It's always a challenge to discern why non-compliance occurs. One would think, you made the appointment, you showed up wanting/needing a doctors' help, you took advice, maybe had the test..then nada! I never see some of these patients again. Maybe they moved away. Maybe they got scared by the treatment, or by the fact they actually need to change a behavior in order to overcome illness. Maybe you, as the treating physician, just rubbed them the wrong way.
Communication gaps and expectation gaps are the two factors contributing to noncompliance. I see this popping up over and over. The patient didn't understand, or didn't WANT to understand, the illness or the treatment. Patients seek to apply their mental framework to their condition. "Doc, I know you say the biopsy showed it's a skin cancer, but I know I got bitten by a bug and I want to know how to avoid it". They want to put things into their schema. They understand bugs...skin cancer is too abstract and scary. It's a struggle to try to get people to see that their own wishes are irrelevant in the aging process or the illness process. Dealing with an elderly population they bring their set-in-stone ways, in addition to their other concomitant medical issues which may make treatments more difficult or prolonged recoveries.
My most recent struggle is a patient I have seen a few times over a 2 year period. He's an octogenarian snowbird, which means he's physically present in my town for 6 months out of the year. He's loaded with skin cancers of the face, being of Scottish ancestry and a lover of golf in subtropical climes. He has numerous scars from skin cancer surgeries over decades of treatment. When he is in town, his life is consumed by golf games, bridge games, going out to lunch, board meetings with his condo association, and Caribbean cruises. It must be a nice life. But these lesions pop up on his nose and face and bleed incessantly and he comes to me for help. He is pleasant, nods his head, I prescribe treatments, I perform biopsies, he leaves my office in agreement, but then he cancels the follow up surgical appointment. The first time it happened I gave him the benefit of the doubt, called him, asked him to reschedule. He comes back 4 months later, the skin cancer site has healed over and I can't find it, but lo and behold, there's a new one bleeding on his cheek. Out of side out of mind for this patient. If it bleeds it gets his attention. He is seemingly delusional and will not, despite my efforts, see that he has recurrent skin cancers. We've had conversations at every visit about his skin cancer propensity and condition and what to do to get it under control. But then he leaves for Ohio for 6 months; he's gone and it's beyond my efforts. The most recent visit was a repeat of last years' pattern of behavior and diagnosis, so I advised the patient I cannot be his doctor under the parameters he has unfairly placed on me. Your skin cancer cannot be resolved in 1 visit. It can't be addressed when your priority is your golf game. You have to stay put for a suture removal. You have to pick one place to get care and stick to it. I will no longer be the one. I will no longer waste my time and block other patients' accessibility because we're holding an appointment for you.
I feel sorry that somehow I cannot pierce his delusion and I cannot treat him within the part-time residency /paradigm he has chosen in my sunshine state. Medicine and the human body is not a part time endeavor. It is full time and takes up your full attention and care. I wish there was a screening set of questions I could administer to gauge how motivated a patient is before they're scheduled for an appointment. This is unrealistic but I too can dream.
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