“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.
Too many doctors that have a “god complex” and don’t bother to work with the patients. Heck, use of the term reinforces the “god complex” as it makes the entire problem the patient’s fault.
In today’s world, with so much more information and better educated people, a doctor should work WITH a patient instead of just ordering them around. In Corporations, management theory has changed (for good reason), and good companies dumped the heavy-handed top-down management for a more collaborative approach.
Words like “orders”, “compliance”, “non-compliance”, “refusal” need to go out of the lexicon of doctors, who need to listen to their patients (if a medication is causing a problem, don’t poo-poo it) and find an optimal solution rather than just throwing pills at it.
A family member had hypertension – and ended up taking 10 different pills as a result of the side effects of the first medication for hypertension. Instead of trying other classes of antihypertensives, the doctor just threw pills at the resulting side effects. That’s unacceptable.
Lululemon gets ready to explode a large number shares due to target pilates designed garments, that has become popular among within within the last decade.
For all the enlightenment of you who advocate the use of the word “noncompliant,” you seem not to understand the obesity issue. First of all the food companies are making “plastic food.” The stuff is high calories, made from the leftovers of real food, mass produced, preserved and frozen.
Look at the economics of poverty: there are no stores that carry fresh vegetables in poor neighborhoods. How many people can afford to shop at Whole Foods?
The people who can afford better food are buying fast food because they are killing themselves working 12 hours a day. Nobody grows a garden (afraid of getting dirty or germs), kids don’t play outside because someone might abduct them and toys are no fun (bike helmets).
I have a half acre garden every year, buy from farmers’ market weekly. When I was 10, I use to leave the house in the morning be back at night. Many times I ended up on a major river (running through Pennsylvania) on a homemade raft. Never wore bike helmets, when I was 12 was nothing for me to ride my bike 10 miles away from my house.
Work was not sitting behind a computer (even for white collar). Today we don’t even go to see people face-to-face. We Skype, text, email.
As to the issue of “noncompliant,” this is a very derogatory word to use. The reason for much is as much the medical profession’s fault as the the patient’s. Physicians have over prescribed.
The reason we came to find out was direct financial rewards provided to physicians and surgeons which have included trips, meals and direct cash payments. One method of rewarding physicians who frequently prescribe a company’s medications to their patients is by compensating them as speakers for the company.
Another method that the drug industry uses to promote their products is continuing medical education. “By 2005, the drug industry and other medical companies were paying hundreds of millions of dollars to the nation’s accredited medical education courses, enough to cover 65% to 80% of the cost.
As a result, most of the events have become little more than a pharmaceutical sales bazaar. By paying for the doctors’ continuing education, the drug companies made sure they [physicians] learn what is important for the corporate bottom line.” (Source: Our Daily Meds: How the Pharmaceutical Companies Transform Themselves into Slick Marketing Machines and Hooked the Nation on Prescription Drugs, by Melody Petersen)
Why should we blindly trust you???
Heard a patient once say,; “Doc, the only thing saving the public today from medical care is non-compliance”.
Sometimes, it’s a medical necessity to be “non compliant”. For example, I after a near-total thyroidectomy, I found that I could not take a full dose of levothyroxine and so, ‘refused’ to do so.
I also couldn’t take the beta-blockers prescribed for my post-thyroidectomy heart palpitations…
My doctors may have described me as being on compliant – just as I now describe them as being poor diagnosticians.
I had undiagnosed hyperreninemic hypoaldosteronism (congenital).
Compliance or non-compliance is critical to the treatment plan. As Legacy says, if the patient doesn’t take the meds, how will they change their BP, Blood sugar, cholesterol, etc? Now, there may be a very good reason, such as not being able to afford the meds, but this needs to be addressed.
From the standpoint of following guidelines, we have to be very careful. I think most practitioners are wary of every new guideline that comes out and righfully so. Do I trust that a very large number of Americans need to be on statins? I have my doubts. On the other hand, it is very clear not everyone with back pain needs an MRI out of the gate. What we have to do is combine research with some common sense. But I am not going to blindly follow every guideline every time.
I think the basic philosophy of medical treatment has not been correctly understood.
The patients come to a doctor for; advice, treatment, reassurance, etc. Since we live in a free country, the doctors is NOT responsible for the patient following advice.
We do NOT guarantee results, nor should we. If a patient with hypertension does not take their medications, and we have explained to them why they should, it is NOT our fault.
This can be described in many ways; “non compliant”, “free will”, “I am not your mother”, etc.
To make an analogy, if a patient is put on probation and told that he needs to: not use drugs, report to his parole officer, etc. and does NOT do so, is it the fault of the judge?
I assure you, the author will be using the term noncompliant or similar routinely. Reimbursement is becoming attached to outcomes, frequently ones physicians have no control over. Doctors are routinely blamed for poor outcomes and this patient branding is simply a defense mechanism. The same applies to avoiding litigation. The same applies to avoiding administrative penalty for not meeting metrics. So take the advice of your colleagues, your lawyer, your parent company, your third party payer, your metric worshiping government and certification industry, and clearly document noncompliance.
See my post http://acountrydoctorwrites.wordpress.com/2010/10/04/playing-the-odds/
Most patients are shocked when they find out what the nnt is for some of the things we are pushed to do. Prostate cancer is a good example; the data was there for everyone to see and consider, long before the USPHS et al stopped recommending universal PSA screening.
When I did family practice, I was always interested in the “number needed to treat” (NNT) as it is informative and sobering to contemplate. Many of the guidelines call for prescribing medications that have NNTs in the hundreds – i.e. you have to treat hundreds of people before you benefit one. Hundreds receive no benefit (but still significant risk) from the treatment so that one of them, only one, can benefit. It is insanity to expect physicians to be judged by how well they cajole patients into accepting treatment with NNTs in the hundreds. Even a NNT of 10 is iffy – how would you feel if your doctor failed to tell you that you only had a 10% chance of benefitting – and why would they tell you if that might mean you would opt out and spoil the their numbers? The numbers that increasingly determine their pay.
And yet, the type of interventions with a NNT of one (only one person has to perform the treatment to see a difference) are routinely ignored by patients – eating right, exercising, losing weight. Yes, they are actually “non-compliant.” That is part of why I no longer do family practice. My current addiction practice sees very high rates of compliance. I have far more success getting addicts to put their addiction behind them than I ever did getting diabetics and hypertensives to accept guideline based treatment.
See thennt.com if you doubt what I am saying.
I thought where the provider is *aware* of the guidelines, “guideline non-adherence” was called “practicing medicine”.
The elephant in the waiting room is the patient non-compliance called “obesity”.
We may not be able to save patients from their non-compliance when they inflict metabolic syndrome on themselves. There may simply be too many of them putting weight on too fast.
We need a diet pill that works.
Patient-centered behavioralists use the words “did not see the value of” instead of “was noncompliant with”.
In medicine, yesterday’s truths are tomorrow’s fallacies. Guidelines come and go ( as a resident I got my hand slapped for not prescribing estrogen to every post menopausal woman ) and before the guidelines are toppled, critically thinking doctors practice “noncompliance” sometimes. In my case, I disobeyed the now-defunct numerical lipid guidelines for years; I was noncompliant, then suddenly I am first to embrace a new guideline:
Words of wisdom from someone who has never practiced medicine a day in their lives. If the author knew anything about medicine they would know that no clinical guideline anywhere takes into account every patient presentation or clinical scenario. Guidelines are not supposed to ever take the place of clinical judgement or experience. Often if you actually take the time to read guidelines, you would find they are based on poor levels of clinical evidence. We actually live in an age when clinical guidelines have become the apotheosis of clinical opinion(and based on the authors experience and judgement and not clinical data)Would you actually fault a clinician for not always following a guideline recommendation that it’s own authors rate as poor, based on unreliable clinical evidence? Lastly, guidelines are often based on dichotomous variables that don’t take into account multiple abnormalities that a clinician may recognize as abnormal but the guidelines do not. Guidelines are wonderful, and no clinician should deviate from them because they are not familiar with them. However , they will never be a substitute for clinical judgement and should be used to support clinical decision making and not detract from it. My hope for the author is that after she becomes a fully trained and practicing physician she will have a more fully informed perspective.
Give her some time. In a few years she will look back and see how many people can be harmed by blindly following medicines never ending series of fads and half baked industry sponsored “science”.
Alternatively, she could accept only patients who are described in guidelines…
Many people are non-compliant. What is wrong with calling a spade a spade.
It’s called “blaming the victim.” Happens all the time, not just with medical problems but most matters regarding human behavior. Thinking about it makes we want to rant, but I’ve done enough ranting here so I’ll be quiet. Thanks for mentioning this problem.