Joseph Cramer, M.D.: Poor patient compliance or poor doctoring?

Published: Tuesday, July 10 2012 3:00 p.m. MDT

Patient compliance is a term common to medical parlance. It is used as a general description of how well a patient is obeying the doctor’s orders. That means are they taking their medicines, skipping the salt, doing the exercises and showing up for appointments. Unfortunately, all too often the phrase degenerates into criticism of patients for their individual behavior.

Compliance has a meaning of obedience or submission. One dictionary used the words “a tendency to yield readily to others, especially in a weak and subservient way.”

Hence, the traditional use of the phase implies subservient behavior by patients. The current cultural norm is that the relationship between a patient and the doctor is not symmetrical. This asymmetry develops because the healer is educated and has access to the technology and medicines that make a person whole or as close as they can. The patient is ill or nervous about being ill, and the doctor has the power to identify the sickness and cure it or at a minimum reassure the walking worried.

It shouldn’t be that way.

The use of patient compliance to monitor whether a person is following the doctors’ orders suggests whenever there is non-compliance the patient is at fault. There is the labeling of being a rebel or lazy or contrary. The patient doesn’t want to get better, or they act like they know more than the doctor.

Poor patient compliance in this context implies that the physician optimally outlined the full course of therapy and the patient totally disregarded it. But as you know, that is not the full truth.

What physicians say and what we communicate may be totally different. Doctors are known to use medical lingo when a simple sentence in English would do just fine.

We also at times provide TMI — too much information. We will go into the pathophysiology of the condition with a triumph of remembering the complexity learned in medical school.

Admittedly, I would rehearse such knowledge because what I was explaining was so cool to me that I was certain everyone would want to know that part of the reason for hyperbilirubinemia in newborns is due to ineffective production of hemoglobin and shorter life span of red cells. Cool, ay?

We forget that the last time a person had anything to do with health was as a distracted sophomore in high school.

We should move away from patient compliance to patient understanding and partnership. It means we have to know what the person thinks and feels about their condition and their possible therapies.

Mere distribution of information does not guarantee the patient's comprehension. The ton of facts may obscure your doctor's needed knowledge to answer your particular concern. There is no pretesting to know your needs and your fears. Also how doctors inform may not suit the style of the patient. A doctor gives spoken instructions, but maybe the patient is a visual learner. The doctor uses printed words where pictures would be more informative.

One almost universal attempt to motivate is to describe, sometimes in horrible details, what may happen if one doesn’t do as the doctor orders. Paradoxically, picturing the worst could actually reduce patients’ compliance.

We all are emotional animals. Therefore, when faced with complications, the patient may freeze or escape.

It is not that we want to have bad outcomes; it is just that if we don’t think about it the problem it will go away. Logical, no, but understandable when we appreciate how people react to tension.

Poor compliance can also be traced to poor follow-up. With no continued care there is no accountability of the patient to anyone. There is also no feedback to the doc.

Patient compliance should also consider the individual biological reactions to therapies. There are nasty medicines. Mostly poor compliance is because that patient knows something the doc doesn’t.

Next time you hear poor patient compliance, think poor teamwork, poor systems or even poor doctoring.

Joseph Cramer, M.D., is a fellow of the American Academy of Pediatrics, practicing pediatrician for 30 years, and an adjunct professor of pediatrics at the University of Utah. He can be reached at jgcramermd@yahoo.com.

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