“Patient noncompliance.” I wasn’t very familiar with this term until I started my clinical rotations. But after just the first week, I started noticing that health care providers throw this phrase around all time.
We particularly like using it as an excuse. Why did this diabetic patient require a foot amputation? Why does this patient come in monthly with congestive heart failure exacerbation? Why did this patient suffer a stroke? It’s often simply attributed to patient noncompliance.
What bothers me the most about this phrase, though, is how it’s often stated with such disdain. We act as if it’s incomprehensible that someone would ignore our evidence-based recommendations. If the patient would only bother to listen, he or she would get better. If we were patients, we would be compliant.
But that’s simply not true. We are no different from our patients. We practice our own form of noncompliance. It’s called guideline non-adherence.
Despite the fact that many guidelines are created after systematic reviews and meta-analyses – processes we would never have time to go through ourselves – we, like our own patients, are often noncompliant.
Research on guideline adherence has been around since guidelines started becoming prominent in the early 1990s. Despite the many studies and interventions to improve guideline adherence, the rates of guideline adherence still remain dismally low.
I find this particularly disconcerting. Despite my own interest in research, it makes me question the value of research. Why do we spend millions of dollars to find a better intervention that does not change how most providers deliver health care?
In the current financial climate, our distaste for guidelines poses another concern. The American Board of Internal Medicine has sponsored the Choosing Wisely campaign. This campaign encourages medical specialty societies to publish a list of “Five Things Physicians and Patients Should Question.” These are evidence-based recommendations from specialists on the interventions in their own field that may be overused.
In other words, these are guidelines on how to practice medicine in a cost-effective way. Guidelines that, if history is any guide, we are likely to ignore. But now more than ever, we need to learn how to encourage guideline adherence. To capitalize on the millions invested in research, we need to do a better job of translating research into practice.
This is exactly what the field of dissemination and implementation science hopes to do. (For those less familiar with this field, a brief description of dissemination and implementation science can be found at the National Library of Medicine.*)
Dissemination and implementation researchers seek to understand how to ensure research findings have their full impact on patient health. For the future of our health care system, I hope they discover how to increase adherence, not only among patients, but also physicians.
*A more detailed explanation of these fields can be found here as well as a book titled Dissemination and Implementation Research in Health: Translating Science to Practice by Ross Brownson, Graham Colditz and Enola Proctor. For full disclosure, these authors are affiliated with my current institution and one served as my research mentor.
Elaine Khoong is currently a fourth year medical student at Washington University in St. Louis and a fellow of The American Resident Project, where the following post first appeared.