Patient f/u frustration

[malapata]

Hi all, I am a new NP working in the primary care setting and have a patient who was recently transferred to me from another clinic. The patient has multiple comorbidities including but not limited to hypertension and psychiatric illness. The first time I saw the patient I referred them to the ER because of an acute issue. The second time I saw the patient I ended up refilling some prescriptions (based on medical charts I received from the previous clinic) and told the patient they would need to come back in for labs and also to show me all the medication they were taking at home. I would have done labs that day but the phlebotomist was out and I didn't have time to do it myself. After that appointment, I tried contacting the patient nearly every week to get them into a f/u appointment, get some baseline labwork done, and get a handle on the prescriptions. The pt showed up unannounced once and then no-showed on an appointment for blood work after that. Most recently (after I called the patient and prompted them to make an appointment with me), they showed up 90 minutes late to a scheduled appointment. I was busy with another patient and told them they would have to reschedule and that I could not do anymore Rx refills until we got some baseline labs and I was able to take a look at all the medications the patient was taking at home. I had to turn the patient away and I felt bad but I didn't want to continue the cycle of no-shows and non-compliance. I did not feel safe simply handing out meds without at least having a grasp on labs and the meds being taken at home. Was it wrong of me?

[Alicia777, MSN, NP]

I don't work in primary care but it sounds reasonable that you wanted that information before continuing to refill scripts and you gave them several opportunities to provide this..

[synaptic]

don't worry about it just chart thoroughly. its their problem. don't get emotionally involved with patients. That is weaksaucemedicine

[PG2018]

1. Why would you even entertain drawing blood yourself?

2. Unannounced or unscheduled patients don't get seen.

3. Charge for a no show visit and require payment up front when they do show up.

4. Don't sweat people that aren't interested in following your instructions or paying you. Document and move on with life.

5. You're too emotionally invested.

[NutmeggeRN, BSN]

I don't think you are over involved...just being thorough.

You gave them options, they chose not to exercise those options.

Document accordingly.

[Psychcns]

You have to have rules that allow you to protect your time . Provide treatment within this time. You have to teach them the rules. Be thorough but detach emotionally-- it is their treatment not yours. Be efficient. Help them to care about their treatment. Document your recommendations and pt response. Do the best you can and move on.

[rnsrgr8t]

Sounds like you did fine. As a new NP, you have to learn your professional boundaries of what you feel comfortable doing and what you don't. I would never write scripts for someone without doing what you did. Sometimes, the only way you can get a patient to come in and see you is if they need you to write scripts for their meds (and if they are noncompliant with their meds, that is a whole other animal).

One of the MD's I work with taught me a great lesson when I was new. She had been practicing a long time (20 + years). She told me, "All I can do is offer my expert opinion. I give them all the information I can on the reason why I am recommending something and what the risks are for not following my advice. After that, it is up to them to follow my advice or not. If they chose not to follow my advice, it is on them, not me".

If you can honestly look at an interaction with a pt and know you presented your recommendations thoroughly and they still ignore you, do not take it personally. There are going to be some that do this no matter what you say. As you get some experience, you are going to know as you are talking to them that they are going to completely ignore everything you say. You just do the best you can and document, document document so you are covered.

It is not wrong to not see a patient that shows up 90 minutes late without calling and without a reasonable excuse, especially if you are busy. When I do have patients that are late (I will typically will see them if I can unless they are REALLY late) I do ask them, nicely, to really make an effort to show up on time so I have enough time to spend with them. This is actually received very well and typically all my patients, for the most part, show up on time. Sometimes they are having transportation issues (that our social worker can help them with) that they just do not say anything about. They are relieved when I ask them about it.

When you are knew, you worry that patients are noncompliant because of something YOU did. Most of the time it isn't.

[malapata]

Thank you to everyone for your responses. I appreciate the advice and will definitely take it with me into practice (especially the recommendations to separate emotionally -that's a hard one). I feel better about the choice I made.

I am very thankful for this forum and for those who share their wisdom!!

[blackribbon]

I am not an NP but the one thing that stood out on your post is the psych diagnoses. Did you have anyone ask why the patient hadn't come or came late? Often psych diagnoses get in the way of responding properly to normal expectations. Other times, they simply don't have anyone to bring them in when they are supposed to come in and they have burned so many bridges from irradiate behavior in their past. You still need to set boundaries, but I'd at least ask what the problem is. Not having their RXs filled is often a strong motivator to find a way to follow the rules though.

After my husband died, I had bout of depression and was constantly amazed by how my psych's office expected me to react in a normal healthy way when I actually would have been perfectly happy to just died in my room. All the expected symptoms of grief and depression were what I found myself being scolded for. For example, I really did think that this was the day for my appointment and until the office staff treated me like I was an idiot, I was feeling quite proud that I had showered, dressed, and made it to the doctors office on time without having a breakdown...

[DowntheRiver]

I'm not a NP either (just a RN), but I think you responded appropriately. I frequently don't have people who don't follow up in a timely manner. You can't make patients follow up, you can only educate them on their illnesses, treatment, and consequences if they don't follow up and then chart like crazy about it. I like to consider myself a nurse that goes above and beyond for my patients but there's only so much you can do.

[malapata]

It's true that making an appointment when you are suffering with mental illness can be a huge undertaking. I didn't ask the patient what the reason for being late was on that particular day.

[cayenne06, MSN, CNM]

One of the MD's I work with taught me a great lesson when I was new. She had been practicing a long time (20 + years). She told me, "All I can do is offer my expert opinion. I give them all the information I can on the reason why I am recommending something and what the risks are for not following my advice. After that, it is up to them to follow my advice or not. If they chose not to follow my advice, it is on them, not me".

.

Quoted for truthiness.

I am still a new CNM, just a year in, and I struggled with follow up for a long time, becoming waaay too invested in ensuring my patients followed up with my recommendations. My follow up is soooo much less stressful now that I've stopped feeling personally responsible when patients don't follow up. I make sure my recommendations are clear and make sure they know to call the office if they are having trouble getting the recommended follow up. The amount of follow up I do obviously depends on the situation. Anything nonurgent gets one reminder letter (notification of abnormal results will get three contact attempts, and urgent-ish follow ups like suspicious breast masses get three as well- 2 of which are always in writing). I document my attempts and put a tickler in the chart so if the patient returns to the clinic, we can be sure to address it then.

There is no reason for you to be calling a patient to set up a follow up appointment. To be nice, you could ask the receptionist or MA to make a courtesy call to set up the appointment. But you told the patient they need to be seen; it is up to them to make the appointment. If they do not, I will send one reminder letter.

While I will sometimes draw blood/get vitals/room a patient etc, I am doing it because my assistants are swamped and I happen to have the time. Are you really expected to draw your own labs if your phlebotomist is out? In the future, can you just give the patient a req to take to the lab instead of having them come back in? You could have also done that when they showed up 90 minutes late for the appt. Do you have adequate support staff working with you? Can they not draw blood and handle non-urgent follow up?

My organization also has clear follow up guidelines in our protocols, and i'd imagine most places have the same.

The only other thing I want to add is that sometimes patients just don't care, and sometimes they have barriers that prevent them from getting the care they need- mental health issues, lack of transportation/money, anxiety/fear about results, etc etc. When I have a patient in my office who is chronically not following up with care, I will ask them about it directly and nonjudgmentally. It's important to not take it personally or treat them like a disobedient child (not saying you do that, of course). Sometimes we can figure out what is keeping the patient from getting care. One example is I found out that my patient had no reliable childcare for her 3 young children, and was always missing appointments when her childcare fell through. The easy fix was welcoming her to bring her kids with her (this is obviously not always possible; can't bring your toddler with you for your MRI). Other patients are helped by getting them signed up for medicaid, or getting authorization for medical transportation, or whatever.