It should’ve been a simple procedure.
Neil Baum, a urologist in New Orleans, recalls one instance when he inserted a ureteral stent to relieve a kidney obstruction in one of his patients. The patient then left the office, after being told to return in three days time to have it removed. He never did, despite countless attempts to reach him by phone. An inevitable infection set in, at which point the patient began threatening legal action, blaming Baum’s standard of care.
But Baum was prepared. “I showed him the consent form that clearly stated he had to return, along with our records showing he didn’t return our calls,” says the associate clinical professor at Tulane Medical School who estimates that up to a third of his patients don’t hear what he tells them in the exam room. “Patients are out of their comfort zones when it comes to healthcare,” he says. “It’s very stressful. They’re often anxious or frightened and not fully focused on listening to what you tell them.”
Such is the quandary facing physicians in all specialties: You spend inordinate time and energy educating yourselves on the latest medical therapies, and yet all too often you’re stopped by patient noncompliance. “There are volumes of research in this area, but most studies find that patient noncompliance with taking medication is roughly 50 percent,” says Jacqueline Dunbar-Jacob, dean of the University of Pittsburg School of Nursing, who has investigated patient adherence for 25 years. “Where lifestyle changes are recommended, that figure is probably higher.”
Why don’t they listen?
There are countless reasons why patients ignore healthcare advice. Older patients, in particular, may believe the treatment will be ineffective, or they worry about unknown side effects. Or, says Dunbar-Jacob, they may simply forget. “The ‘forgetting’ phenomenon seems to be a real one,” she says. “The person who gets into the routine of taking medication every morning becomes so habitual that they don’t notice if they’ve missed it on any given day.”
Sometimes noncompliance is purely a financial issue, as some patients — particularly those on fixed incomes — may not be able to afford the out-of-pocket cost of what you’ve ordered. What can you do to help mitigate this problem? “A lot of times the recommendations for a specific lab test or treatment may be fairly expensive and if it’s not covered by their insurance they may not have it done,” says Jim King, a family physician in Selmer, Tenn., and president of the American Academy of Family Physicians.
Give out samples of high-priced drugs if you can, or help put patients in touch with pharmaceutical companies that provide medication for free to those in need. “If it’s a pill that can be broken in half, we’ll also sometimes write a prescription for a stronger dose so the patient can break them in half — which is cheaper for them,” says King. “If it’s a test that we feel the patient really needs, we’ll also try to discount our own costs or negotiate with a hospital for a reduced rate.”
Finally, says David Hunt, president of Critical Measures, a Minneapolis-based consulting firm that specializes in cross-cultural healthcare, consider the demographics of your patient population. Do you have patients with limited English proficiency? Certainly, this makes comprehension of medical terms that much more challenging.
“Physicians should use qualified interpreters,” he says. “Using family members and friends or even children to interpret is not safe or quality practice.” Why? Because physicians often assume incorrectly that the adult child not only is going to speak English, but is able to speak their parent’s native tongue at a level that allows them to translate complex health terminology. Many hospitals have interpreters on staff who can be called to come in, or at least translate remotely via telephone.
Reading your patients
Unfortunately, it’s virtually impossible to know for sure if your patients are putting your advice into action. But there are signs that suggest noncompliance, the most obvious of which is that the patient’s condition remains the same, says David Dale, president of the American College of Physicians. “You may have an adherence issue if the patient still has high blood pressure, but you’ve been prescribing powerful drugs, the patient does not lose weight under a recommended diet plan, or he is still having chronic headaches in spite of the medication you prescribe,” he says.
Body language in the exam room is another important cue. “Sometimes silence speaks louder than words,” says Hunt. “When the patient looks at you with a pained expression, or there’s a lengthy silence after you ask them to do something, you need to encourage further discussion.”
Also, be on the lookout for patients who nod in agreement to everything you say during an exam. Nodding does not necessarily mean compliance; it may in fact just be a form of etiquette. “Physicians need to understand that sometimes, yes means no — not just for culturally diverse patients, but for lots of older adults, too, who have been taught to respect, if not revere, physicians,” Hunt says. “Many would consider it insulting to disagree with a doctor.”
Upping the odds
