“Why aren’t you taking your cholesterol medication?”  I asked the woman.

With the coronary disease I diagnosed a year ago, my discovery that she had not taken her medication was very troubling.

“It made me tired,” she replied matter-of-factly.  ”And besides, the cardiologist said the stress test was negative, so my heart is fine!”

I ordered the stress test after her heart calcium score was significantly elevated, revealing significant atherosclerosis.  She totally misunderstood the results, and I needed to fix that problem.  So I pulled out my secret weapon: a good analogy.

“The purpose of the calcium score test was to see if you had termites in your home”  I explained.  ”I found them.  The negative stress test just said that the termites hadn’t eaten through your walls.  It’s good news that your walls aren’t falling down, but they will if we don’t stop the termites.”

Her eyes opened wide comprehension: the termites were eating her walls.  She was living on borrowed time.

“Would you take a medication if it didn’t have side effects?” I asked.

She quickly nodded.  Of course she would.  From now on she would be a compliant patient.

Compliance is good.  Noncompliance is bad.  It’s something I learned very early in my training: patients who do what their doctors say are compliant (good), and those who don’t follow instructions are noncompliant (bad).  If you are lucky as a doctor, you have compliant patients.  They are the best kind.   They obey their doctors.  They are submissive.  Noncompliant patients are bad; they are a bunch of deadbeats.

Please hold your nasty comments; I don’t really believe my patients should obey or submit to me.*

Sadly, however, many doctors wouldn’t flinch at that description of noncompliance, heaping all the blame of noncompliance on the patient’s shoulders. But this woman’s story (true, albeit changed for anonymity) illustrates one of the most common cause of noncompliance: misunderstanding. She was thrilled when her stress test was negative, grasping at the opportunity to be out from under the diagnosis of heart disease.  The cardiologist told her that her “heart was fine,” and that was all she needed to hear to be excused from taking her cholesterol medication.  She didn’t understand, and the blame of that misunderstanding can be shared between me, who didn’t adequately explain the test before sending her to it, the cardiologist, who gave her “good news” that didn’t tell the whole story, and the patient herself, who didn’t ask questions when she should have.  It wasn’t until I gave the termite analogy that she really understood.

I love good analogies.

In the “good old days” of medicine, doctors were not obligated to explain things like they are today.  Patients didn’t have access to medical information and so would have to take the doctors at their word about what they should do.  Today, however, patients have far more knowledge at their disposal than the doctor has in his/her head.  Contrary to what some doctors think, this is (usually) a good thing. The doctor is forced to defend and explain medical decisions, making truly bad decisions less likely.  True, some questions come from untrustworthy medical sources (websites selling “miracle” cures, those relying on anecdotal data, conspiracy theorists, and Dr. Oz), but if I can’t give a convincing enough argument to counter these foes, one of two things is true:

  1. I am not on solid scientific ground.
  2. The patient doesn’t trust me.

Either one of these is valuable for me to know.

So I have come to see compliance not as a monicker of disdain, but as a challenge to overcome.  I will never get  near 100% compliance, but I don’t get this from my kids, my car, or my dog, so why should I expect it from my patients?  Besides, I get paid the same amount if the people ignore what I say; my job is simply to give them the best advice I have.

Once I get that taken care of I can turn my attention to more important things: compliance with “meaningful use,” “medical home,” and other fun stuff.  I need to make sure I am obeying and submitting to those wonderful Washington bureaucrats.  I never question them because they know what’s best for me.

*I’m using the crazy language tool called hyperbole. It’s good clean fun.  You should try it some time.

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at More Musings (of a Distractible Kind). Where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.

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6 Responses for “Compliance”

  1. SJ Motew, MD says:

    btw, the medico-politically correct term is “adherence” not “compliance”.

    Compliance usually denotes an obedient relationship, adherence a cooperative one.

    Don’t blame me, this was pointed out to me during a lecture on “recurrence” and “failure” for treating vascular disease.

  2. MarkH says:

    How about physician compliance to evidence-based practice? I don’t think the most recent CAC guidelines from ACC suggest additional noninvasive testing is useful in asymptomatic patients.

    “Current clinical practice guidelines indicate that patients classified as high risk based on high risk factor burden or existence of known high-risk disease states (e.g., diabetes) are regarded as candidates for intensive preventive therapies (medical treatments). There is no clear evidence that additional non-invasive testing in this patient population will result in more appropriate selection of treatments. ”

    Why are you sending her for a stress test when she is asymptomatic? That’s a big money waste right there.

    I might buy an argument that statin therapy is justified in an asymptomatic patient with high risk factors and high CAC score, even though data on efficacy of statins for primary prevention of MI has been poor, CAC might be an independent marker of a patient population that will benefit from medical intervention. But in the presence of muscle pain from the HMG-CoA inhibitor, an alternative cholesterol lowering therapy makes sense, and I think she made the correct decision to stop therapy. She should have just told you about it so you could modify your treatment strategy.

  3. JimE says:

    So, what if you didn’t get paid the same if people ignored what you said? Would you practice medicine differently?

  4. DeterminedMD says:

    Read in an old issue of The Week magazine that a Marist poll said 37% of people go on the Internet to diagnose their problems.

    Gee, do ya think they’ll find a site that tells them they are likely to be irresponsible idiots!! Again, ready to be renamed health care serviceman soon?

  5. Peter1 says:

    “Compliance usually denotes an obedient relationship, adherence a cooperative one.”

    Is that so bad?

    “How about physician compliance to evidence-based practice?”

    Maybe we should use “adherence” to get better results.

    “what if you didn’t get paid the same if people ignored what you said? Would you practice medicine differently?”

    It’s never about results, it’s about FFS.

  6. Rob says:

    Peter1:
    That is exactly why I included the last paragraph in the post. Docs complain about patient compliance, but then they scream when they are held to comply to the expectations of others. The hypocrisy is blatant, but generally not acknowledged.

    Jim: The purpose of this post was to underline the reality that compliance is something we can’t just lay on the patient. In fact, the term “non-compliant” has become a term of derision when applied to a patient – a fact that really bothers me. I see non-compliance as one of two things:
    1. A gap in education – I need to do a better job explaining things.
    2. A personal choice by the patient – if I have done #1, then the patient has the right to not listen to me. I am OK with that. That’s where “I get paid regardless” fits in. My “job” is to allow an informed decision. I don’t want to be measured by what the decision is; I just want to make sure I allow them to make the most informed decision possible.

    SJ: sorry for not using the right words. I will confess this to my priest and try to be better. (I do realize you are exasperated by this as well).

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