm sure that short description brings dozens of patients to mind. With advances in technology, we have diuretics to help remove fluid for our CHF patients, insulin drips to lower hyperglycemia, and a range of other tools and procedures that can make living with chronic diseases possible. But instead of seeing these tools as back-up plans, Mike and others like him, use them as their primary medical care. They give up on controlling their condition at home and instead come into the hospital when their condition becomes too difficult to manage.

Dietitians play a major role in most chronic conditions. If a patient is admitted with CHF, we complete diet education on limiting fluid and sodium. If a patient is admitted with uncontrolled diabetes, we complete diabetic diet education with that patient. Hospitals today spend millions of dollars on resources to help their patients understand and manage their diseases. So then, why do the Mikes of the world keep coming into our hospital?

I believe one of the primary reasons is that Mike gets tired. And, that's understandable. Always having to read food labels and watch your salt intake gets old. Mike gets tired of counting carbs and having to turn down dessert after every meal. So, he lets things get out of hand but, thanks to his local hospital, gets a few days in a hospital and then gets to go on living his life. Sure, it's a minor inconvenience, but it's easier to let the professionals manage his problems. I don't mean this to be condescending, but Mike knows that we have a responsibility to heal people and he knowingly or unknowingly has come to rely on the system. I think we might all fall into the same habit, to be honest. I don't have any chronic diseases, but while I try to follow a healthful diet, I often fail. I'm not sure I would be much more successful than the Mikes of the world.

Additionally, Mike gets tired of the constant stream of education and lectures coming his way. This hospital stay isn't his first rodeo but each time he's admitted, he has to go through multiple rounds of education. It's really a waste of everyone's time and he doesn't mind saying so. I've seen Mike. He comes on my floor once and month and I receive a consult to complete diet education with him. I visit him and he shuts down immediately except for complaints about the foodservice. We drag through the education materials and then I leave with more frustration each time. The patient in this scenario may change, but the experience is always the same.

So then, how can we respond to Mike every time he comes into the hospital? The short answer is that I don't know. I could give you a textbook answer from a counseling strategies book but, even for a generic patient, each Mike has his or her own reasons for non-compliance. One approach I've used is less of a lecturing approach and more of a listening one. Engaging with Mike on his personal life and the challenges he faces there doesn't work all the time, but building an open relationship with him is a potential approach. Showing some empathy also can work wonders. Let's face it- most of us aren't good at self-control.

I don't have the perfect answer for the Mikes in your hospital, but I'm taking a different approach and seeing if that makes a difference. I'm hoping that kindness works better than condescension. I don't think I'll ever see the end of Mike but I'm hoping to see a lot less of him. And maybe, when I do see him, we'll have better interactions and be able to develop a plan that keeps him out of our hospital.