Compliance happens when it’s the patient’s treatment plan

Compliance.  I really hate that word!  The general impression given throughout the blogosphere is that patients:

  1. don’t take their medicine
  2. prevaricate

A few typical quotes:

  • Comp-LIE-ance:  ”There are only 2 settings where compliance actually takes place; controlled substances and patients with high copays/no free ride.
  • On Your Own With Multiple Meds:  “Even though people ‘know’ they should take their pills as directed, for the most part, they don’t.

It drives me crazy to read accusations such as these.  I am a patient.

I don’t have a high co-pay, and I’m not taking narcotics, but I’m highly motivated to do everything in my power to retain the ability to walk and dress myself, so I take those pills religiously.

It’s condescending to assert that patients have an obligation to comply with the doctor’s treatment plan.  In an attempt to avoid the word “compliance,” now patients are supposed to “adhere” to the doctor’s treatment plan.  Nomenclature is irrelevant.  It’s still condescending to dictate from on high how patients ought to go about living their lives.

The problem is that it’s the doctor’s plan.  Without buy-in from the patient, it just won’t work.  People do things when it’s to their advantage to do them, and they don’t do them when the costs outweigh the benefits.  It applies to other areas of life, and there’s no reason to think that the same philosophy doesn’t apply to medication.

If a patient says, “The doctor wants me to take all these pills, but I don’t see the need,” then it isn’t the patient’s treatment plan, it’s the doctor’s.  Patients have buy-in when their explanation becomes, “I have a medical condition that could kill me, but there are prescriptions that give me a better chance of survival.  I want to live as healthily as possible, so I’ll take these prescriptions the way they’ll be most helpful, and follow-up with my doctor to monitor my progress.”

Compliance with a treatment plan happens when it’s the patient’s treatment plan.

I am fortunate to have doctors who don’t talk down to me.  They listen to me, they answer my questions, and they don’t act like I’m too stupid to understand the basics of what’s going on with my health.  It’s not easy to take multiple medications, but my doctors have made it as easy as possible by explaining why this is a good treatment plan.

“WarmSocks” blogs at ∞ itis.

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  • Sharon Dietrich

    Your discussion of the “compliance” issue is spot on. I am a Family Doc, and I hate the use of that word, or similar words, in describing patient behavior. I agree completely that any plan needs to be a joint plan, with patient buy in. I work in a clinic for the poor and underserved, and my experience has been that most of the time a patient who is not following the plan has a good reason: no money to buy the meds, no insurance, lack of understanding of the need for the med(we didn’t make sure we were on the same page), or significant family/home/other issues.

  • http://www.cedarhillpt.com Paul Weiss

    As a physical therapist, I often am asked about how I “make” somebody do their exercises, or correct their posture, etc.

    I don’t.

    I train people to associate performing their exercises and using the right posture for their condition with relief of their symptoms. If someone can’t take step towards reaching their goals with what I have shown them, then I have to question what I have done with them.

  • http://fertilityfile.com IVF-MD

    I agree. The word, compliance, suggests one party FORCING the other to do something against their will with reluctant obedience as in “the Jews showed compliance in wearing the Star of David as ordered” or “the workers showed compliance in giving their earnings to the government as commanded”

    A doctor-patient relationship can be much much better than that because it can be consensual and voluntary. How so? Well, as an example, in my specialty, many of the medications are given via injection. As you can guess, this is not something that patients look forward to with delight. Sometimes, they resist or avoid taking them. Therefore it is beneficial to take actions that will increase the proper administration of the medication.

    If there is the suspicion or the outright confession by a patient that they are skipping their medication, I have a conversation with them that goes something like this.

    MD: So, Jane, it is my understanding that you are not taking your medications as we had originally planned. Can you elaborate on what’s going on?
    Pt: Doctor, I really don’t like taking shots. I hate needles.
    MD: I see. Well, that’s certainly a reasonable statement. There are not too many people in the world who enjoy intentionally poking themselves with needles. Can you see the reason why I’m asking you to take these injections then?
    Pt: Well, I know that it will help me grow my eggs better so that I have a higher chance of having a baby quickly.
    MD: You are absolutely correct there. Knowing that, then do you think it is worth the sacrifice of poking yourself once a day like that?

    If the patient says “No, I absolutely can’t keep up these injections. It’s too traumatic”, then we either explore less effective ways of treating her infertility which don’t involve injections or we just risk the danger of her ending up never having children. The choice is hers.

    If the patient says “Yes, I know that it will help me get what I want, but it’s still very stressful”, then I ask them “Can you think of some ways that would make it less stressful and can you think of some ways that will ensure that you take it perfectly every day?”. Often, at this point, the patient comes up with some good ideas that particularly will work for her. Some of these are very creative and I file them away in my head. In the future, if I encounter patients who can’t think of any tips to try, I can suggest some of the ones that other patients have succeeded with.

    In summary, the term COMPLIANCE, puts us at a disadvantage right from the start, because it suggests that we doctors are authoritarians commanding obedient little subjects to do what we say. That is just not a pleasant image. Instead, we should realize that we are helpers who engage our patients in a cooperative effort to better achieve their goals. With that approach, we can better tackle the challenge of persuading them to eat better, to show better life habits and to take their medications properly while respecting their autonomy.

  • Docasaurus

    I understand your post and agree with it.

    Coming to a “common ground” is something that is taught in many medical schools these days and I would hope that all (most?) of the current graduates will remember the importance of having both physician and patient agree to a plan and double checking that the patient understand the whys and hows of their plan.

    And

    From my perspective as a physician who’s been working a number of years, many people decide to take their pills how they want to do DESPITE having come to a consensus with them (having double checked their understanding and any barriers to their plan) and despite the pharmacist having marked clearly on the bottle how to take the medication. You know how cliches form, yes? They form from the truth — while I’m not jaded and I wouldn’t say “ah, patients, ya can’t trust ‘em”, I do often feel tired and less hopeful when yet another person says, “oh I stopped that beta-blocker/blood thinner/thyroid supplement-medication because I didn’t think it was helping”. I agree it is sad that the short-hand term has been not compliant. In some cases, it’s, “I don’t remember”. In other cases, it’s, “I don’t want to see the physician simply to ask a question, so I’ll make my best guess”. I’m sure there are a hundred more reasons why a person might not take their medications as planned.

    People are people — on both sides of the conversation of finding common ground.

    I’m curious, what verb would you apply to a person who, having made a plan and agreed to follow it, then doesn’t follow it? I appreciate that adhere, comply, are verbs that can be “hot buttons”.

    Another issue here is that some physicians will say non-compliant and not mean “that guy’s a lazy so-and-so” but simply mean a short-hand version of saying “that guy has been confused and/or has forgotten the purpose of the plan”. No, seriously. Same thing with the word “failed”.

    Maybe we all (not just the original poster) need to lighten up some.

    • http://warmsocks.wordpress.com/ WarmSocks

      I’m curious, what verb would you apply to a person who, having made a plan and agreed to follow it, then doesn’t follow it? I appreciate that adhere, comply, are verbs that can be “hot buttons”.

      It depends on the situation. I don’t think it’s appropriate for doctors and pharmacists to broadcast throughout the blogosphere how horrible patients are for not taking medication as prescribed. Accusations, name-calling, and finger-pointing harm the doctor-patient relationship. OTOH, discussion of the challenges people face in taking medication on an ongoing basis, with tips on what works (such as IVF-MD has done above), can be helpful. Physicians read and find ideas that might be adapted to their own practice; patients read and find ways to make things easier for themselves. On the internet, I think it’s appropriate to define such a loaded term so that it’s clear that one isn’t saying “that lazy so-and-so.”

      Entirely different in the patient’s chart. If a patient doesn’t follow through on a treatment plan, then in the privacy of the patient’s chart, I don’t have a problem calling a spade a spade. One would hope that the documentation would include the reason that the patient isn’t taking medication as prescribed (or doing whatever it is they need to do), and how that issue was addressed by the doctor. IMO there’s a difference between saying, “the patient intended to follow this treatment plan, but for some reason didn’t do it even though he wants to” (non-compliant) and “the patient has determined that this treatment plan won’t work and wants a different plan” (change in plan).

  • aek

    This is a terrific post. Two things come to mind:

    I find the veterinarian/client relationship serves as a beneficial model of health management partnership. The vet succinctly addresses the options for the presenting problem clearly including costs, time frame, the expected goals and risks/benefits (quality of life versus lengthening survival times, increased comfort, aggressive vs. palliative care, etc). The client chooses from the options or opts out entirely. There isn’t any judgment made as to compliance. And it’s much, much easier to contact vets directly with f/u questions. I have never received the detail, content and individualized context in health education from any physician or other human healthcare provider that I routinely did from large animal, equine and companion animal vets.

    Second: When treatments do not work, the traditional medical record note reads, “patient failed treatment” instead of the other way around.

    There are many subtle and blatant ways that patients are labeled as undesirable, Non-compliant, treatment failure, non-adherent, and difficult are all labels that are used. Also, there is an ICD code for non-compliance, so for the physician who commented above implying that non-compliance is a benign term, I respectfully disagree. It’s a very malignant term, and it can be and is used against patients.

  • elmo

    Honestly, this is little more than wordsmithing. If you want to give me a more “politically correct” term for not taking ones meds as prescribed or following treatment recommendations I will use it.
    PS: I nor any MD/DO I have ever met has used ‘noncompliance” in the setting of coding.

    • http://warmsocks.wordpress.com/ WarmSocks

      I’m not a big fan of political correctness. In patients’ charts, it’s probably important to document when they say that they’re not taking medication as prescribed. Go ahead and use a medical term when it’s appropriate in patients’ charts. That’s different than patients saying they’re taking their meds and the doctor charting disbelief.

      I do think there’s a difference between patients failing to follow a treatment plan that they fully intend to follow (go ahead and say “noncompliant”), and patients deciding that the plan won’t work for their situation and looking for other options (change in plan).

    • anonymous

      I have seen the “noncompliance” code on the superbills my old group used. I have checked it a few times thinking that it gives the insurer justification for a longer appointment (i.e. 99214 for hypertension in which I spent 25 minutes with the patient) but have never asked the biller whether the code prevented any denials and/or requests for chart notes.

  • Kevin

    I agree with above posters.
    If non-compliant, non-adherent, etc. are too pejorative, please tell me the politically-correct term and I’ll use it.
    Perhaps we should just describe the behaviors w/o giving it a name, e.g. “patient has elected to not take medications as prescribed for xzy reason,” i.e. just give the definition in lieu of the word.

    • aek

      Thought-provoking comment, Kevin. What is it we are evaluating? Patient self-efficacy? Self health management?

      I like the notion of simply describing the patient’s actions w/ rationale, but given the EHR environment, not sure that free texting without categorization will be functional for all of the usual suspect reasons.

      The only different term that comes to mind for describing this is patient “endorsement” of prescribed plan. But endorse is different from implement, establish, maintain, etc. Back to Wordnik….

      • Kevin

        As a psychiatrist, I’ve had my share of practice with documentation of treatment compliance. Being a military psychiatrist, I do a lot of clinical writing that is read by those outside our profession, and often need to be very careful with my language, i.e. ‘scrubbing’ it of any editorializing, judgmental-ness, etc. So, I’ve adopted a very “Just the facts, ma’am” approach, which often means not using words that have become “loaded,” i.e. “non-compliant. So, when I come across a “loaded” word, I delete it and just describe the behavior, sans judgment.

      • Kevin

        As far as what we’re addressing. I think some of it is medico-legal, i.e. that the treatment alternatives were explained, that he/she understood, and if treatments are refused (explicitly via outright refusal, or lack of compliance), that we made a reasonable attempt to address barriers to compliance.

        One thing that always struck me is this: if a patient is not compliant (there’s that word again) with treatment, then why does he/she even come to the appointments in the first place? I know one of the answers probably lies with different agendas, i.e. patient wants pain or sleep or some other distressful symptom addressed, whereas doc is more focused on HTN, A1C, dyslipidemia, etc. Similar split-agendas exist in psychiatry as well. Many of my schizophrenia patients don’t take their neuroleptics while making sure to remind me to refill the BZD script. (I don’t say this judging-ly, btw, as I wouldn’t want to experience neuroleptics’ side effects either.)

        My long rambling point is that I think that many “compliance” issues stem from split agendas, and that we have to strive harder to align patient and doctor treatment goals. That may involve some acquiescence on our part. I don’t lament the loss of our paternal role as physicians. I already have kids; I don’t want to ‘parent’ my patients. If a patient is competent, he/she has every right to refuse care, and suffer the consequences. I’ve met my obligation as long as I’ve done my best to communicate the rationale behind my recommendations to the patient, and–again–ensured that I’ve done everything in my power to address potential barriers to compliance (ooops, I said it again!)

        • Diora

          if a patient is not compliant (there’s that word again) with treatment, then why does he/she even come to the appointments in the first place? I know one of the answers probably lies with different agendas, i.e. patient wants pain or sleep or some other distressful symptom addressed, whereas doc is more focused on HTN, A1C, dyslipidemia, etc.

          Exactly. Consider for example “dyslipidemia” since you metioned it. There are a lot of times that statins are prescribed these days for primary prevention i.e. to reduce the risk of a FIRST heart attack. I’d imagine in some cases this risk is fairly large, but there are often cases when it’s not. There is some variety in how doctors go about it. Some doctors do look at absolute risk numbers but there are quite a lot of doctors out there who just go by numbers e.g. LDL> some number. There are also quite a few doctors out there who don’t seem to understand the difference between the absolute risk and relative risk. Sometimes the doctors say “this will reduce your risk by X%” making it sound like without a drug this bad-thing is imminent. How about some honesty here?

          For example, a few years ago my doctor wanted to prescribe me a statin because my LDL was about 4 points higher than the table-guidelines given the risk factors. Now, considering my risk factors, my 10-year old absolute risk of heart attack is under 1%. Now, you can label me non-compliant if you want, but there is NO WAY IN HELL I’ll go on a drug for the rest of my life to reduce my risk from <1% to <.7%. It is entirely my right to choose if it's worth it to me. The same would apply to osteoporosis-prevention drugs or any kind of preventive drugs for that matter. Even if the risk had been higher, say 6%, it's still my choice if say reducing the risk from 6% to 4% is worth it to me.

          I still can go to the same doctor if I feel some symptoms and I trust his ability to diagnose it. Respecting your doctor doesn't mean constant agreement. We are still individuals, and it's still our bodies. Your doctor may feel that because of the guidelines the benefit/risk ratio is favorable, but for the patient the same numbers may mean a completely different thing.

          But these days especially when there are so many preventive drugs that are prescribed to symptomless people for risk reduction (often small in absolute terms), I think doctors should respect the patient's rights to evaluate whether a small reduction of risk is worth to him or her also small risk of side effects.

          I wonder if pre-WHI a woman could've been labeled non-compliant for refusing HRT? What other things that are right today might turn out wrong tomorrow?

          Sure, there are cases when patient's non taking medications has very high risk of consequences. In these cases, there may be a reason why the patient isn't taking the drugs, but ultimately it's his or her body.

          • http://myheartsisters.org/2011/03/30/statins-overprescribed/ Carolyn Thomas

            Statins are an excellent example, Diora, of why patients may be reluctant to “comply”. Statins are the true darlings of the pharmaceutical industry, especially for “primary prevention”.

            But a recent study at Johns Hopkins reported at the American Heart Association’s scientific meetings in Chicago questioned the way Big Pharma has convinced physicians to prescribe statins based on arbitrary lipid numbers instead of on outcomes-based evidence: “Our results tell us that ONLY those adults with some measurable buildup of calcium in their coronary arteries have a clear benefit from ANY statin therapy.” Dr. Roger Blumenthal, director of the Ciccarone Preventive Cardiology Center at Johns Hopkins, explained further:

            “Statin therapy should NOT be approached like diet and exercise as a broadly-based solution for preventing coronary heart disease.”

            Is it any wonder that patients like Diora feel reluctant to “comply” with the doctor’s prescription to take statins every day for the rest of their lives?

          • anonymous

            Diora, if you were my patient, I would NOT have labeled you noncompliant (or whatever word you want to use). You had a legitimate and logical reason not to take statins and you said so upfront. The patients I label as noncompliant (again, substitute whatever word you want to use) are the ones who say they will do their labs but keep forgetting (or other excuse), but still show up for appointments needing refills for their meds (which can cause the lab abnormalities I am trying to test for). I would rather a patient told me upfront that she is not going to take a statin or do a test; then we can move on and base our decisions on correct assumptions (don’t start a med if we cannot monitor the side effects).

    • http://warmsocks.wordpress.com/ WarmSocks

      “patient has elected to not take medications as prescribed for xzy reason,”

      In charting, that could work, although I, personally, wouldn’t want to write/type all that out when one word would suffice. Adding the reasons is a good touch.

      I think the word is more of a problem as seen in blog posts, where it sounds like patients are being condemned.

  • http://www.BocaConciergeDoc.com Steven Reznick MD

    In most patient – physician visits I have seen in my 30 plus years of practice the physician identifies a problem and tries to explain it to the patient in lay terms. The physician then outlines the choices and options for treatment and will say which one he/she prefers. The risks and benefits of the choice are discussed. In most cases the physician and or staff access the patients drug plan to make sure what is being prescribed is covered by the patients insurance. Most practitioners ask the patient if they have any questions or concerns before the visit is complete. Once the patient leaves without raising a question or concern , as the physician you assume the patient is going to follow the mutually agreed upon care plan. You also assume that if there is a problem with the plan after the patient leaves, they will call you, stop back in the office or set up another visit to address their concerns. You do not expect the patient to not fill the prescription or not take it and then show up at a follow-up appointment to check on the efficacy of the treatment only to find out they have not taken the medication at all. It clearly is a two way street communication between physician and patient. If a patient believes a medication is causing an adverse effect or if they want to stop the medication for other reasons it is reasonable to assume that the patient will contact the prescribing physician to discuss the options and choices including how to safely eliminate the medicine . These options are explained at most visits, they are written in practice instruction books and welcome to the office manuals, they are placed on practice web sites. Debating whether the term ” compliance” implies patient subservience isn’t going to alter the problem. It is another example of political correctness diverting attention from improving the problem to a debate on semantics.

    • http://warmsocks.wordpress.com/ WarmSocks

      I think there’s more than one issue here. You’re looking at whether or not patients follow-through on your recommendations after they’ve said in the office that they’re going to.

      I’m looking at what’s published on medblogs and how that comes across. Think about it. If multiple patients ranted about their physicians saying, “Doctors ______” (don’t listen, are only in it for the money, etc. – fill in any complaint), that’s a pretty broad brush to paint all doctors with. Maybe some are that way, but it’s unfair and inaccurate to make such a statement about doctors in general. It wouldn’t take long before you’d get mighty tired of hearing it. That’s the situation with discussions of compliance in the blogosphere: complaint after complaint about how patients aren’t compliant. Well, that’s an inaccurate generalization. Many patients are very good at following their treatment plan: swallowing zillions of pills, poking themselves with needles regularly, doing the exercises that have been recommended. We are compliant.

      You also assume that if there is a problem with the plan after the patient leaves, they will call you, stop back in the office or set up another visit to address their concerns. You do not expect the patient to not fill the prescription or not take it and then show up at a follow-up appointment to check on the efficacy of the treatment only to find out they have not taken the medication at all.
      That’s good to know. Thank you.
      If those instructions are made explicit to your patients, that’s great. None of my doctors have ever said that I should call about medication problems/adverse affects, so I honestly had no idea that my doctors might have that assumption. If there’s a problem with a prescription, I’d assume we’d discuss it at the next appointment. Guess I’ll ask my current doctors their preference next time I see them. Thank you.

  • http://briarcroft.wordpress.com Emily Gibson

    I document that a patient “chooses to defer my recommendation” –it is not a judgment on my part about “compliance” but rather my documentation that the patient has made a choice about his/her treatment plan.

    “Defer” is such an interesting word. I’m using it in the context of “postpone to a later time” in the hope that the plan I’ve proposed may still be considered at some future point. But “defer” also means “to submit humbly to” which is not what I’m implying in this sticky situation.

    • Kevin

      I like using “elect” instead, as it–to me, at least–seems very neutral. I also use “forgo” a lot, in lieu of “refuses.”

      E.g. “The patient has elected to forgo treatment at this time.”

      That way, if re-read (in a courtroom, for example), the notes don’t convey any sense of contentiousness. It’s funny, some above posters have commented that our (i.e. physician) notes are ours alone, which is true *until* they’re being used by a litigant, a state medical board, etc.

      I’m a psychiatrist (early career), and very quickly changed by attitude towards documentation after my first suicide. I’m in the military, and it happened in a combat zone, and the response was insane. The investigators (yes, plural) picked apart my documentation word for word. Bear with me for one example: I spent a great deal of time trying to explain that there was no difference between the following two sentences:

      “Strongly recommend no access to weapons.”

      “Strongly recommend no access to any weapons.”

      I wrote the top sentence; the military’s legal wizards insisted I should have used the bottom. I could write an entire blog post on this, as the investigation’s lunacy didn’t stop there…but I digress.

      So, I think the first time a physician has his/her documentation used against them in some sort of ‘blame game’ scenario (every bad outcome is due to negligence, right?), they’re thereafter changed. I know I am. I write all my notes now imagining how they’ll be re-read to me by an investigator.

      Sorry. I guess I really went off-topic!

  • http://nomidazolam.blogspot.com Jackie

    I have a high deductable AND I am a seasonal construction worker. I don’t go to a Dr. unless absolutely necessary. Here’s the problem with “patient compliance.” (loathesome term) My NP says I have high blood pressure. I can’t keep my job with high blood pressure, so I’m motivated to keep it down. Here’s the problem; My NP wants me to go to the clinic during normal business hours (when I’m at work) ONCE A MONTH to check my blood pressure and get a refill. She will not hear of me just getting refills. That means 95 bucks out of my pocket monthly, plus loss of a days work and possible termination by my employer. Where is HER COMPLIANCE WITH MY WISHES???? I wish to have at least 6 months between visits and a prescription which allows me to do this. This is not unreasonable. I do NOT wish to pay for MRI’s, stress tests, blood work, vein dying episodes etc. I can’t afford them. Why am I branded non compliant or disgruntled, my mental capacity impugned (I read the notes) and all the rest of it when it is the medical practitioner who can’t seem to comply with my needs? Who is in charge, me? Or the medical person? BTW I live way out in the sticks. I have limited access to medical care, so I’m kinda stuck until I move. So right now I am doing without bp meds and medical care. Because of noncompliance on the part of medical personnel. I think this is what medical people want…

    • http://www.BocaConciergeDoc.com Steven Reznick MD

      The medical practitioner is advising based on the information he/she needs to control your blood pressure. If you show a pattern of control they will space out your visits. There are multiple options to comply if you negotiate with your NP . You can stop at a firestation and see if the EMT’s will check your pressure and send in the results. You can obtain a home BP devlce which you can calibrate with your NP and take readings at home and phone them in. You can go into a pharmacy and see if they have a nurse or BP device for public use and report those readings to your NP. Its all about negotiating and communicating and compromising. I can not imagine that you would be turned down if you presented such a plan and agreed to be seen quarterly supplementing your visits with frequent outpatient BP readings that document that you are coming under control.