Healthcare Blog of Dr. Remo Aguilar

A Perspective on Non-Compliant Patients and the Contractual Doctor-Patient Relationship

in Education/Medicine/Orthopedics/Politics by

I have long been an advocate of a no refusal, admit all patients policy for physicians . Any physician is bound by his Hippocratic oath and the law to treat any patient (within the bounds of his skill and expertise) whatever the circumstances of that patient will be. The physician also has the social responsibility of reporting any patient (to proper authorities)  that  may pose danger to any other person or to the society for which the patient belongs.

Lately however,  I’ve noticed a few non-compliant patients pushing limits of our patience and  resources. My case in point.

A thirty something male patient brought to the ER (allegedly from another hospital) for a 2 day old gun shot wound. The GSW entry point is at the postero-medial portion of his right leg, with no exit wound noted. He has a comminuted fracture on the middle part his tibia. On examination, the bullet  slug is palpable on the  postero-lateral side of his knee. I noted a wide area of contused skin from the leg, extending to the lateral posterior of his right thigh. Patient is febrile and have an elevated BP. We immediately started IV antibiotics and  scheduled the patient for an emergency debridement and external fixation of the fracture.  Surgery went well and while the skin contusion did grew to a alarming size, the patient eventually recovered and was on his recovery 5 days  after surgery.  The patient ran away from the hospital without proper discharge procedure and without paying his bills. As we learned later, all patient’s data and circumstances were dubious and the patient is nowhere to be found.  My worst fear is the danger of this patient contracting osteomyletis if ever his fracture isn’t followed up carefully.

If he ever goes back to any hospital, and if you are the physician, what would you do?

The dilemma is much more difficult in government hospitals. In the Philippines, government hospitals are funded by people’s taxes. Funding that are at less than optimal and is finite. Government physicians sometimes sees patients, that for some reason,are rarely compliant. Most often these patient’s’ non compliance results to complications and prolonged treatment. Prolonged treatment siphons physician and hospital resources that could have been allocated to other patients. This is where the decision making abilities of a physician enters and is very crucial. It can actually make or break his career because litigation and malpractice suits isn’t easy to come by.

My take on this? I’d still treat the patient according to what his medical problem requires and to what treatment the patients consents to. But I’m going to document it very carefully and protect myself with detailed consents and waivers. I will also get the opinions of  appropriate legal or social services department. Sometimes, its more with communicating with the patient and convincing them of their most beneficial treatment option. This is not easy. But aren’t we surgeons and doctors now if our job is easy?

I may sound like crap but again, the simple fact remains the same. We are the physicians, the very persons privileged to touch and care for sick people. When we treat patients, we (and the hospital) enter a ‘contract” with that patient. Contract that to an extent, requires both the doctor and the patient to work for the wellness of the patient, for so long as that treatment is not detrimental to others. It all boils down to both parties being aware of their responsibilities in this contract. If one violates this contract, that ceases the existence of the contract and therefore, ceases the doctor- patient relationship.

If you are a physician in this situation, what would you do? If, you are a patient, what do you think should the physician do?

Dr. Remo-tito Aguilar co-founded #HealthXPh. A board certified orthopedic surgeon, he is previously Chief of Clinics at St. Louis Hospital in Tacurong City and a consultant in Orthopedics at the Southern Philippines Medical Center in Davao City. Dr. Aguilar is a healthcare social media evangelist and writes his medical musings at The Cast & Curious (www.remomd.com).

7 Comments

  1. I remember back in senior clerkship, when I was about to go on duty for my pediatrics rotation, my groupmates told me with a smile that one of my patients absconded the night before. The mother wasn't able to afford the ward admission at a private hospital so she decided to sneak out with the child, leaving a lot of stuff behind in the ward, including the little girl's doll. I think they were able to look for the mother though as she was distantly related to one of the hospital staff.

  2. I'd do the same thing, treat the guy. I suppose it is not my place to chastise him and beat him up verbally. He, after all, didn't know any better.Still, i would pretty much do what you did too, doc, make sure the paperwork is in order. I'm scared to death of losing my license, this early. paranoid even. 🙂

  3. I dont know Remo… all I can say is I'm glad I'm not in your situation! 🙂 My take is, nobody will fault you for being a conscientious surgeon, it's negligence that will probably not stand well in court.

    I was just wondering, did you need to report the incident to the police because it was a GSW victim?

  4. @JA, sad really that much of our health care decisions nowadays are limited by funds and logistics alone..and @ Sonia, a "waiver" is all there is that separates us from destroying a career we rooted for years!

  5. @Jill, yup part of the hospital policy is to report and log every gun/bomb/knife related incidents to the police. But here, at the rate those incidents are happening and the lack of police manpower, I think logging is usually the only thing they can do…pretty sad.

  6. I experienced otherwise.. I already had two surgeries and two doctors still left with a non functional stiff elbow. (around 35-90 arc) The first one was ORIF and the second was arthroscopy. Both are members of POA and was told that these doctors are skilled and one of the best in their (expensive) institution. Unfortunately, they don’t want to perform any treatment anymore and advised to accept the limitation. I’ve been searching over the internet on possible treatments and found that even the most complex injuries are fixed to at least a functional arc. (pubmeds from other countries) I had a radial head fracture fixed with two screws and yet I’m stuck with this complication. I’m still on the hunt for a doctor that can help me with this disability. Sorry and thank you.

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