Bioethics Discussion Blog: What Should Doctors Do With the Non-Compliant Patient?

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Tuesday, April 21, 2009

What Should Doctors Do With the Non-Compliant Patient?

A patient whom the doctor finds is "non-compliant" (essentially does not accept or follow what the doctor advises or prescribes) is particularly troublesome for some doctors who, despite this age of patient autonomy, consider themselves in a "father knows best" role. They may look at their relationship with the patient, in an era of lowered payments for the time and expertise, as a waste of time and waste of their skills. However, patients may have complex psychosocial reasons and well as biologic (related to the illness or side-effects of prescribed medication) for not following the physician's advice. With regard to adherence to a drug prescription, the patient may because of finances either not purchase the drug or reduce its dosage frequency for the bottle of pills to last longer. For a description of how another doctor looks at the non-compliant patient, read an article from the Permanente Journal Fall 2003 by Fred Kleinsinger, MD titled “Understanding Noncompliant Behavior: Definitions and Causes”

“What should doctors do with the non-compliant patient?" I would agree with Dr. Kleinsinger, first talk to the patient and begin to understand the reason for the non-compliance. Then it is up to the doctor, not to ignore an issue but to actively attempt to mitigate it. This may range from obtaining a social worker to help the patient with ways of financing the medical regimen to ways of more easily getting to the doctor’s office or it may require the doctor to do things, along with patient education, like revising a dosage plan which is simpler and more likely to be followed but yet still potentially therapeutic. But first, the doctor must take the time to talk to the patient. Yes, this takes time but if there is no attempt by the doctor to recognize and find a solution for non-compliance further time "treating" the patient may be wasted to the detriment of the patient's health.

Have any of my visitors had problems with compliance with their physician's advice and prescriptions? ..Maurice.

6 Comments:

At Wednesday, April 29, 2009 1:36:00 AM, Blogger Mandy said...

I am surprised more professionals don't comment on your site.

Maybe that is due to their workloads (although I have come across many medical professional blogs) or perhaps is that there are now so many blogsites around the medical profession that some really thought provoking ones are overlooked.

I'd hate to think that it is because medics think themselves above having to quesiton what they do or don't like being in arenas where patients have as much say as they do.

As someone who could be described as 'non compliant' (due to severe side effects of medication I have taken in the past) I would welcome quality time (as in more than 5 minutes) with a medical professional to discuss this and ways to deal with it more effectively. Sadly, I have been caught between my general practioner who totaly ignored the evidence in regards to physical problems which could be aggrevated by taking new medication and my psychiatrist who is more aware of the implications but can only be seen every 3 months.

Sometimes, it is a matter of accessing professionals, when necessary and the time given and level of attention paid to patients when they are seen.

I agree with what you have written but fear that doctors do not have the time (those that want to) to give due care to all their patients.

Maybe more of an issue in the UK as people don't pay for their care directly...although I prefer a system that provides care for all and not dependant on their income.

 
At Thursday, April 30, 2009 7:41:00 AM, Blogger Dr S. said...

I work in a community based primary health care facility in Cape Town, South Africa.

We have private health care for those who can afford it and state subsidised clinics and hospitals for the majority of our population.

Our clinic is a state-based facility.
We are understaffed and during the clinic days doctors can be expected to see up to 60 patients! This does not provide our patients with much time in the consultation room, nor does it give us medics enough time to properly assess the issues around treatment and compliance.

However, I have noticed that a few well-timed questions, and a non-confrontational or accusatory attitude can help enormously in discovering the truth for not taking medication.

For example, my patients start to queue from 5am in the morning to ensure that they are helped during the day. They often are in a rush to get to the clinic and thus forget to take their meds. Thus, by the time they get to see me, their BP's are sky high and their sugars are through the roof.

I see these high readings, and instead of accusing them I simply start by saying that it must be difficult to be completely organised so early in the morning, and that I understand if medicine was not taken.

Often the patient's are forthcoming after that and admit that they don't usually take their meds. They also open up about other reasons for not taking the medication.

I've realised that it doesn't take very long to enquire about common side effects and to change treatment accordingly.

In my setting of course, I also have the problem of patients being too poor and thus not having the 6 bucks taxi fare to come to the clinic to fetch their free medicines. In these cases I usually try to refer them to the social worker for help.


In summary, I feel that the majority of patients do have valid psychosocial and biological reasons for not taking their medication. Of course there are the stubborn die-hard individuals who consistently ignore advice despite all our best and most empathetic advice.

However, I believe that it IS possible to get to the root of the problem,despite limited time, given the correct non-accusatory attitude from the professional and correct questioning.

 
At Saturday, May 02, 2009 11:20:00 AM, Anonymous Anonymous said...

I could be considered non compliant because I learned after a very bad medication response that i was sensative to medications.... Doctors dont want to hear that the medications they dish out readily really do harm people... I think this is delusiona, on doctors part. I also think that the pharmaceutical companies research is biased....
Many drugs are proven in the field, tried out on patients... many people have died . I am afraid of every drug there is now.
Every time I have objected and then complied, I have gotten worse, ruined liver, etc.. and then the doctor dumps me.... presumably for liability sake...
There isnt anything fair about the medical profession vs. its patients.
I think the doctors view of him/her self is delusional and the role of the patient is near impossible to meet the demands of the delusion.
Secondly, It is specifically because someone who simply doesnt want to take the drugs they get labeled 'delusional' or psychotic, or some other horrible label when there is ample evidence to support their claims/fear in taking the drugs... and there is ample evidence that alternatives work better in some cases...
So, call me crazy....... bah humbug.
This produces the normal feelings of someone educated and literally forced into compliance by a system that doesnt allow anything else...
The patient always pays. You wonder where the anger/hatred and non compliance come from... it is you.... simple.

 
At Thursday, July 09, 2009 7:52:00 PM, Anonymous Anonymous said...

I have a chronic disease that has been in remission for almost 4 years. When I was sick, I was compliant to a fault. For this disease, I take a maintenance medication that requies a blood test every 8 weeks. When my disease went into remission and stayed there, I fell out of compliance here and there with the blood tests, once for a stretch of 5 or 6 months. The reason is that I felt well for so long that the disease held no more significance for my life. Intellectually, I know I still have the disease. However, physically, a disease that ceases to cause dis-ease, ceases to be a disease.

I think in cases like mine, a standard unsigned letter sent periodically, about 3x a year, congratulating the patient if they're doing well, but also reminding them of the disease and the possible implications of not complying with blood tests or medications would be helpful.

NN.

 
At Thursday, July 09, 2009 9:38:00 PM, Blogger Maurice Bernstein, M.D. said...

I have not heard of a doctor sending out a letter to a patient with a chronic illness congratulating them for remaining stable and asymptomatic. It's not a bad idea, though. ..Maurice.

 
At Wednesday, August 19, 2009 6:41:00 AM, Blogger Maurice Bernstein, M.D. said...

A visitor wrote yesterday:

"Very interesting topic. Seems like doctors should have some right or ability to refuse to deal with the patient after a certain amount of time of non-compliance. Is there any law about this or is it a personal decision that the doctor can decide?"


The answer is no, there is no law and yes, it is a personal decision that the doctor can decide. Again, it is the decision of the patient as to the degree of cooperation with the physician's advice. Most physicians will be humanistic about the situation and continue care but carefully document in the chart whether and in which way and to what extent the patient is not following the physician's advice. The physician, at some point, could consider terminating the relationship by referring the patient to another physician who will continue care but the patient cannot be abandoned. ..Maurice.

 

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