Every physician, regardless of specialty, faces the non-adherent patient. When the patient has diabetes, things become even more complicated. Even though we as podiatrists are not actively managing the patient’s diabetes, his or her glycemic control directly impacts the effectiveness of our treatments.
The HbA1c does not lie but proper management of the patient’s blood sugar is only part of the equation. Subtle or sometimes not so subtle signs can tell the physician if the patient is changing the dressing as instructed or remaining non-weightbearing. The majority of patients with diabetes develop the disease later in life, long after they have become “set in their ways.” Humans are creatures of habit. As physicians, it is our responsibility not only to educate patients but also to form a relationship with them that will overcome their disregard for their health.
Obviously, this is easier said than done. A patient may think to him or herself, “Why do I need to stay off my foot? It does not hurt and I feel perfectly healthy.” Since the patient has the lost “the gift of pain,” this patient does not realize the detriment that his actions are having.1 In regard to the patient’s knowledge of the disease process and adherence, the physician must assume both ignorance and non-adherence. The doctor must build a foundation of understanding and help patients be aware of the consequences of their actions.
How do we as physicians overcome these obstacles that compromise our surgical and wound care outcomes? As with many other facets of life, the answer may lie in establishing relationships and communication. Identifying the problem is the first step in fixing it. Is it something as simple as a language barrier or one’s income/social standing? Alternately, is it something much more complex such as cultural or religious barrier? “The greater the discord between the culture of the practitioner and of the patient, the greater the opportunity for miscommunication and misunderstanding.”2
Other variables that may contribute to patient adherence are: psychological issues; neurological diseases, such as dementia or Alzheimer’s; psychosocial stress; and secondary gains, such as when a patient uses the disease or condition to get off work or to get sympathy. Additionally, the doctor, because of his or her education, intellect or demeanor, may intimidate patients. Subsequently, patients sit in silent bewilderment instead of expressing their confusion, questions or concerns.
Establishing a relationship with the patient will go a long way to getting the patient to open up and trust you and your advice. Understanding the stresses in the patient’s life and being able to devise a feasible means of managing those stressors can be the difference between adherence and non-adherence, success and failure. As I like to tell patients, “An ounce of prevention is a pound of cure.”
So where do we begin? Something as simple as getting the patient’s family involved can make a significant difference. The family can provide another person to reinforce the treatment protocol that you have set forth. They can help address some of the external stresses on the patient. Taking it a step further may involve getting the patient’s clergy involved to help both physically and spiritually. As doctors and surgeons, we may prescribe a pill, dispense a shoe or fix a broken bone. However, we may often neglect to address or even consider the mental and emotional anguish that patients deal with while they are being treated month after month for ulcers or other problems.
Understanding the dynamic of the patient’s household may also shed light on the non-adherence. Is the patient the caregiver for others? Does the patient have to do all of the grocery shopping and errands him- or herself? We instruct patients to limit their activities but if they have no one else to rely on, what can they do? Not everyone has the luxury of having family that is in close proximity or is willing to help. Fortunately, there are programs that can help patients with day-to-day chores and activities.
Have patients bring in some pictures of their house and neighborhood. This will not only let the physician evaluate the living conditions and the physical demands on the patient (number of steps, hills, sidewalk conditions, etc.), but it also helps further the relationship with the patient. Ask questions since many people like to talk about themselves.
In regard to applying these principles, we encountered a patient in his late 50s with diabetes, who had sustained a calcaneal fracture. The fracture occurred a couple of years prior to the patient presenting to our practice. It appeared to be a Rowe type II fracture. A previous doctor fixated the fracture without incident. The patient is on dialysis and has peripheral neuropathy.
By the time we met the patient, he was essentially walking on his talus with his calcaneus displaced laterally. After discussing expectations, treament options and possible complications, we determined a plan for the surgery but this was only a portion of the overall picture. Lengthy discussions ensued with the patient about his living situation, medical needs and the absolute necessity to remain non-weightbearing.
Armed with as much information as we could gather, we decided to have the patient go to a rehabilitation facility for the month or so of the postoperative peroid. This may not have been exactly what the patient wanted but we were able to explain the importance of remaining non-weightbearing, maintaining proper nutritonal status, smoking cessation, glycemic control and monitoring of his mental health. All of these were things that the facility offered.
We performed a talo-tibial-calcaneal arthrodesis with an intramedullary rod and external fixator. The postoperative course continued as planned without incident.
Despite your best efforts, wounds dehisce and ulcers get infected. When the dust settles, you end up just being fortunate that the patient was able to keep the leg.
Another patient that comes to mind is the exact opposite of the previous patient example. A patient with a venous stasis ulcer, she always wanted a quick fix to the problem whether it was skin grafts, hyperbaric oxygen and superficial venous ablation. However, the patient would constantly miss appointments, remove her dressings and place whatever she felt like on the ulcer.
We were frustrated. The patient only seemed to come in when it was time for pain medication or she needed a form filled out for disability. We pondered whether she really wanted to get better. Eventually, the patient received a second opinion and we were relieved to be rid of this incredibly non-adherent patient.
Reflecting on it now, we knew things about the patient but did not really get to know her. We never met her family nor did we really know all of the stresses in her life. Maybe if we had gone the extra mile and developed a more significant relationship with the patient, she would have had a different outcome.
A final example involves a patient we just recently met and whom we are currently deciding how best to manage. The patient is a non-adherent patient with diabetes who is in the early stage of a midfoot Charcot. Even in her own admission, she has noticed changes in the way her foot looked between our first and second visits. Despite what her own eyes have observed, she was more concerned with going in the pool over the Fourth of July weekend than the long-term consequences of her actions.
We asked her, “Would you rather swim this summer or hold off on swimming this summer to be able to swim in the future?” Did the message get through to her? We will not know until the follow-up appointment. At that time, there was minimal dislocation and the foot remained in relatively good alignment. If no further deformation occurs, the plan is to place an external fixator to prevent collapse and further dislocation.
There are different schools of thought on the best way to manage an acute Charcot joint. Do you let the foot “cool down” and perform an arthrodesis, or are you proactive and place an external fixator to prevent collapse? We contend that applying the external fixator to an active Charcot foot, particularly on a patient whom you know will not stay off her foot, is more “conservative” than convincing yourself that the patient will remain non-weightbearing. The external fixator may in fact obviate the need for further reconstructive surgery.
One can enhance the doctor-patient relationship by taking the following actions.
• Reach out to family members, friends, clergy, etc.
• Evaluate and respond to unique home situations and psychosocial factors.
• Facilitate the delivery of ancillary services and products like offloading devices, wound care products, home nursing, etc.
Do all of this in an effort to reduce the incidence of non-adherence. We have even started doing more home visits on high-risk patients with diabetes and complex diabetic surgery patients in an effort to enhance the relationship, and evaluate a home situation that might be limiting adherence.
Furthermore, anticipate the non-adherence that you are unable to overcome and design the treatment plan accordingly. “Hoping” the patient will follow your advice, instead of coming up with a treatment plan based on what most likely will occur, is not good medical practice.
When all is said and done, you as the physician have to own the outcome. Regardless of what the patient may do postoperatively or in between visits, it is not the patient’s “fault.” You can only look in the mirror to point the finger. The success of your two-hour reconstruction or months of wound care treatments may often hinge on your ability to cultivate a strong and trusting personal relationship with your patient.
In terms of the commitment we need to make to our patients each and every day, no one said it better than Coach John Wooden: “Perform at your best when your best is required. Your best is required each day.”
Dr. Belken is in private practice at Foot Healthcare Associates in Michigan.
Dr. Mozen is in private practice at Foot Healthcare Associates in Michigan. He is a Diplomate of the American Board of Podiatric Surgery.
1. Armstrong DG. Lavery LA. Harkless LB. Treatment-based classification system for assessment and care of diabetic feet. J Am Podiatr Med Assoc. 1996; 86(7):311-6.
2. Kleinsinger F. Understanding noncompliant behavior: definitions and causes. Permanente Journal. 2003; 7(4):18-21.
3. Yacopetti N. Re-thinking the approach to health care delivery: reviewing patient compliance. Nurs Monograph. January 1999.
4. Schwarzer R, Fuchs R. Self-efficacy and health behaviors. In Conner M, Norman P (eds.): Predicting health behavior: research and practice with social cognition models. Open University Press, Buckingham, UK, 1996, pp. 163-196.
5. Bachman MO, Eachus J, et al. Socio-economic inequalities in diabetes complications, control, attitudes and health service use: a cross-sectional study. Diabet Med. 2003; 20(11):921-9.
6. Breuer U. Diabetic patient’s adherence with orthopedic footwear after healing of neuropathic foot ulcers. Diabet Metab. 1994; 20(4):415-9.
For further reading, see “How To Facilitate Adherence In High-Risk Patients” in the March 2010 issue of Podiatry Today or “Secrets To Facilitating Patient Adherence” in the March 2007 issue.