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Monday, January 16, 2012

Contracts with Patients in Clinical Practice

By Michael L Volk, Sarah R Lieber, Scott Y Kim, Peter A Ubel, & Carl E Schneider
(Volume 379, Issue 9810; January 7)

Written documents called contracts are increasingly present in clinical practice and medical publications.

There are behavioural contracts for management of so-called difficult patients, opioid contracts, suicide prevention contracts, and healthy living contracts.

Some practices have even asked patients to sign contracts in which they promise not to litigate or post defamatory comments on the internet.

Despite widespread adoption, the use of contracts in medicine has had little critical appraisal.

Patients' contracts do different things in different clinical situations: they can serve administrative purposes, by deterring mistreatment of clinical personnel or diversion of narcotic drugs; some are educational, drawing patients' attention formally to information; and others clarify expectations and foster transparency, such as when a prospective organ recipient agrees to respect rules on substance misuse.

Other contracts--e.g., for suicide prevention--can help doctors to express concern for their patients, or help patients hold themselves to better health practices, by bolstering willpower with a written commitment (Ulysses contracts).

The effectiveness of contracts in general is uncertain.


A unilateral or authoritarian style of implementing contracts might cause patients to feel threatened or coerced, and perhaps even to view the contract as a "prelude to abandonment".


In view of the inconclusive evidence about the effectiveness of these contracts and their possible disadvantages, we have some recommendations.

First, clarify terminology; written patient-physician agreements generally do not fit the usual definition of a contract.

Second, clarify aims; for example, if the main aim is to state non-negotiable terms (such as substance-misuse criteria for transplant candidacy) it would be franker to label the document an acknowledgment of clinical policies.

Third, treat the contract as part of a therapeutic process--a standard form contract is one thing, and helping patients set and meet goals is another.

This is the fundamental principle behind motivational interviewing, a technique with strong empirical support.

Finally, patients should be given resources and assistance to meet their goals; for example, structured weight-loss programmes work better than advice to diet and exercise.


Whenever possible, written agreements should be bilateral, tailored to the individual patient, and presented in a way that signals continuing commitment.  Otherwise, we risk alienating patients and damaging the therapeutic alliance."

Thanks to Ken Pope for the story and excerpts.