Let’s face it — we clinicians can be a bit disdainful when it comes to our patients’ participation in medical care. For years, the term “non-compliant” has conveniently encapsulated the reasons for treatment failure while casually shifting responsibility for the shortfall. We, the health care providers, did our part, but the patients didn’t follow through. Lately, we’ve tried to soften the blow by adjusting the term to “non-adherent.” Non-compliant sounds a little . . . autocratic, after all. The message, however, remains the same: the treatment plan failed, and it’s the patient’s fault.
I know. If you’re a clinician, you’re probably having a visceral reaction right now thinking about all the times that you painstakingly wrote out instructions and had a heart-to-heart with your patient, only to have them return a week later with diabetic ketoacidosis. Or volume overload. Or a surgical site infection. Each condition has its own unique set of challenges, but I see a lot of the same attitudes, assumptions, and missteps leading to treatment failures of all kinds.
For starters, I don’t think a lot of us communicate with the average person nearly as well as we think we do. After being completely immersed in "medical-ese" for much of our lives, we can start to forget how non-medical people sound in everyday conversation. What we should not lose, however, is our ability to recognize comprehension (or lack thereof). Too many times, I have witnessed colleagues blather on in doctor-speak to a bewildered patient before slipping out of the room, having fulfilled their duty to inform. Never mind the “deer in headlights” expression on the patient’s face or the slow, tentative nod that says “I hear you, but I don’t understand what you’re saying.”
These non-verbal cues are critical because patients often don’t know what to say. Maybe they’re overwhelmed. Maybe they’re embarrassed by their lack of comprehension. Maybe they don’t want to be a bother by asking you to repeat yourself. Whatever the case, it’s our responsibility as clinicians to ensure that patients are given a basic understanding of their medical condition and treatment plan. Not a printout. Not the medical monologue we practiced in front of the mirror. They need a dialogue tailored to their level of medical literacy with confirmation of understanding, like a teach-back. This is the first, and arguably, most, important step in preventing “non-compliance.”
Next up, “shared decision-making” is more than just a buzz term foisted upon us by the regulatory powers. Time constraints have a way of bringing that old physician paternalism back to the surface. It’s quicker to say “here, take this,” rather than sitting down for a conversation about risks and benefits. The problem is that we pay dearly on the back end for this approach with treatment failures, readmissions, and even more time spent deciphering what went wrong.
It’s easier and safer for everyone involved when clinicians put in a little extra time up front to explain what treatments are being given and why. When I prescribe an antibiotic, I volunteer information like common side effects, symptoms that would warrant urgent evaluation, and why I’m recommending this particular medication despite these potential adverse outcomes. You don’t have to recite the entire package insert — just hit the highlights. Offer alternatives if the patient expresses concern about a particular side effect. The important point is that people are much more likely to follow through on a treatment plan when they understand what they’re getting into and feel that they have a say in the process.
Even with appropriate education and shared decision-making, however, treatment courses can break down if we fail to recognize issues of practicality. Maybe that antibiotic you selected is a perfect fit for the patient’s medical condition, goals, and desires, but if they get to the pharmacy and can’t afford the $500 copay, it doesn’t matter. Our health care system is broken in many ways and as the prescriber, it’s tempting in these cases to say “not my problem.” Let the case manager handle it. Let the patient call the appeals line for their health insurer. I believe, however, that it’s the clinician’s responsibility to choose a workable treatment plan. If you pick an unaffordable medication and walk away, expecting someone else to figure out how to pay for it, there’s a very good chance your patient won’t get treated at all.
Likewise, it’s critical to consider social and environmental factors. One patient of mine was discharged from the hospital on IV antibiotics without much discussion about how he would be administering them. At his first clinic follow-up visit, his peripherally inserted central catheter was partially dislodged and the dressing was filthy. When asked about this, he informed me that he worked in construction and couldn’t afford to take time off, so he wasn’t able to keep the dressing clean and dry. He also had trouble finding time and clean space in which to administer antibiotics, so he had been missing doses. I could have labeled him “non-compliant” with IV antibiotic therapy. Instead, I switched him to oral antibiotics, and he completed treatment as prescribed and his infection resolved.
Give your patients the benefit of the doubt. If a surgical patient comes back with wound dehiscence, don’t accuse them of poor wound management until you ask yourself: “What am I missing?” Are their blood sugars completely out of control? Did another doctor start them on high-dose steroids? Could this be an early sign of deeper infection? As it turns out, we have no evidence to show that post-op dressings have any bearing on infection rates with closed surgical wounds, so “non-compliance” should absolutely be a diagnosis of exclusion in this situation.
The next time you consider coding Z91.14 (“patient’s other noncompliance with medication regimen”), take a moment to consider these issues. Of course, there will always be some patients who simply will not go along with the plan despite our best efforts. Let’s just be sure we’re adhering to our own best practices before making that call.