How to Improve Medical Care of the Non-compliant Patient

Written by on November 1, 2016 in Features - No comments

We have all had the patient that just won’t follow the medical recommendations that they are given, no matter how many times we explain to them why it is so important. My worst experience was with a pregnant diabetic who refused to follow a diabetic diet and kept trying to overcompensate for this by adjusting her insulin. At 31 weeks gestation, she was brought to the hospital unconscious with a blood sugar of only 31. In the process of evaluating her in the labor and delivery triage area, she went into cardiac arrest. While the resuscitation team was performing CPR, the operating room team was taking her back to the O.R for an emergency cesarean for severe fetal bradycardia.

In the end, I was able to deliver a viable baby girl safely, who was immediately taken to the NICU for what was to be a rough few months. During the cesarean, the patient got a pulse again and was stabilized. The mom spent a few days in the ICU, eventually recovered and went home. When it was all over, I was left wondering if this entire situation could have been prevented if I had only done things differently and convinced the patient to comply better with her care.

I began researching for better ways to communicate with non-compliant patients and found several good ideas. One method that I did find useful in working with patients to achieve better compliance was the following ‘SIMPLE’ mnemonic [Atreja 2005].

S - Simplify the regimen

I - Impart knowledge

M - Modify the patient’s beliefs

P - Patient communication

L - Leaving the bias

E - Evaluating adherence

This method recommends making the treatment course or the drug regimen as simple as possible to help patients achieve better compliance. One thing that may help patients take their medications as prescribed is to reduce the number of pills a patient has to take every day by using a combination medication, if available. Trying to find medications with fewer dosing requirements or a more comfortable delivery system may also motivate patients to take their medications regularly. Writing everything down for patients while they are in the office is also useful in reducing any confusion about what was discussed during their office visit and may motivate the patient to follow the written instructions when they are at home.

Helping the patient understand what the illness is that they are being treated for and how the recommended treatment is going to make them feel better or improve their quality of life is key. It is important to take the time to explain the patient’s medications or treatment, how it will impact their illness, and why it is important to the patient’s health. If you can convince the patient that what you are asking them to do will have a real benefit on their health, they may be more willing to follow the recommendations.  In general, the more the patient understands about their disease and treatment, the more likely they are to follow the recommendations they were given.

Managing patients with a chronic disease can be especially challenging because there is no specific end point to their care. You can’t just tell them to take something for 10 days and then they are cured. It takes a long-term commitment from the patient, so it is important to take the time to understand what the patient believes about their disease and what their intentions are for treating it. Addressing the following has been shown to help improve compliance [Atreja 2005]:

- The patient needs to understand their disease is serious

- They have to perceive that they are at risk if they don’t comply with healthy behavior

- They need to believe their medical regimen will improve their outcome

- They must have methods to address their fears about their disease or the treatment

- They need to believe that they are capable of changing so they can follow the medical recommendations

All of these can only be accomplished through good patient-physician communication, plenty of time, and sometimes, a lot of patience.

One challenge in dealing with non-compliant patients that is frequently overlooked by physicians is the physician’s own bias. While treating patients, it is always important to never assume a patient is following the recommended treatment based solely on their education, sex, race, income, occupation, or ethnicity. Studies don’t support compliance of a patient based on any of the previously mentioned factors. Every patient needs to be evaluated for compliance by simply asking them if they ever forget to take their medications or are careless about taking them and whether or not they are following the medical recommendations they were given. By directly asking the patients what they are and are not doing, it can help better direct conversations about compliance.

By following the SIMPLE method, compliance can be improved and so can outcomes. However, this clearly will not solve all patient compliance problems. Sometimes the physician-patient relationship just won’t work and in these situations, it is frequently best for both parties to end the relationship. But, when possible, putting in a little extra time and effort with a patient may significantly enhance the results the patient is able to achieve with their health.

References:
Atreja A, Bellam N, Levy S. Strategies to enhance patient adherence: Making it simple. Medscape General Medicine. 2005; 7(1): 4.

By Carrie A Noriega, MD

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