Revisiting the thorny topic of patient non-compliance

(Originally published by Hospital Impact)

A number of years ago, I wrote the post for Hospital Impact titled, “The bane of many physicians: The ‘non-compliant’ patient,” in which I highlighted:

We must lose the ego that exists in the system, lose the hierarchical approach to healing, and truly engage with and help patients get well.

More recently for the Arnold P. Gold Foundation, I wrote the piece, “Non-compliance explained … and what healthcare leaders can do about it,” and noted:

In too many cases, women and men who are considered “non-compliant” by the traditional medical system were victims of abuse as children. For example, experiencing sexual abuse as a child can lead a person to have an insecure relationship with their body and thus with food. Those who have been bullied by coaches and others during youth sports may end up with severe distaste for exercise. But physicians rarely hear about these experiences, and do not understand these barriers in their patients’ way.

On Feb. 4, as part of the Robert Wood Johnson Foundation (RWJF) LinkedIn Reader Leaders Club–which featured wonderful speakers Michelle Segar, who wrote the book “No Sweat,” and Dr. Victor Montori, healthcare delivery researcher–we again discussed “non-compliant” patients along with the many barriers to individuals engaging in healthy habits. We discussed wonderful motivational tools and tactics to make a difference. We discussed the challenges faced by clinicians, patients and families. We discussed the socioeconomic factors involved and their impacts. And we again discussed the impact of a history of abuse in this space.

And it was powerful.

And then, Dr. Montori added another perspective. Montori shared that through his work, he has found that many women have noted that they have consciously chosen to not become physically fit because it is easier on their marriage when they are not attractive to other men and/or so that they do not have to deal with unwanted advances from men.

In essence, these women have found that it is safer for them (and we talk about patient safety quite a bit) to be less healthy due to the potential for future abuse from spouses and/or others.

Again … powerful.

How about you? Do you believe we have a healthcare system designed to hear these stories? To recognize and honor the voices of these patients and these challenges?

I think not. Our current system does not allow for an authentic relationship to be established between a clinician and his or her patients. It does not allow for continuity and trust to grow. It does not create a safe space for patients’ whole story to be told–which may very well include stories of abuse and fear–nor their voice to truly be heard and honored. And it does not allow for a true partnership to form and a care pathway (a healing journey) to be co-created that addresses these many challenges from a health and well-being perspective.

We can do far better. We must.

One of the top reasons for a patient to be dismissed from a physician practice is due to non-compliance.

And yet when we truly understand the reasons and the rationale for this non-compliance … is dismissal from a practice truly honoring our mission to care for others? To be of service? To help?

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14 comments

  1. […] Patient non-compliance is and will likely always be a huge issue in healthcare.  There are so many intricacies involved…I was reminded of this while reading the following article written by Thomas Dahlorg of Hospital Impact.  You can access the article here: https://tdahlborg.wordpress.com/2016/02/16/revisiting-the-thorny-topic-of-patient-non-compliance/ […]

  2. I think good rapport and the basis for trust could be developed If a health care provider spent just 5 uninterrupted minutes listening to a patient with eye contact. Without typing in the EMR.

    The front desk staff should also be trained in the proper treatment of patients. Many a rude or uncaring front desk staffer has turned me off to returning for f/u.

    Empathy training is also important for healthcare providers. Especially if it doesn’t come easy for some people.

    Motivational Interviewing skills are very effective in improving patient compliance, especially in diabetes and nutritional management.

    It takes time and practice to become skilled, but well worth the investment.

  3. When patients realise that they are truly cared for, their compliance is better.To gain their trust, the clinician may have to make several followup calls, maybe even outside office hours, to motivate the patient, and make them realise that they have to act urgently and follow the clinicians guidance for further care, and not delay their treatment. Once, the patient realises that the clinician is truly concerned, they comply.

    • So very true. When a patient (and family) feel cared for, and this care manifests in actions such as taking the time necessary to truly hear and honor the patient’s whole story, authentically connect with the patient, understand the patient specific barriers to healing, and co-create care plans (healing journeys) that helps the patient maneuver around or through the barriers care will be optimized. Thank you so very much for sharing, RS.

  4. None compliance is loosely used by health practitioners for patients who don’t do what we say. How many times do we really listen to our patients? In no subtle ways patients try to communicate with their health providers but they are limited to one complaint per visit. In the hectic day of the health care provider empathy and listening is seldom practiced. How then are we to know that the patient had discontinued a medication because of the side effects or financial reasons. We label this noncompliance.
    If we as health care providers take the time to listen to our patients, we will be able to empathize with them; thereby opening the door for honest conversation between patient and provider. Adherence and productivity will then increase.

    • Exactly, Corinthia. You are spot on. Listening, empathy, time, continuity, relationship, trust … all essential to optimal adherence and thus optimal care, safety and outcomes. Thank you for sharing. Tom

  5. Dr. Dahlborg, I participated in the event, and do not recognize your summary of it. I recognize that you have a point of view and espouse it, but to lay it on a discussion of which your points were not central doesn’t seem quite fair. There was quite a bit of discussion about how to create a two-way street between provider and patient and to recognize patient autonomy while still providing evidence-based expert counseling.

    • Mr. Kahan,

      Thank you for taking the time to comment on this post as it is extremely important that we all maintain open dialogue, share and learn together, have open hearts and minds, as we seek to best support patients, families and communities for optimal health.

      I have been blessed with the opportunity to get to know Dr. Segar very well and both her book “No Sweat” and her message is extremely important and valuable. It sounds like much of her sharing along with the rest of the very open dialogue in this specific space resonated with you … as it continues to do with me. That is wonderful.

      Dr. Montori’s message relative to the link between adherence and fear, safety, and abuse (in response to the data points I shared) also resonated with many on the call. Which is also wonderful as we all seek additional wisdom in our efforts to be of service and help others.

      As far as my point of view, yes I truly believe it is important that we understand our patients, their families, and the communities we serve and develop models which allow us to truly discern the specific barriers to healing, whatever they may be, and work with this knowledge and with these folks to best support their healing.

      Thank you again for your comment and for participating on the RWJF call.

      * And please note that although I am not a physician, as a long time patient, caregiver, and healthcare worker and leader, I care very deeply about these topics … as it sounds you do to.

  6. Just look at the language used. Compliance indicates the patient follows the (doctor’s) orders. How parentalistic and archaic. Until providers get that health self-care changes might only come from a partnership, and use language that reflects that level of caring and respect for the other as a co-creator, ‘noncompliance’ will persist. And remain the provider’s problem. Providers who get it provide information and co-create a process led by the patient. It is, then, the patient’s ability to participate that we can hope to encourage.

  7. Dear Tim

    I saw your post some time ago but only found time today to reply. I work in the field of HIV. Compliance with treatment (or what we term adherence) is a big issue. I am not sure that abuse is the only reason. To make abuse the root cause of every thing is to stretch the elastic band too far in my opinion.

    There are many other reasons.

    From my own perspective as a person who underwent a 6-month treatment course for tuberculosis I recall the challenge involved in recalling the pills and my meal schedule. I was very motivated. It was only in the last 15 days that I missed 2 doses. But I remember the sheer nuisance and inconvenience. For those who are not motivated, there is plain old forgetting.

    During this period, I recall that the physician I was referred to had required me to make some dietary changes – one of which was a daily glass of milk with protein powder. I barely took one glass and then threw away the rest of the tin. Every week I would go for my check up and lie through my teeth that I was taking my protein powder. Fortunately, my colleagues – also health workers – suggested dietary substitutes. I took their advice, and even went back to them to figure out how to manage my diet on a trip to Singapore. The treating physician just lumped me in with all his other patients. He never looked to see that in a land of mostly vegetarians, I was an active non-vegetarian, and that protein deficiency wasn’t really an issue for me. It was such a wasted opportunity for him.

    To return back to my own practice, I acknowledge that compliance is a major worry for treatment personnel. For some though, the patient is a disobedient and ignorant individual. For others, the patient is a person who probably has not been engaged sufficiently to take charge of his/ her own treatment, has not been made a partner. For the former, the patient is processed – patient in, patient out… The latter who are very few have a better chance of getting people to comply because they engage the patient to take up what becomes a shared goal.

    And don’t patients have a right to say No to us completely? They are not our captives. But this takes a lot of soul searching to accept.

    MMV

    • Dear Melita – Thank you so very much for sharing such wonderful insights as well as your own personal story. Greatly appreciated.

      And yes we agree, abuse is not the only reason for care pathways to not be followed. Rather … abuse is one of many many reasons and in our current healthcare system many of these reasons are not shared, noted, discussed and addressed together.

      We also agree re patient preferences.

      It is only when we create a relationship centered care model where patients (and families as appropriate) are positioned to tell their whole stories (which may include abuse but may include hundreds of other key nuggets of wisdom) and that these stories are truly listened to, honored and used to co-create care paths will we truly be innovating and improving care (healthCARING) for patients, families, and communities.

      This will also serve to benefit clinicians as they too note that they miss the authentic relationships with their patients.

      Thank you again for sharing.

      Tom

  8. Hmmm…so the “red” dot on my doctors charts are a result of non- compliance! (Like Elaine on Seinfeld?!) Dad

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