Getting the 'Straight-A' Patient

April 1, 2006

With malpractice lawsuits and pay-for-performance schemes on the rise, it's more important than ever to get patients to follow your advice - but it's also more challenging. We help you sharpen your teaching skills.

Today's patients are better informed about their health than ever before. Or at least they think they are. That may be why some of them don't follow your directions - and why you need to be a better teacher.

It's dark and temperatures hover at zero, but Thomas Kottke, MD, is undaunted.

Unless the roads are too icy, the 57-year-old cardiologist is bundled up and out of his house before 7 a.m. each workday, biking the first leg of a 14-mile roundtrip to his St. Paul office.

The owner of five bikes, Kottke has regularly engaged in this type of exercise his entire adult life. He says he does so not only for his health, but also to be a good role model for his patients.

"Clearly, 'Do as I say, and not as I do' doesn't play very well with patients," he says.

So when Kottke tells a patient recovering from a heart attack that he must get regular exercise, he's not about to accept Minnesota's harsh weather as an excuse. Kottke doesn't expect patients to duplicate his dedication. But his years in practice - and those he spent serving on the American Heart Association's (AHA) national patient compliance taskforce - have taught him that every bit of persuasion helps.

"I search for something that they used to do, that they used to enjoy," Kottke says of his patients. "Many people used to swim or run or bike. They don't have to try to be world-class; that just causes injuries. I point out to them that the biggest benefit they can get is really to go from doing nothing to doing something."

Kottke has enjoyed success with his approach of tailoring his instructions and suggestions to the lifestyles of individual patients. That was one recommendation of the AHA's taskforce, which concluded that a combination of techniques can best enhance patient compliance. They advise to learn - as Kottke does - what might motivate individual patients and then deal with the preconceptions they may have about certain treatments. Consider ways to simplify regimens. Repeat your suggestions and get patient buy-in, similar to how a salesman would close a deal.

Finally, don't let today's "empowered" patients overpower you. Yes, you can negotiate treatment plans and discuss options with your patients. But you're the one who went to medical school. Help your patients make sense of all the information they've gotten, but feel secure in your recommendations.

Why the big deal?

Patient noncompliance is a significant problem in healthcare delivery. Up to half of all patients fail to follow their prescribed drug regimen; some 5 percent to 20 percent of prescriptions are never filled in the first place. Patient compliance with protocols for coronary artery disease and other chronic illnesses continues to be poor.

A study by researchers at Duke University published in the Jan. 2006 issue of Circulation found that in 2002, just 39 percent of some 30,000 patients with coronary artery disease consistently followed their physicians' recommendations for taking aspirin, beta-blockers, and lipid-lowering medications.

Adherence levels were only slightly higher than those reported in 1995 among the same group of study subjects. Lead researcher Kristin Newby called "eye-opening" the finding that only 71 percent of the patients studied regularly took aspirin, despite the fact that it is cheap and readily available.

Clinical outcomes for patients who follow recommended protocols are understandably better than for those who don't. But more than your patients' health is at stake if they are not compliant with your directions, says Manoj Pawar, MD, the medical director for Denver-based Exempla, a nonprofit physician network. You'll make more money in pay-for-performance programs if you can demonstrate that your patients are compliant in receiving preventive care such as mammograms and other recommended screenings.

Successful patient compliance could also boost your practice numbers. Patients who are compliant with recommended treatments are likely to be more satisfied with their care and thus rate your practice more highly on surveys conducted by health plans, says Pawar. If you spend time working with your patients to improve their compliance, they might talk you up to their friends and neighbors.


"By virtue of the fact that you dug deeper, patients feel you care about them, and they will tell other people to go see you," Pawar says. "They will say, 'He listens to me.' People are paying higher copayments, and there is not as much disposable income as there was. They want to know if they are getting value for their dollar. It is easy for patients to switch doctors if they are not happy."

A PARADOX

But improving patient compliance defies easy answers. Drugmakers spend millions developing pills that are more palatable to the public. Medications today go down easier, fizz into action on your tongue, and come encased in easy-to-track blister packs. Today's treatments are more effective and often have far fewer side effects than previous regimes.

And patients are better educated. Health plans and local hospitals send helpful tidbits to patients aimed at keeping them healthy and successfully managing their chronic conditions. The Internet is packed with healthcare information offered by the federal government, patient groups, research organizations, and companies with something to sell. Self-help resources abound. Medication information even comes stapled to bags holding patient prescriptions.

But patient compliance rates have not improved. In fact, these factors may actually be contributing to a worsening of patient compliance over time, says health researcher Judy Z. Segal, PhD, author of the book, Health and the Rhetoric of Medicine.

"Noncompliance often has very practical reasons behind it," says Segal, an associate professor at the University of British Columbia in Vancouver. "People can be confused about dosing schedules or cannot tolerate side effects. But I think often doctors have failed to persuade patients that complying is in their own best interest. The idea is that people need good reasons, sometimes very specific reasons, for following their physicians' advice.

"It could be that 20 years ago we weren't complying because we didn't understand the advice or we couldn't afford the medicine," she continues. "But now I think it has more to do with our sense of being somewhat in charge of our own care. We often think we can make medical decisions for ourselves, and often we are wrong."

Physicians have historically adopted a paternalistic approach toward their patients. That has changed in recent years, as many physicians now advocate a "partnership relationship" with those they treat. Some experts say that physicians should accordingly strive for patient "adherence" or "concordance" rather than "compliance," which connotates an authoritative relationship.

"Patients are, it's true, experts on their own experience," says Segal, "but they don't know what doctors know. Part of what I write about is that physicians shouldn't give up their special claim to medical expertise. I don't think establishing expertise means appearing superior or paternalistic or bossy. The conversation needs to be respectful and open. Patients have access to so much health information, but they don't always have the means to make sense of all that information. It is a mistake to think that medical information is the same as medical knowledge. The physician could say, 'I've done research on this, I've seen a lot of patients, I follow the literature.' ... I think there is a certain amount of persuasion that should be done. What physicians say to patients really does count."

One reason Segal suggests patient compliance is not improving may be that although physicians acknowledge the problem is widespread, they don't believe it's an issue among their own patients. So when a patient comes in complaining of continuing pain, the physician's first thought is to order more tests or try another treatment without investigating whether the original regimen was followed.

"I've always been struck by the fact that physicians don't really have strategies to tell if their patients are responsive to therapies or not. ... It is kind of a hidden problem," says Zachary B. Gerbarg, MD, president of Eagle Medical Management, LLC, in Scottsdale, Ariz. "Many times physicians don't know if the patient is noncompliant or just nonresponsive."

Kottke says this attitude is dangerous. "For the noncompliant patient, the most important thing is finding out, through a careful history, what the barriers are to compliance," he says, and then developing specific strategies to overcome them.

ENHANCE PATIENT TRUST

One way to discover those barriers is to strengthen your patients' trust in you to the point that they feel comfortable revealing personal compliance issues. You probably think your patients already trust you; if they didn't, why would they keep coming back? But take a moment to think about that attitude. On some level, your noncompliant patients may not be buying into what you're telling them.

Pawar suggests listening more closely to those patients. He recommends beginning every visit with a bit of chitchat. Just 30 seconds may be enough to detect an individual's compliance obstacles. Ask open-ended questions and wait for your patients to answer. "Don't say: 'How's the family, good?' Say, 'So tell me what's new in your life,'" Pawar says.


If the patient is new, spend more time with him. With each subsequent visit, his trust in your abilities should increase, and the time you spend talking about nonmedical issues can accordingly decrease, says Pawar. "Physicians think, 'How can small talk build trust?' But it can." Such informal conversation can help physicians pick up on subtle cues that may indicate a patient's needs, Pawar says. Physicians can then use that information to help motivate patients to become more compliant with their treatment regimens.

Pawar recently used this technique with a patient who smoked. He knew from previous conversations that the man was getting close to achieving his dream of owning a vintage car. In discussing how to care for such an antique, Pawar noted that the man might not want to smoke in the car.

The man agreed, and that opened the door for a renewed conversation about smoking cessation. During the visit, the man said he would quit smoking and followed up on that promise, says Pawar. "My assumption is, if a patient is not following your instructions, I think you may not be framing the recommendation in a way that is meaningful to the patient."

USE TOOLS THAT WORK

One of the most effective ways to enhance compliance, says Kottke, is to simplify a patient's instructions or regimen as much as possible. Prescribe blister packs whenever possible, he says, and be on the lookout for other advances in packaging and in medications themselves that might benefit certain patients.

"There was a guy I saw just the other day - he is a shift worker," says Pawar. "He is on something twice a day, and it is difficult for him to take his second dose while he is at work. A new version is available for once a day. He is [now] much more compliant [with this regimen]."

EMRs provide physicians additional tools that can enhance compliance. With his system, Kottke can identify the medications a patient is taking as well as others that might have been tried in the past, with notes telling him why they were discontinued.

Such organizational support can help physicians "remember what the patient is on, what changes have been made, and what has been done to support the patient," Kottke adds. If compliance issues arise, communication is critical among all members of staff - as well as external pharmacists - to get a complete picture of the issues involved.

Kottke has computer access in every treatment room in his office. He takes notes during patient visits and then prints them out for the patient at the conclusion of the visit. "It gives them a record of the encounter," including the names of any prescribed medications, Kottke says. For those who would balk at this, he adds, "If you are putting something in the record that you don't want the patient to see, then maybe you shouldn't put it in."

Physicians can point patients to additional tools - many available online - that include exercise logs, journals, and mood diaries (for mental health conditions). You may also want to consider drafting a doctor/patient "contract." Kottke asks some of his patients - particularly those trying to quit smoking or increase their physical activities - to sign a contract pledging to make such changes.

Patients who take multiple drugs could benefit from an organizer, or "tackle box," as Kottke describes it, to help keep track of their medications. He got such a box for his parents, who are 94 and 88 years old, and he helps them sort out their pills by day.

You can further boost patient compliance with preventive care and checkups by having systems in place that generate patient reminders. Pawar's office created a database of its diabetic patients. Using automatically generated reports, staff members call patients whose hemoglobin A1C was not under seven at their last visit, and invite them to come in for follow-up. The office also tracks patients who haven't been seen in three months.

If you choose to contact patients, Pawar cautions physicians to be careful about what is said during reminder calls. You don't want patients to think the physician is "angry" or that there is some medical problem that is prompting the call. Rather, patients should get the sense that the physician cares about their health.

Additional steps physicians can take to enhance patient compliance include:

Broaching the subject of costs. Medications are increasingly expensive, and patients with drug coverage are paying larger percentages than they used to. Significant numbers of patients have no coverage at all. "I fully acknowledge that medications are expensive, and I encourage my patients to talk to me about that. If there is a cheaper option I will help them figure that out," Pawar says.

Discussing new or controversial medications. When you prescribe something the patient hasn't taken before - particularly if it is something that has been in the press or is controversial - Segal suggests asking the patient leading questions. "Create an opportunity for patients to voice their fears and their objections to the medication, whether it is about becoming addicted or gaining weight," she advises. "Patients are more cautious these days. They have beliefs coming in the door."

Make an effort to uncover patient anxieties regarding specific medications, and then attempt to defuse them with a frank discussion about risks and benefits. Segal gives an example: "If you are prescribing Ativan, you could say, 'What have you heard about this drug? Do you feel comfortable taking it or do you have concerns about it?'" A patient may not volunteer that he is worried about issues such as addiction unless you pose the question for him. By doing so you can get such objections on the table and deal with them before they lead to noncompliance.

Warning of side effects. Tell patients ahead of time about any potentially troubling side effects they may experience with certain medications and how to deal with them. If they are informed and know how to cope, they are more likely to stick with their treatment, says Segal.

But don't allow this type of discussion to obscure the fact that the patient would benefit from the treatment, says Kottke. When a patient is overly concerned about side effects he may experience from an essential medication, Kottke says to remind him, "The major side effect is that you will live longer."

Probing for supplement use. Get the whole picture. Don't forget to ask patients if they are using supplements to help with their symptoms or conditions, says Kottke. Some patients may turn to supplements over their prescription drugs because they are cheaper. Talk frankly to patients about supplement use and their possible interactions with prescription medications.

Making an impression. Like Kottke, try to practice what you preach. And hone your communication skills and your presentation so your message sticks with patients. Segal says statistics indicate that patients only retain about 20 percent of the information they hear, and about half of what they remember is wrong. Providing patients with written instructions also helps.

Paying closer attention. Perhaps some of your patient encounters suffer because you zone out during visits. To combat this, Pawar says he stops in front of the exam door, takes a breath, briefly reviews the patient's chart, and then reminds himself what is important to that specific patient.

Reinforcing patients' successes. Making note of patients' improved adherence to treatment regimens also encourages you to take similar steps with other patients rather than continuing feeling cynical that "people won't change," Kottke says.

Closing the sale. Review your recommendations at the end of patient visits and seek buy-in from the patient. "I might say, 'How does this sound?'" says Pawar, who adds that many physicians fail to take this simple step, either because they don't think it is necessary or they forget. It's helpful to watch the patient's reaction as you explain the treatment plan. When he senses some hesitation, Pawar probes gently by saying, "Let me check in here. Something seems not right."

Kottke says he asks patients if they are willing to take the medications he prescribes. "That may seem heavy-handed, but it will increase the probability of finding those barriers," he says.

"Many physicians feel there is a certain level of responsibility for patients to follow through and take care of themselves," adds Gerbarg, who has studied patient compliance issues. Still, he strongly recommends that physicians improve their communication with patients. "Can you get into a partnership, can you understand the emotional issues that might be barriers, and can you connect with the patient?" he asks.

How patients feel about the message and the messenger can be a decisive factor. "The biggest influencer still is the physician," Gerbarg affirms.

Theresa Defino, editor for Physicians Practice, can be reached at tdefino@physicianspractice.com.

This article originally appeared in the April 2006 issue of Physicians Practice.