Dealing With "Bounce Back" Patients

Anthony Rudine -- It is quite disconcerting to see patients whom I assisted treating last week, or two days ago, or last month, showing up in the emergency center when I am on call. On one hand, the patient is obviously sick or they would not be there. On the other hand, it is frustrating to treat someone, "heal" them, send them home on medications, and have them return with the same problem three days later. When you ask them when the "new" problem started, they reply commonly -- "when I stopped taking the medications you gave me."

What am I to do? On one hand, we have the obligation to treat patients who are sick and in need of help. On the other hand, we have indeed treated them correctly, and likely due to their noncompliance, we are forced to admit them and treat them again, basically changing nothing from the last four admissions.

This could suggest two things. One, are they noncompliant because they simply do not see the reason for following their doctor's orders, or because they have some other issues going on that prevent them from obtaining their medications? Two, what could we do differently to prevent future admissions for the same treated problem?

The first issue is rather easy. If they are noncompliant because they cannot afford their medications, which is common, we can prescribe cheaper medications, call the social workers, give them samples, and set follow-up appointments in our clinic, which is very cheap. However, if they are noncompliant because they do not want to take their medications, or do not understand the reasons, then where does the fault lie? In the treating team for not providing a formulaic expression for the patient to fully grasp, or with the patient, who for whatever reason, will never take their medications?

For the second issue, what can we do to prevent this? Well, for starters, we can not admit the patient, treat them in the ER with the same medications, and send them home. But that doesn’t always sound so peachy when it comes down to it. Or we can transfer them to a different team, but the different teams already have their share of problem patients, and certainly do not need any of ours to deal with. Or finally, we can admit them again, like we usually do, treat them again, and discharge them again with the same message.

But clearly, this is not working. There are multiple patients like these, whom we call "bounce backs," and this is not a new issue.

I just don’t know how to solve it. I am still new at this game.