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challenges of trying to be as effective as we can with the patients we care for. We still face challenges that handcuff the effectiveness of our recommended treatments for a variety of medical conditions and grapple with the very serious consequences that result from both of these terms. The reality is that we clinicians have had little training in identifying the common causes of patient non–adherent
or noncompliant behavior, and as such have few tools to cope with this type of behavior. All of that said--- I have had to re-examine my use of the term non- compliant. This is not a recent enlightenment for me, I saw flaws in this term many years ago. We have to be careful with assigning this label without taking the time to find out why a patient may appear non-compliant. It all boils down to our making the effort to find out “if ” and “why” we are experiencing either an unintentional or intentional refusal by some of our patients not to comply with clinical recommendations, directives, advice and more. Because non- adherence or non-compliance, based on our written clinical assessments, is listed so ubiquitously as “the reason” why our patients are not improving health-wise in a way that we would expect them to, I think we are overdue for changing our approach and understanding of this terminology in our practices.
Perhaps starting with –not asking “why does my patient NOT adhere or comply” but by asking rather “what are the reasons why my patient cannot adhere or comply.”
This seems to be a clever twist on words but with a far more expansive landscape for the exploration of “Why.” As it turns out, the literature is full of examples of both non-adherence and non-compliance and the related consequences but looking further the literature also provides insight into how these “labels” often completely miss the reasons why patients may appear this way.
In a Permante Article entitled “ Understanding Non- Compliant Behavior: Definitions and Causes, by Fred Kleinsinger, MD, he states that he just tells the patient he is frustrated and concerned and needs to know what he or she understands about the disease process and problems being faced—then he stops talking gets quiet and listens as nonjudgmentally as possible. While there is nothing novel about this approach, the enlightening aspect about this technique is what clinicians can learn from this direct approach. As you have likely surmised, non-adherence
or non–compliance in most circumstances, is not an active decision by your patient not to comply. There are a myriad of reasons why patients cannot always “do what
Third Quarter 2021
you are teaching them about, making recommendations for, educating them on, offering training for, providing instructions about, or ordering equipment for, etc.
The most frequently cited reasons for non-adherence or non-compliance in the literature are numerous as follows: Physician communication skills –(the style and manner in which information is presented to the patient), the patient’s ability to comprehend and effectively use the medical information in an actionable manner, Language barriers— Native English speakers or English as a second language, Education level, Cultural practices and differences, individual or family behavioral health issues (Depression, anxiety, bipolar disorder, dementia – other), relationship security, Home stressors/homelessness, Other stressors/ financial/coping skills and more. The literature further informs that once the root causes of the contributors
to less than optimal outcomes are identified, clinicians can utilized motivational interviewing techniques to acknowledge concerns. The literature also suggests that physicians could benefit from recommending maybe 2 to 3 “key” health improvement recommendations verses 10. Other thoughts were to consider involving Social Work and/or Behavior Health for psycho-social, emotional, and environmental challenges. Also, most health systems have access to multi-language interpretation services available 24/7 if needed for those who may not fully speak or understand English.
Dr. Kleinsinger concluded his article with this piece of advice “instead of my earlier ineffective tactic of repeatedly hammering the same advice and information into the resistant ears of my non-adherent or noncompliant patients, I found that making the effort to understand
the causes of each patient’s behavior helped me tailor an approach to removing obstacles and encouraging the patient’s full participation in their own health care.” One more meaningful piece of advice from the literature is this: Whether it is an issue of non-adherence or non-compliance it is essential that the provider and the patient, have a common understanding of the medical issue in question, the availability of effective medications, treatments or procedures for their issue, and the risks to the patient if the medical issue remains untreated or undertreated.
References:
1. https://www.capphysicians.com/articles/ noncompliant-vs-non-adherent-patient
2. https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5571787/
3. https://www.capphysicians.com/articles/ noncompliant-vs-non-adherent-patient
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