We are talking compliance

What do you do of your patient does not follow your advice? Patient compliance is important in podiatry or any field of medicine. It contributes toward helping patients. Compliance implies a patient follows advice sufficiently to be helpful. In other words if a patient is not compliant then it is unlikely your management will succeed. Attitudes relate to our personal beliefs about actions that we actually take during practising our skills. Inevitably other people’s behaviour may or may not agree with our own interpretation. Legal opinion attempts to remove the black and white to satisfy society. Ethical issues are not always black and white. In a recent Facebook post and reader response the patient in question felt their treatment expectations had not been met. The problem was one of patient compliance.

Likes and comments

Thirty-six responses and three likes were entered on this Facebook post by the end of the first working day. The responses seemed fluid and it was good to see few thumbs up likes. Thumbs up mean little in terms of feedback and they convey no certainty of interpretation. Certainly the stream is worthy of debate. But debate about what, and, is there an angle? Of course, there must be an angle or how can we reflect? This case is about solving non-compliance. The aim of this article is to look at attitudes from correspondent podiatrists and how they would tackle the problem identified below as THE CASE. 

Failure of a patient to follow advice

The patient turned up at a podiatrist’s practice. The podiatrist noticed that the patient ‘had more H.Ds than before’. Having managed these by standard enucleation one assumes the patient decided not to book another appointment but preferred to make an appointment when she thought she needed to be seen next. Ten days later the same patient contacted the podiatrist indicating that one of the H.D lesions was still there and painful.

The request for opinion

Posting on Facebook the podiatrist asked, “Do you see the patient for free or reduced time and fee appt? I’m busy and have no spare appointments so would have to be at the end of my  day?”

The principles described in the reader’s feedback covered 4 main options.

  1. To charge or not to charge
  2. Provide a ‘free’ but given a cooling off period 5 – 14 days
  3. Use this as an opportunity to review practice policy
  4. Restructure appointments where gaps cause unrealistic expectations and adjust the fee

It would be easy to copy all the comments out but in reality reflection is about looking at the big picture and separating the ‘wheat from the chaff’.

Option (1)

Ethically it might be a case of providing a return treatment free. This will keep the patient happy and she will return and spend the same amount again. Refusing treatment or charging more may lead to her deciding to post a remark on social media or influence others.

What is your role as a podiatrist?

Answer: Fairness in providing a quality service following a standard that meets the demands of registration and professional adequacy. But ask yourself two questions. Is your practice about fixing up or promoting better health? Here is your dilemma. The boundaries are often blurred on the one hand and yet clear on the other.

Moving to option (4)

Take a view that because the patient just treats each visit as a fix. She had little understanding that her aim should be to seek a solution to sustain improvement. Charge her more as you are in a no-win situation. Of all the responses this one (below) was pithy and to the point and yet emanated from experience.

“The Old Private Practitioner I worked for when I first graduated. Always began the conversation with the patient, emphasising how they had neglected their feet and advising how important regular treatment was to maintain healthy feet. He would always make the patient take responsibility. He would always charge for his time if it was down to their neglect.” Anon. FB comment

My old friend, an anaesthetist, took a view that there were some tasks that needed resolving and it came with the job. This meant preparing not to make a charge.

Managing patient compliance in a podiatry practice 

The facts

We enter a case of the patient being responsible for their own outcome and failures. Of course an expert witness could look at the fact that one H.D was ineffectively managed and de facto this was negligence; then collect a nice fat fee! The bottom line is that there are times when waving a fee is correct and at other times unwise. Business wise we do not want to lose income or patients. The reality is that some patients will never make compliant patients. If your practice is a ‘fix it practice’ you may not want to lose a fee or a patient. If you are a diagnostic – treatment plan practice, then you certainly do not want a patient who might fail to benefit from your skills. As a business you also have the right to choose.

Now let’s move to options 2 and 3.

One cannot implement a policy without it being transparent and in place prior to any commercial arrangement. As the whole ethos is based on ‘money’ the point made is partly commercial. The role and duty of a podiatrist might also fit option 3 to extend to a review of what the purpose of the practice is. The correspondent podiatrist who posed the question has not determined this part of the discussion and no doubt will have to decide which type of function they fall into. ‘Fix it up’ or ‘diagnostic and plan orientated’. Clearly the patient views the podiatry practice as ‘fix it up’. One response that came back was a little wordy but broadly uses the term diagnosis, expert and change the clients mindset. Each is a useful focal point.

The patient compliance solution in practice

Taking the professional viewpoint. The podiatrist wants to deliver a diagnostic service and provide patient care plans. The narrative suggests a quirk of patient care has crept in. The person is a patient who wants to distort that plan but is also seen as part of practice income.

  1. Inform the patient that they can have a review for ½ an appointment time.
  2. Do not charge for the appointment if they agree to a quick review and assessment. Your treatment may be deferred if matters take longer. You will not charge for a review but you will for any further appointment.
  3. Hand the patient a single sheet that outlines the policy for managing podiatric problems. Highlight concerns about the cause and expected management associated with H.D problems. This assures that communication is clear.
  4. Keep a copy of all written materials in the records including times of telephone calls.
  5. Develop a policy manual for the practice to isolate each aspect of care to make sure your modus operandi is clear. This takes you beyond just one aspect of planned foot care. The policy should be numbered and have a contents page. Each policy must be dated at the bottom and have a review date. Ensure the practice name is shown on each page.
  6. Each time a patient comes to see you for a plan of action have them sign it or provide a copy so they know a protocol exists.
  7. Anyone not following the protocol will need to be counselled and will have to seek care elsewhere. It is your right to make a judgement based on THEIR BEST interests. Your practice is built on management and skills developed to reach a particular outcome. Use evidence based material for H.D management.
  8. I would not charge the patient even if they fail later to return because it is better to fix YOUR problem as you cannot fix the patient.
What have you achieved?

In each of the solutions most of the advice colleagues have provided fit to some extent but not completely. It is important not to see the patient as a product of blame. It is YOUR system and YOU must account for ‘blips’ in practice with a constructive plan. In short it is time to improve the business process. Resolve to change your method of practice and patients will not only follow you but allow you to achieve your own personal belief about how to practise your skill. The word will get around that your brand is clear, concise and trustworthy. 

FaceBook Series has been developed to expand on clinical discussion trails that appear to deviate or remain unclear by way of conclusion. Articles provide feedback. ConsultingFootPain concentrates on those clinical issues that are unclear or have greater interest to the podiatry world. All correspondence is anonymous and there is no intention to be critical over actions and attitudes. These articles are intended purely for reflection.

Thanks you for reading ‘Patient compliance in podiatry’ by David R Tollafield 

Published by Busypencilcase Reflective Communications Est. 2015

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