Physicians are noncompliant too

Patient noncompliance.

I wasn’t very familiar with this term until I started my clinical rotations. But after just the first week, I started noticing that health care providers throw this phrase around all time.

We particularly like using it as an excuse. Why did this diabetic patient require a foot amputation? Why does this patient come in monthly with congestive heart failure exacerbation? Why did this patient suffer a stroke? It’s often simply attributed to patient noncompliance.

What bothers me the most about this phrase, though, is how it’s often stated with such disdain. We act as if it’s incomprehensible that someone would ignore our evidence-based recommendations. If the patient would only bother to listen, he or she would get better. If we were patients, we would be compliant.

But that’s simply not true. We are no different from our patients. We practice our own form of noncompliance. It’s called guideline non-adherence.

Despite the fact that many guidelines are created after systematic reviews and meta-analyses — processes we would never have time to go through ourselves — we, like our own patients, are often noncompliant.

Research on guideline adherence has been around since guidelines started becoming prominent in the early 1990s. Despite the many studies and interventions to improve guideline adherence, the rates of guideline adherence still remain dismally low.

I find this particularly disconcerting. Despite my own interest in research, it makes me question the value of research. Why do we spend millions of dollars to find a better intervention that does not change how most providers deliver health care?

In the current financial climate, our distaste for guidelines poses another concern. The American Board of Internal Medicine Foundation has sponsored the Choosing Wisely campaign. This campaign encourages medical specialty societies to publish a list of “Five Things Physicians and Patients Should Question.” These are evidence-based recommendations from specialists on the interventions in their own field that may be overused.

In other words, these are guidelines on how to practice medicine in a cost-effective way. Guidelines that, if history is any guide, we are likely to ignore. But now more than ever, we need to learn how to encourage guideline adherence. To capitalize on the millions invested in research, we need to do a better job of translating research into practice.

This is exactly what the field of dissemination and implementation science hopes to do. Dissemination and implementation researchers seek to understand how to ensure research findings have their full impact on patient health. For the future of our health care system, I hope they discover how to increase adherence, not only among patients, but also physicians.

Elaine Khoong is a medical student. This article originally appeared in The American Resident Project.

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  • Dr. Ivo Robotnik

    I certainly hope the prevailing view amongst medical students is not to shun critical thinking and just become another cog in the wheel. Guidelines are that; a guide. And although they might be supported by the latest research, many are also proposed by a committee of “expert opinion,” which can be wrong. There are examples throughout history of what is “mainstream” being harmful to the patient.

    There are docs out there that are quacks and still practice like it’s the 1950s, and I think you have a valid point in regards to them. But unquestioningly following guidelines is reckless. Read the latest research yourself and decide whether or not it applies to your patients. If you’re just gonna follow guidelines, you’ll find that other levels of providers will happily take over your job when administration decides that you’re being paid too much to be an assembly line worker.

    • Patient Kit

      I agree. We should all, doctors and patients, resist the idea that critical thinking isn’t necessary anymore. It is and always will be.

  • Dr. Drake Ramoray

    I have this question for the author. If my value or quality as a physician is based on following guidelines which do you propose that I use for thyroid nodules? AACE has one set of guidelines, ATA has a different set of guidelines, Radiology has a different set of guidelines, even the Koreans have their own set of guidelines (noting different characteristics in their patient population associated with malignancy). There is variation in size, composition, an characteristics that vary (although also many similarities) amongst the different guidelines.

    Is it my role solely to look up guidelines, use Uptodate or some other service, and conform to these processes? Sounds like a severe waste of education and life long training. You don’t need an MD to follow guidelines, something that MBA managers are acutely aware of if you are not. In fact our resistance to these metrics and pushback to some d these guidelines (such as mandating certain BP meds on certain heart patients (even those 90 years old who suffer side effects as a result) is one of the things that may some day get you labeled as a “disruptive” physician.

    Yes there is inappropriate testing out there, but guidelines aren’t the end all be all.

    • buzzkillerjsmith

      I think you all have different dyslipidemia guidelines from the AHA/ACC ones, right? Beautiful.

      It does give me a chance to let me use my wonderful new random number generator, which of course I use anyway just for fun.

      • Dr. Drake Ramoray

        Yup lipids are different. The current debate is also now blood pressure goals in diabetics. See that’s the thing about guidelines, as you know, they have this habit if changing all the time.

        And FYI I still prefer the magic 8 ball when I don’t know what to do. Old school I guess.

        • SarahJ89

          Magic 8 ball. Definitely the way to go. None of this fancy pants stuff, Mr. Buzzkiller. {;>)

  • http://www.thepatientdoc.com The Patient Doc

    I agree with following guidelines, but at the end of the day you have to do what’s best for the patient. Sometimes you can’t follow the guidelines strictly when tailoring treatment for a patient. There is an art to practicing medicine.

  • Kristy Sokoloski

    The financial aspect of a patient’s life is a huge reason for non-compliance. Also, sometimes patients will refuse to comply because the “guidelines” that are outlined are not necessarily in their best interests. We have had discussions on this blog in the past about whether annual physicals are truly of any value or not as one example of this.

    • SarahJ89

      Also, the reasoning behind the treatment plan are usually not presented very clearly. I take nothing on faith and need to have a clear explanation as to why some course of action is suggested before I’ll even consider following through. Once I work my way through a period of research and information gathering and buy into a course of action I’m totally committed.

      My husband used to roll over and play dead, taking any pill the doctors shoved at him, no questions asked. But a few really bad mistakes have taught him to think and ask questions. He only has to look at his scars to be reminded not to just follow orders.

  • azmd

    Yet another medical student who knows everything! No doubt a promising career as a non-clinical medical administrator lies in her near future.

  • FEDUP MD

    It’s amazing all the medical students on this site who know everythinpg about medicine after being on the wards a few months, or even not at all!

    Heck, I admit I don’t know crap and I’ve been doing this for a decade.

  • Thomas D Guastavino

    Guidelines have some value for physicians in training. They may also be helpful when medical thought makes a radical change. However, I have seen little evidence that they actual improve upon what an experienced physician was already doing. Can anyone give me an example where following a guideline did improve upon what you were already doing?

  • JPedersenB

    It is also a good idea to really look at the “guidelines” and see how they came about. Many committees were filled with members with significant conflicts of interest (i.e., the lipid panel where 8 out of 9 members had significant ties to the drug companies).

    One would hope that doctors can still think independently, consider the patient’s best interests and not just follow the “one size fits all” type of practice!

  • nautis

    Dr. Khoong brings up a great point. I’ve been reviewing literature on medication adherence and most researchers point to patient non-compliance and lack of education as root causes. There isn’t much about transportation, prior authorizations, side effects, or expense as root causes. A doctor has never called me to ask how I was feeling on a new or changed medication, if I had begun taking as prescribed, or if I even picked up my prescription.

    In other words, most doctors blame medication non-adherence on patients without understanding the larger context. Does a doctor’s accountability end when the patient leaves the office?

  • SarahJ89

    And sometimes the knowledge on the patient’s part that the diagnosis, and hence the “cure,” is wrong is what’s driving the noncompliance bus. I spent over 20 years as a “noncompliant” psych patient refusing unhelpful, side effects laden drugs. The actual cure turned out to be ten dollars worth of levothyroxin.

    I avoid doctors now at all costs, having experienced their disdain at my “noncompliance.” I consider myself lucky to be alive and still in possession of a few brain cells.

  • SarahJ89

    Actually, that’s how it used to work, JD. I miss those days. I miss having an ally in my health maintenance. Being a widget just doesn’t suit me much.

  • Alene Nitzky

    Hmmm…sounds like robotic action and lack of critical thinking is what you’re suggesting.

  • FEDUP MD

    I really think this articlw is an example of why a little knowledge without context is more dangerous than none. Medical student sees that there are “rules” she must learn and that this encompasses the practice of medicine if done correctly. The “rules”come from “experts” who know more and hence should be followed blindly. This is the viewpoint of the passive learner. What she doesn’t understand is how to be an adult learner. This involves investigating herself WHY these rules were developed and if they are the best for the given situation, given the strengths and weaknesses of these studies. It doesn’t involve just accepting them because you blindly believe that the authors are smarter than you or know more than you. That is how a child learns, and it is an attitude that works well getting you to med school and through the first two years- just learn everything put in front of you and you will be successful. This is not what makes an adult learner or a good doctor, however, in fact quite the opposite. If you want to be a true lifelong learner, start with being active and ASKING your superiors WHY in certain situations they are making decisions that are different than guidelines. (Obviously you have to choose your words and tone carefully here to convey curiosity, not confrontation). You might learn something from their answers as opposed to just dismissing them as wrong because they aren’t “following the rules.”