Q&A · Vol. 6, No. 01
Summary
When a care plan is not working, the next step is not always more of the same. Doctors can use patient concerns, measurable results, and clear choices to adjust treatment. Insights from experts in the field show how small, practical changes can lead to better care and progress.
SB
JS
Dr. Cameron Rokhsar MD FAAD FAACSFounder & Medical Director, New York Cosmetic Skin & Laser Surgery Center
I set a checkpoint before treatment starts, because the decision to revisit a plan gets easier when the patient already agreed to the timeline. For acne, I tell patients to expect real change at 8 to 12 weeks. For melasma, I say improvement takes months and relapses with sun. For laser resurfacing, I schedule a photo review at the first follow-up. If the checkpoint arrives and the photos show less than the agreed change, the plan changes.
Before I change anything, I check the usual culprits. Missed doses, wrong application technique, skipped sunscreen, and a wrong diagnosis cause most failures. Acne that stalls on a topical often turns out to be hormonal or a rosacea variant. A pigment that will not lighten often has a dermal component that a cream cannot reach. A biopsy or a second look at the history settles it faster than another month of the same regimen.
Patients accept a reset when I put the original photos beside the current ones and say plainly what did not work and why. Blame stays out of that conversation. Then I offer two concrete options with a timeline for each, such as switching to an oral agent or adding a laser or peel series, and the patient picks. Patients who choose the next step themselves stick with it far better than patients I instruct.
I also write the new goal in the chart and on their after-visit sheet, so the next checkpoint has a clear measure.
I revisit a care plan as soon as a patient tells me it isn't working. I don't wait for the next scheduled visit. Just today, a patient reached out frustrated because her GLP-1 had stopped working and she'd hit a plateau. We like to think of GLP-1s as the silver bullet, but what helps one woman does not help all women. Weight loss is one of the most challenging areas in my practice, and plateaus are a normal, expected part of the process, not a failure. Care is a two-way street. If a patient truly feels her plan isn't progressing, that feeling is data, and it deserves a sit-down conversation.
We start with the numbers, not the frustration. I sit down with the patient and review her actual data together: weight trends, body measurements, and body composition where we have it. The scale often hides real progress, like inches lost or muscle preserved. From there, we clarify two things: expectations and timing. Many women expect steady weekly losses, but the body adapts, and progress often comes in stages. Putting their own trajectory in context resets the conversation from 'this isn't working' to 'here's where we actually are.' Then we decide together whether to add to the plan. That might mean adjusting the medication or dose, adding strength training or nutrition support, or looking at sleep, stress, and hormonal factors such as perimenopause that can stall progress.
Finally, we talk honestly about accountability. Weight loss requires patients to be honest with themselves about what's happening day to day. When a patient leaves with a clear next step she helped choose, she's far more invested in making it work.
Judy Serfaty, LCPC, LPC, NCCClinical Director, The Freedom Center
I decide to revisit a plan when the patient can no longer see how the current work connects to the change they want, or when the plan produces discussion without a workable action between sessions. A patient's disappointment matters, but it is not automatically evidence that treatment has failed. It may mean the goal is too broad, the timeframe was unclear, or the first step asks for more readiness than the patient has. I would also reopen the plan when avoidance, disengagement, or emotional overwhelm repeatedly interferes with participation. In dual-diagnosis care, that review should consider both substance use and mental health needs rather than treating either in isolation.
To reset expectations, I recommend replacing a distant outcome with one behavior the patient considers meaningful and achievable. A motivational interviewing approach can help: ask what improvement would look like in life, what the patient feels ready to do now, and what would make that action easier to begin. Then reflect the patient's own reasons for change and offer options rather than prescribing a single answer. The next step should be specific enough that both people can recognize whether it happened, with a scheduled review point and an agreed alternative if it does not fit. That turns expectation-setting into a collaborative choice and gives the next conversation information.
I decide to revisit a care plan when the measurable outcomes we set at the start show little or no change over the review period. In our practice we measure progress quarterly and look at signals like preventive care uptake, pharmacy trends, and absentee days to judge whether the plan is working. If those metrics are not moving, I hold a focused review with the patient to identify barriers and gaps in daily habits. To reset expectations I reframe goals as small, consistent behaviors and agree on concrete next steps tied to the data, such as posture and mobility education or an ergonomic assessment, and then monitor those specific measures for the next quarter.
Zaher MerhiFounder & Medical Director, Board-Certified OB/GYN & Reproductive Endocrinologist, VELVA Sexual Longevity
Whenever a cycle result comes in or new hormone labs show up, especially when they're not what we wanted, we need to sit down and reassess. I've found it helps to just draw the numbers out on a piece of paper. It makes the whole situation clear and helps people see why we might need to adjust course. From there, we can focus on what matters most to them right then and look at the options together, maybe changing some habits or moving to a more advanced treatment. That's how we figure out the best next step together.
Andrzej KuleszaCo-Founder & Medical Director, Zeus Detox & Rehab
In addiction medicine, a plan that is not working is common, and the biggest risk is that the patient reads it as personal failure and disengages. So the first step is separating "the plan is not working" from "you are not working." I say it explicitly: "This approach isn't giving you what we hoped. That tells us something about the plan, not about you."
The signals that it is time to revisit are usually behavioural before they are clinical: the same difficult week repeating, sessions becoming routine without change, or a patient who stops bringing anything new. A relapse is another trigger, and treating it as information rather than collapse makes the reset possible.
What helps most is asking the patient what is getting in the way before proposing anything. Their answer is often practical, such as evenings alone or a trigger at work, and the next step can be smaller and more concrete than the original plan. Agreeing on one change and a date to review it works far better than rewriting everything at once.
Dr. Talha Qadir BDS, RDSRegistered Dental Surgeon, Brightway Oral Care
A very young patient of mine was midway through a root canal treatment on an upper first molar. We had achieved full patency and cleaned the canals in all three roots, and the tooth was under observation before the canals were sealed.
3 weeks had already passed since the treatment plan was started, the pain on percussion still wasn't going away. That was unexpected, and it was the point where I decided to dig deeper, because pain should be present in this phase of treatment.
I took X-rays from different angles and eventually found an extra canal in the mesiobuccal root, the MB2, sitting slightly mesial and about 1.5 mm below the level where canals are normally found.
I explained to both her and her parent how the anatomy of the tooth works, and that she had an additional small canal, which isn't uncommon. They understood the situation and stayed with the treatment a little longer.
Thankfully, at the recall 3 days later, the pain had fully subsided. The canals were sealed, and she had her crown made.
Harvey HillyerFounder, dermani MEDSPA®
We use patient satisfaction scores as a clear trigger. When a score drops, it signals our process or communication needs a fresh look. Instead of just fixing the issue, we collaborate directly with the patient on a new plan. This turns a negative moment into a co-created solution, showing staff we value their input while re-engaging the patient in their care.
Tammy Gold MSW, LCSW, CECTherapist/Author/CEO, Care Map Method
I revisit a care plan when Manage-stage monitoring shows the expected outcomes are not being met or when one of the BESE areas—Biological, Emotional, Social, or Environmental—has changed. I use the Prioritize page to turn observations into one clear next step, identifying immediate safety concerns and what affects daily life most. Then I plan one respectful conversation using the Next Step template: open calmly, state observations without labels, and offer two choices that preserve the person's autonomy. We agree on a specific action, who will own it, and a follow-up date so we can monitor progress and update the map if needed.
Dr. Lauren Grawert MD, FASAMClinical Advisor, Retreat of Boston
I revisit a care plan when it works in the treatment setting but does not translate into the patient's daily environment. In addiction care, that can mean the plan does not adequately account for access to substances, housing instability, family dynamics, transportation, or the times and places where cravings intensify. I also reassess after a return to use. That event does not automatically mean the entire plan is ineffective, but it provides information about where protection was insufficient. The review should examine what happened before and after the return to use, whether the current level of care remains appropriate, and which parts of the plan the patient could realistically follow.
To reset expectations, I separate recovery goals from a fixed timeline. I explain that progress may be uneven, then ask the patient to identify which part of the plan felt least workable outside treatment. From there, I offer a limited set of clinically appropriate options and ask which one they are most willing and able to try. We can then define one near-term outcome and agree in advance on what happens if it is not met. For example, the next step might be increasing treatment intensity, revisiting medication options, or changing the recovery supports involved. A pre-agreed contingency makes the next review less about disappointment and more about using new information to make a clinical decision.
Valerie Briggs OTR/L CLTCertified Lymphedema Therapist, Occupational Therapist, Sunflower Neurolymph Therapy, LLC
As an occupational therapist, we are trained to re-evaluate progress with standardized and objective data. If a care plan is not working for patient progress as expected, we re-evaluate the interventions to see where the breakdown is occuring in the treatment plan. Maybe there is a comorbid condition affecting the body in a different way, or the information presented is not fully understood by the patient.
For example, If I give a patient a home exercise program, and they start doing exercises on their own at home, this is a great way to see how the plan is working. The patient will return to their next appointment and either demonstrate competence with their 'homework', or they will not be able to replicate the program. There could be multiple issues with the plan at this point. These issues include not being able to understand how to perform the exercises, not being able to read or comprehend the information (literacy), or another related health system is affected. This is most common in older adults that may have a urinary tract infection. These infections have a mysterious effect on the ability to understand and make their needs known. As a evidence based healthcare provider, we are responsible for contributing to our patient's success. I lead my sessions in a Teach, Learn, Do format, with hands on practice in my sessions to ensure understanding of the education. If the patient is not able to understand the care plan, there are other ways to ensure capacity with alternate ways of teaching. This mindset helps to reset expectations and formulate next steps in a person-first delivery model. It takes time, but creates tremendous value in a hurried world.
Dr Amir Saeed MDCo-Founder, Prosper Medicine
I define success before the treatment plan begins. Every care plan includes three things up front: the marker we expect to change, the degree of change we are targeting, and when we will reassess it. Whether the goal is lowering ApoB, improving glycemic control, or increasing muscle mass, the patient should know from day one what progress is expected to look like at 8 or 12 weeks.
That turns "this is not working" from a subjective impression into a scheduled clinical decision point.
When progress falls short, I work through three questions.
First, was the timeline realistic? Some biomarkers respond within weeks, while meaningful changes in body composition or bone density may take months or longer.
Second, was the plan actually feasible? I approach adherence without judgment. If a treatment does not fit a patient's schedule, budget, lifestyle, or tolerance for side effects, that is often a problem with the plan, not the patient.
Third, do we need to reconsider the diagnosis or physiology driving the problem? When someone has followed the plan and the expected response is not there, I look for what we may have missed, including sleep disorders, thyroid dysfunction, hormonal factors, medication effects, or other contributors.
I also reassess earlier if side effects develop, biomarkers move in the wrong direction, or the patient's goals change.
When resetting expectations, context matters. Patients often focus on one metric, such as body weight, while overlooking improvements in blood pressure, waist circumference, metabolic markers, or fitness. Putting those measures side by side often reveals meaningful progress that a single number misses.
I also prefer shared decisions over a single directive. I will usually outline two or three reasonable paths, such as intensifying the current strategy, changing approaches, or investigating further, along with the tradeoffs of each. Then we choose the next step together and set a new checkpoint.
Patients generally understand that good medicine requires adjustment. Trust is lost when no one explains why a plan changed or what happens next.
Will KallaStructural Chiropractor & Creator of the R3NEW X™ Protocol, Dr Neck Pain
Structure dictates function, and pain relief is not the same as a corrected neck. As a chiropractor with 29 years of practice, I’ve learned why symptoms sometimes return despite temporary relief.
