When the Patient is “Noncompliant”

by Danielle Ofri
New York Times

“A 63-year-old man with hypertension, elevated cholesterol and diabetes,” the intern recited as he presented the case to me in clinic. He read the list of seven medications the patient was prescribed. “But he’s noncompliant,” the intern added.

“Noncompliant” is doctor-shorthand for patients who don’t take their medications or follow medical recommendations. It’s one of those quasi-English-quasi-medical terms, loaded with implications and stereotypes.

As soon as a patient is described as noncompliant, it’s as though a black mark is branded on the chart. “This one’s trouble,” flashes into most doctors’ minds, even ones who don’t want to think that way about their patients. And like the child in school who is tagged early on as a troublemaker, the label can stick around forever.

Despite efforts to change the term to the slightly more accurate “nonadherent,” the word “noncompliant” remains firmly entrenched in the medical lexicon. No matter what it’s called, however, it’s an enormous problem. Experts estimate that some 50 percent of patients do not take their medicines as prescribed or follow doctors’ recommendations.

When I address this issue with my patients, I – like most doctors — typically ask the basic question, “Are you taking your medications?” and then write down “Yes” or “No.” But a recent article in The Annals of Internal Medicinemade me rethink that approach.

“It’s an immense oversimplification” to reduce compliance to whether or not a patient swallows a pill, says the author, Dr. John Steiner, a researcher at Kaiser Permanente in Colorado.

To illustrate his point, he constructed a chart for a theoretical 67-year-old patient with diabetes, hypertension and high cholesterol and tabulated what it would take to be “adherent” with all medical recommendations.

Besides obtaining five prescriptions and getting to the pharmacy to fill them (and that’s assuming no hassles with the insurance company, and that the patient actually has insurance), the patient would also be expected to cut down on salt and fat at each meal, exercise three or four times per week, make it to doctors’ appointments, get blood tests before each appointment, check blood sugar, get flu shots – on top of remembering to take the morning pills and then the evening pills each and every day.

Added up, that’s more than 3,000 behaviors to attend to, each year, to be truly adherent to all of the doctor’s recommendations. Viewed in that light, one can see how difficult it is for a patient to remain fully compliant.

Even if they do succeed in some areas — cutting out salt and taking their blood pressure pills, for example — they may still get chided by their doctors for not exercising, or for missing a colonoscopy appointment.

I once did a small experiment with a group of medical students. We wrote up prescriptions for a number of common medications—metformin, lasix, albuterol, lisinopril, ranitidine. I handed each student two prescriptions and two boxes of Tic Tacs, and instructed them to take the “medicines” for a week. When we met for our next session, I asked them how they did, and they all had abashed expressions on their faces. Not one was able to take every single pill as directed for seven days.

“Be compassionate,” Dr. Steiner advises doctors. “Understand what a complicated balancing act it is for patients.”

Doctors and patients need to work together to figure out what is reasonable and realistic, prioritizing which measures are most important. For one patient, taking the diabetes pills might be more crucial than trying to quit smoking. For another, treating the depression is more critical than treating the cholesterol. A water pill may be out of the question for a taxi driver on the road all day; a low-salt diet may be impossible for someone living in a homeless shelter.

“Improving adherence is a team sport,” Dr. Steiner adds. Input from nurses, care managers, social workers and pharmacists is critical.

When I discuss the complicated nuances of adherence with my students, I often offer up the example of my grandmother. A thrifty, no-nonsense woman, she routinely sliced all her pills in half. Whatever the doctor prescribed for blood pressure, cholesterol and heart disease — she took only half the dose. If I suggested she take the pills as instructed, she’d wave me off with, “What do those doctors know, anyway?”

She died suddenly in her home, at age 87, most likely of a massive heart attack. It was a painful loss for all of us. Had she taken her medicines at the appropriate doses, she might have survived the heart attack. But then maybe she would have died a slower and more painful death from some other ailment. Her biggest fear had always been ending up dependent in a nursing home, and by luck or design, she was able to avoid that. Perhaps there was some wisdom in her “noncompliance.”    (from the New York Times)

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Danielle Ofri’s newest book is What Doctors Feel: How Emotions Affect the Practice of Medicine. She is an associate professor of medicine at N.Y.U. School of Medicine, and her clinical home is at Bellevue Hospital. She is editor-in-chief of the Bellevue Literary Review.

 

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