“The Snarled Stumper” – Noncompliant Patients

The Case

The “snarled stumper” is a case of a logger who incurred a relatively mild knee injury at work. He underwent a simple arthroscopy. After the operation, he experienced much more severe pain than before. Every intervention since that point has been ineffective.  Within eight months, his quality of life has been completely destroyed.

I would like to make a couple of comments with regards to the “snarled stumper.” I think this is an archetype example of the kind of case that frustrates us on every level. Unfortunately, it’s one I see every day. It’s also probably this kind of case that brings most of us to the roundtable.

My Notes from the Roundtable

Dr. ____, I am interested in your Health and Behavior assessment tool. My observation is that many injured worker’s are already under a lot of work and personal stress. Often an injury and dealing with workers comp system puts them over the edge. The treatment paradigm should be the same for all–early intervention, giving patients the tools to fend for themselves, creating as many system solutions as possible, and treating them with a lot of respect.

Dr. ____, thanks for your support.  Your commitment to tackling these patients’ situations head on is admirable and I am a witness to your tenacity.  It is incredibly rewarding to see your patients “wake up” and move forward.  It is unpredictable who that person might be.

My Note about Noncompliant Patients

Dr. ____, I agree with your concept of “disengagement” and “stuck.”  The term I have used for a while is “entrenched.”  What I have learned the hard way is that the common denominator is anger.  The more I have tried to convince a given entrenched patient to not become angry the worse it gets.  I am in the middle of a disaster right now that has dramatically reinforced my perception.  I had submitted a paper to the roundtable a few months ago, “Ability and Motivation.”  If the patient is angry their motivation is destruction, including self-destruction.  Their ability to deal with the situation is limited, as they cannot see it clearly.  I have learned that I have to let go but still keep the door open.


Dr. Schubiner is a pain specialist in Detroit who was one of the keynote speakers at a course I held last year, “A Course on Compassion–Empathy in the Face of Chronic Pain.”  He clearly defined the Mind Body Syndrome (MBS) for us and has really changed our community’s paradigm on how we approach pain patients. Inadvertently, my approach also treats mind body syndrome with similar tools but in a different format. I don’t think the exact approach matters as much as starting with the correct diagnosis. Currently, medicine has taken a neurological disorder, Mind Body Syndrome, and treated it like a structural problem.  The real tragedy is that MBS is predictably treatable with full engagement from the patient.


My personal goal is that when the medical system is dealing with an entrenched patient, we should quit doing procedures on them–All procedures, not just spine surgery.  I am developing a proposal to present to my hospital, which will address this issue.  I am changing the term from “entrenched” to “noncompliant.” I have historically felt that noncompliant was a derogatory term.  I now understand the depth of frustrations these patients experience.  Any human that is experiencing this degree of anger is not going to be rational and responsive. I am continually challenged on how to break through this barrier.