Solving the puzzle of patient compliance

by Dennis Grace

I recently received a message from the Center for Connected Health.  I must admit the opening of the letter really put me off. It asked:

How do you solve the puzzle of patient compliance?

I responded to the gentleman who sent the invitation with:

Well, you might start by calling it something less offensive. Patient compliance? The phrase assumes “patient” as direct object rather than subject of participatory medicine. We are all patients. We are not comfortable in the third person. We don’t want to be compliant. We want to be connected, educated, empowered participants.

I went on to say that I expected more from the Center for Connected Health, and I cc’ed the response to ePatient Dave deBronkart, who asked if I’d seen his blog post |about the hospital’s side of compliance. I said I had not and promised to take a look.

Now, in defense of the individual who forwarded me the first message, he did reply with an apology for the insensitivity of his choice of words. He was, however, echoing sentiments to be addressed in the symposium. If you look at Dave’s blog post—especially at his comments—you’ll see just how far this horrible phrase has gone.  Dave quoted the following, but I just want to look at this Wikipedia entry for compliance (medicine) in a little more detail. It begins:

In medicine, compliance (also adherence or concordance) describes the degree to which a patient correctly follows medical advice. Most commonly, it refers to medication or drug compliance, but may also mean use of medical appliances such as compression stockings, chronic wound care, self-directed physiotherapy exercises, or attending counseling or other courses of therapy.

The entry goes on to explain that many prefer adherence or concordance because the problem is seen not as one of refusal to comply with orders but rather as a failure to stick to orders or a failure to come to agreement with the terms. Funny how the variations still blame the patient but remove any onus from the physician. It’s not that the patient doesn’t comply with the doctor’s orders; it’s that she doesn’t adhere to the regimen.You might argue that concordance fixes the problem, but look again. The Wikipedia writer clearly could only accept concordance as another way to obtain compliance:

Concordance also refers to a current UK NHS initiative to involve the patient in the treatment process to improve compliance.

In other words, it’s still the patients’ fault.

This whole compliance (medicine) article comes through to me as blame the patient. My first response, as a patient, is to be insulted that I’m the target. So, I analyze that problem.

Problem part one: the patient. Okay, you handed something (drugs, exercise plan, a diet, an orthotic) over to the patient, and the regimen was never completed; therefore, we should blame the patient. Why? Were the instructions clear and complete? Did they explain the rationale or just provide marching orders? Was it the correct regimen? Were any contingency plans included? Did the patient have any options at any point? Was the patient part of the process or just a vessel? All this blaming accomplishes is making more patients angry and disaffected. Worse than that, labeling us as non-compliant is patronizing. That is, it makes the doctors look just that much more patronizing. Lecture me like I’m a naughty child — yeah, that’ll convince me.

When I try changing the emphasis, however, I see that patient isn’t really the problem.

Problem part two: the blame. Changing one word (compliance to concordance) doesn’t change the approach here (blaming someone); it just shifts the blame from the patient to the patient/doctor partnership. I don’t want to just shift the blame—not to the partnership, the doctors, the nurses, the pharmacists, Big Business, or the Puritan Work Ethic. I don’t care who’s at fault. Blaming just makes someone look incompetent or stupid or belligerent. Fixing the blame doesn’t fix the problem.

Changing one word won’t change this from being a blame game. We need to change the entire approach to the issue of completing a regimen. Instead of discussing the negative implications, let’s stick to the positive. Can’t we just discuss the concept of completion of regimen and put the emphasis on doing it right? Here’s a simple example:

Completion of an antibiotic regimen dramatically increases the odds that we will wipe out the invading bacteria altogether by eliminating even bacteria that attempt to hide from the antibiotic effects by going dormant. Knowing that, how do we ensure that this is the correct regimen and that the regimen is completed satisfactorily?

I know I’m not likely to fix a decades-old problem with a simple paragraph, but I think this at least points the way. Maybe you can come up with something better.

Dennis Grace is co-founder of and blogs at The BillDog Blog.

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