Medicine’s Favorite Default Diagnosis: Non-compliance

August 2, 2012

By Robert Keller

Faculty Peer Reviewed

In a small examination room on the Ambulatory Care floor of a large hospital in Brooklyn, I greet Ms. S, a 53-year-old Jamaican woman, as she walks through the door and plops herself down in the chair across from me. Having spent 20 minutes perusing her chart, I know that she suffers from morbid obesity, uncontrolled hypertension (blood pressure 165/95), and terrible diabetes (A1c 13.8%). I have already concluded that her worsening condition over the past 5 years, despite the extensive medical interventions attempted, can be explained by a simple yet dismissive diagnosis of patient “non-compliance.” I am poised to unleash my spiel on the gravity of her condition and the necessity for change, but before I have a chance to start, she begins speaking in her strong Jamaican accent.

“Doctor, you will be so proud of me. Since the last time I was seen here in the clinic 6 months ago, I have made great changes in my life. I eat only healthy foods—just salads and fruits. I’ve stopped drinking soda and instead take in lots of water every day. I even joined a gym and now walk for 30 minutes on the treadmill each and every morning.”

To say the least, I am caught off guard. My assumptions behind her worsening obesity, diabetes, and hypertension seem threatened, so I ask, “But Ms. S, have you been taking your medications as prescribed?”

“Oh yes, of course, Doctor. I never miss a dose,” she responds.

Her statement leaves me perplexed. How could the conditions of this woman, who over the past 6 months has reportedly been compliant with her medications and adherent to physician-recommended life modifications, continue to be so poorly controlled in so many parameters? The first thought to cross my mind is that maybe she is not telling the truth. She may not drink soda anymore, but loads her coffee with sugar every morning. She may go to the gym, but “30 minutes on the treadmill” includes the 25 minutes of travel to and from the gym each day. And her medications—she probably doesn’t want to disappoint me by admitting that she misses a dose here and there. I cannot escape the conclusion that she is not following doctor’s orders.

After presenting the case to my attending, we agreed that the full story probably wasn’t being told and there was likely some factor of non-compliance at stake. Ms. S was sent home that day with encouragement to continue maintaining her supposed new healthy habits and, in an attempt to provide some control of her chronic conditions, was started on a new regimen of increased dosages and additional medications.

In retrospect, my preconceived notions and hasty conclusions were both stubborn and naïve. Who was I to make assumptions about the patient’s compliance without first hearing her story and, worse yet, disregard her subsequent testaments as not being the “full story”? Perhaps this was the natural course of her disease and our interventions were just inadequate—but why was this option never considered? The case left me with a reality that needed to be faced: patient “non-compliance” is too often a default diagnosis physicians overuse to conceal and ignore a more complicated underlying issue.

In health care, compliance has been described as “the extent to which the patient’s actual history of drug administration corresponds to the prescribed regimen.”[1] While this term has long been engrained in everyday medical discourse, physicians and scholars have recently questioned its political correctness and its ability to reflect the value of partnership in a doctor-patient relationship. In the past, it was generally accepted that healthcare professionals employ a model of paternalism, where the provider specifies a therapy and the conditions of its use while the patient follows these orders as directed.[2] The term “compliance” defined in Merriam-Webster’s as “a disposition to yield to others,”[3] fits quite nicely in the context of such a relationship. However, as the social contracts between doctors and patients have evolved, doctors now assume roles more akin to educators, advisers, and enablers who desire partnership rather than dictatorship.[4] To accommodate this transition, the term “adherence” seems a better fit than “compliance,” as it provides a more supportive and collaborative connotation. Recent literature now strongly advocates the use of non-adherence over non-compliance in the language of health professionals, but many have yet to catch on. They may actually be hindering the process of change toward forming more synergistic alliances with their patients.[2]

Terminology aside, the issue of patient non-adherence is currently plaguing the health care system. It is estimated that half of the 3.2 billion prescriptions dispensed in the US annually are not taken as prescribed, even though there exists substantial evidence that medical therapy improves quality of life and mortality in people with chronic diseases.[5, 6] Not only does medication non-adherence lead to poor clinical outcomes, it is estimated to stress the healthcare system, with costs reaching $177 billion annually.[7] In fact, a 2003 report produced by the World Health Organization argued that improving adherence to existing treatments would provide more health benefits across the globe than from creating new medical therapies.[8]

The scope of the issue is no longer a mystery, but what remains ill-defined are the underlying causes of non-adherence. Barriers to adherence that have been well described in the literature include low health literacy, poor bidirectional doctor-patient communication, failure to negotiate an agreement on a medication plan, cost prohibition, non-response to the prescribed intervention, and unpreventable reasons such as serious mental illness and side effects.[6] When a doctor senses the urge to diagnose “non-adherence,” these barriers ought to be contemplated first. Perhaps the physician will recognize his own shortcomings in explaining why a certain medication is being prescribed—because after all, who is really willing to inject themselves 4 times a day and painfully prick their fingers just because “this helps with your sugar”? Donovan and colleagues argue that the key to eliminating these barriers is the nourishment of cooperative doctor-patient relationships with doctor-recognition of patients’ autonomy, needs, and constraints.[9] Conversely, the patients’ obligation is to convey their needs, expectations, and how they reach their decisions about treatments.[9] While this advice may benefit in the local office, there remains an international need for public health initiatives geared toward non-adherence.

Doctors are trained to be experts at recognizing signs and symptoms that guide them to important diagnoses. Unfortunately, many have yet to see non-adherence as a symptom of underlying pathology rather than a diagnosis itself. Physicians owe it to patients like Ms. S to make the effort to uncover the true reasons behind their non-adherence.

Robert Keller is a 3rd year medical student at NYU School of Medicine

Faculty peer reviewed by Sabrina Felson, MD, Medicine (GIM Division), NYU Langone Medical Center

Image courtesy of Wikimedia Commons

References:

1. Urquhart J. Patient non-compliance with drug regimens: measurement, clinical correlates, economic impact. Eur Heart J. 1996:17 Suppl A:8-15.  http://eurheartj.oxfordjournals.org/content/17/suppl_A/8.full.pdf

2. Holm S. What is wrong with compliance? J Med Ethics. 1993:19(2):108-110.  http://jme.bmj.com/content/19/2/108.abstract

3. Merriam-Webster’s Collegiate Dictionary. 11th ed. Springfield, MA: Merriam-Webster Inc; 2003. http://www.m-w.com/dictionary.htm.

4. Tilson H. Adherence or compliance? Changes in terminology. Ann Pharmacother. 2004:38(1):161-162.

5. Osterberg L, Blaschke T. Adherence to medication. N Engl J Med 2005:353(5):487-497.  http://www.nejm.org/doi/full/10.1056/NEJMra050100

6. Bosworth HB, Granger BB, Mendys P, et al. Medication adherence: a call for action. Am Heart J. 2011:162(3):412-424.

7. National Council on Patient Information and Education. Enhancing prescription medication adherence: a national action plan. http://www.talkaboutrx.org/documents/enhancing_prescription_medicine_adherence.pdf Published  August 2007.   Accessed November 18, 2011.

8. World Health Organization. Adherence to long-term therapies: evidence for action. http://www.who.int/chp/knowledge/publications/adherence_introduction.pdf.  Published 2003. Accessed November 18, 2011.

9. Donovan JL, Blake DR. Patient non-compliance: deviance or reasoned decision-making? Soc Sci Med. 1992:34(5):507-513.

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