A failure to comply arises. A patient calls repeatedly and demandingly. He/she wants copies of all medical notes and records and then edits them for the smallest detail, calling attention to what he/she feels are inconsistencies and inadequacies.
Management to avoid failure approaches include:
a. Ask the patient to maintain copies of all medical records and to meticulously note all errors, inaccuracies and perceived inadequacies in the form of a journal.
b. Ask the patient to “maintain a perfectly organized” copy of this journal in their home and to provide the office with monthly copies.
c. Maintain a second patient folder that remains part of the patient chart (as per HIPPA), and that folder contains solely copies of the journal that the patient is maintaining.
d. Have the patient also maintain a chronological outline of all symptoms, signs and concerns and to keep this in annotated form and to, again, provide you with a copy of this secondary journal.
e. Also inform the patient that he/she should create a list of ten questions, in writing, per week that is submitted along with their monthly compilation but with which they call you weekly at a precise time for an exact ten minute presentation of these questions to you.
f. Remind the patient that this must be carefully and accurately created and maintained and be able to be presented in a ten minute telephone interchange.
This places the organization within the scope of the patient’s obsessive thoughts and compulsive behaviors and permits him/her to discharge anxiety in an effective and productive fashion. It also creates that second chart that clearly illustrates the obsessive-compulsive drive of the patient. Finally, it restricts the infringement upon a practice to a specific time, time span and schedule.
Remember that personality (“character”) disorders are developmental defects. You will not change them, and most often the patient feels that they are without fault. In their thinking, it is the world that is defective, inadequate and in need of modification.
This perception of the flawless self and the imperfections of others will not be altered. To manage such patients, you must function within the system that they have built. Challenging them is destined for failure.
The compulsive patient is arguably among the easiest to modify but only after you understand the ways in which their needs-for-control manifest themselves.