Taking Charge Of The Non-Adherent Patient With Diabetes

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Thomas Belken, DPM, and Neal Mozen, DPM, FACFAS, CWS

   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.

In Conclusion

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.

Additional References
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.

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