Patient Compliance

Poor patient compliance with medical recommendations is a frequent cause of poor outcomes.

A very common scenario in primary medical offices is the overweight diabetic patient who refuses to exercise or diet and then declines insulin when blood sugars are over 250 having already failed oral therapy. Another example is the patient with severe chronic lung disease who won’t even consider quitting smoking. A third example is the patient with a pulmonary embolus who insists on leaving the hospital AMA (Against Medical Advice) before treatment is completed. Another is the patient with severe hypertension, diabetes and chronic congestive heart failure who simply can’t afford to take the 6 or 7 drugs s/he requires. In the latter case, it’s more of a system problem than it is a patient problem; but it still results in poor health care.

These are frustrating situations for many physicians who are trying hard to practice good medicine and who want their patients to do well. We sometimes get angry with those patients who actually have the control to do better but lack the motivation. Our anger of course usually only makes the problem of patient compliance worse.

On the patient’s side, it is sometimes extremely difficult to change old habits, especially when those changes involve removal of one or more of the few things left in life that are still enjoyable to that person. When they are challenged to change, the most stubborn of patients will say, “We all have to die of something”, or “I understand the risk, but I’d rather die sooner than give up the one thing I really enjoy”, or “Its either buy groceries or buy the pills; I can’t do both”.

We’ve all heard these things. Some obviously have no control over their situations; others do, but don’t want to do anything about it. How should we deal with the folks who could change but won’t? Should we just blind ourselves and let them go ahead and slowly kill themselves? Should we dismiss them from our practices due to noncompliance, especially since they will surely skew our pay-for-performance figures and end up costing us money? Should we get angry and shame them into compliance?

The best thing to do with patient compliance issues is to try to understand their situations the best you can. Try to visualize life from their standpoint; and always be respectful of their positions.

Make sure they understand the consequences of what they are doing or not doing and carefully document in the chart that you have explained these things in detail and that they understand, but they still do not wish to comply.

Remember the first rule of medical ethics that says the patient has the right to accept or decline any advice or treatment you may wish to prescribe. Remember also that you are not their parent, guardian, commanding officer or employer, and that you have no authority over them whatsoever. You are their adviser. You are there to assist them and help them with their care as much as they will allow. And you are their teacher. After you have taught them the pros and cons and tried to encourage them to follow the right path as much as you possibly can, you must, in the end, let them have their way.

With the patient’s permission, you may want to try to enlist family support. Many times they will ultimately help persuade the patient to begin making changes or follow the advise you have given. If the patient has dementia and is not competent to make medical decisions, enlisting family support is absolutely essential in those cases.

Your own good judgment must come into play in many of these patient compliance situations. If you have an 80 year-old person who doesn’t want to do screening colonoscopies any more, that is probably a reasonable request. Likewise, a patient with metastatic cancer with a poor prognosis shouldn’t be forced to take niacin to get their cholesterol down. Don’t be so rigid in your rules and regulations for patients that fulfilling a recommendation may create an unreasonable hardship on an individual. Try to remember what the overall goals are for the person and the fact that your goals may be different from the patient’s goals. Remember also that the quality of life is in many cases more important than the quantity.

For the patient who can’t afford to be compliant, try to use whatever drug assistance programs offered by pharmaceutical companies that you can, try to obtain samples of the medications for them whenever possible, prescribe generics when appropriate, and try to “streamline” their meds (Use combinations, and use drugs that may help with 2 problems instead of just one, etc.). You just have to do the best you can to get them the best care they can get without going bankrupt. And let your congressman know these people are getting inferior care because the system is broken, and that their poor compliance is no fault of yours or theirs. Neither the patient nor the physician should be penalized for it.

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