Resident Non-adherence: A Case Study
Eric J. Warm
Department of Internal Medicine, University of Cincinnati Academic Health Center, Cincinnati, OH, USA.
J Gen Intern Med 25(Suppl 4):634–5
© Society of General Internal Medicine 2010
t the end of our ambulatory group-practice experience
called the long-block
, I meet the residents to review their
year. I usually know what to expect, but sometimes, surprises
“How did it go this year? Did you learn anything?” I asked a
“Well,” he said without pausing, “something happened in
clinic this morning. A guy came in and started complaining
about back pain and fatigue. He kept going on and on. Then a
little voice inside my head said, ‘he’s going to ask for disability
—he’s going to pull out the forms.’ And I was like...wait for it...
wait for it... and then, after a million complaints, he pulled out
the papers! I was so right.”
He smiled as if he had discovered an essential truth.
I was horrified. Of all the stories he could have related, of all
the lessons he had learned, he chose this one. He seemed to
have missed the point of the entire year. During the long-block
we train in self-management techniques and motivational
interviewing. We favor the term non-adherence over non-
compliance. We imagine ourselves in another’s shoes and even
go so far as to inject ourselves with saline and check our finger
stick blood sugars four times a day just to see what it is like (no
one can ever do it correctly). We expend a good deal of energy
And yet...it doesn’t always work. At the end of the year, when I
take stock of the residents, most of them have bought into our
philosophy, some are indifferent, and a few are radically opposed
to it. This resident was one of the few. Residents like this cause me
to have the exact same emotional response I get from patients who
‘don’tgetit.’ It’s a funny little echo. I want something for them
more than they want it themselves.
I used to try rhetoric with patients like this. I asked them to
switch roles with me and pretend they were the doctor, and I
had the smoker’s cough or the high hemoglobin A
“Pretend I’m your patient,” I told them, “and pretend I’m
deaf. You see me walking down the middle of the street with a
big truck barreling down behind me unable to stop. What do
Every patient said they would figure out a way to let me
know the truck was coming and get me out of the way.
“That’s exactly how I feel about you!” I would say. “The
cigarettes and diabetes are about to run you over. I’m telling
you to get out of the way!”
As a young physician I thought this was a brilliant way to
help people gain insight. Except, it rarely worked. People have
to believe that a truck is coming. Many don’t. It’s easy to be
discouraged by people who appear to be making the wrong
choice. If I’ve gained any wisdom over the years it’s to get past
the what (the bad decision) and get to the why. No reasonable
patient would choose to go blind, get a foot ulcer, and go on
dialysis. And no reasonable resident would choose to let a
disability claim define a person, or an entire year’s worth of
I fell back on my training.
“Why did you choose to share that particular encounter?” I
asked the resident.
“These patients can do it,” he said. “They can work. They can
take their meds. They just don’t want to. I’m more optimistic for
them than they are for themselves.” Then he looked at me,
primary care doctor to the underserved. “I don’t know how you
do it all day,” he said. “I’m an optimist. These people let you
down. It makes me unhappy.”
I laughed unexpectedly. I didn’t of think of myself as a
“Look,” I said, “a few years ago I was on the verge of burnout.
I redefined my job description, and it saved me. I believe in the
compliance/adherence rubric we’ve been teaching you. Com-
pliance connotes a kind of moral failing—
as if the patients
could do what we ask them, they just choose not to. I believe
many patients can’t do what we ask given the set of
circumstances life has handed them. My job is to understand
these circumstances and help patients overcome them so they
can take better care of themselves.”
He didn’t think that was his job. After this, our discussion
shifted to society as a whole, the current divide in American
politics, and then to a locus of control argument.
an internal locus of control believe that their own behavior is
guided by personal decisions and efforts. People with an
external locus control believe that their behavior is guided by
fate, luck, or other external circumstances. Was I hard-wired to
be an internal, thinking that my actions could affect those of
my patients, and was he hard-wired to be an external, thinking
that his patient’s actions were essentially independent of his?
Can these attributes be taught and learned?
In the end, of course, we did not agree.
Interestingly, a good majority of the residents who ‘don’t get
it’ every year, go into critical care. This resident was no
exception. Maybe some people are just not able to thrive in the
ambulatory setting. In the ICU he will be in control. Running a
ventilator requires very little shared decision making or
motivational interviewing. Still, I worry about all the family
meetings and end-of-life care decisions that will require a sense
of the other. I wonder how many ethics consults he will call that
will be less ethical dilemma and more failure to communicate.