In Practice: Do As I Say … Pretty Please?

It should’ve been a simple procedure.

Neil Baum, a urologist in New Orleans, recalls one instance when he inserted a ureteral stent to relieve a kidney obstruction in one of his patients. The patient then left the office, after being told to return in three days time to have it removed. He never did, despite countless attempts to reach him by phone. An inevitable infection set in, at which point the patient began threatening legal action, blaming Baum’s standard of care.

But Baum was prepared. “I showed him the consent form that clearly stated he had to return, along with our records showing he didn’t return our calls,” says the associate clinical professor at Tulane Medical School who estimates that up to a third of his patients don’t hear what he tells them in the exam room. “Patients are out of their comfort zones when it comes to healthcare,” he says. “It’s very stressful. They’re often anxious or frightened and not fully focused on listening to what you tell them.”

Such is the quandary facing physicians in all specialties: You spend inordinate time and energy educating yourselves on the latest medical therapies, and yet all too often you’re stopped by patient noncompliance. “There are volumes of research in this area, but most studies find that patient noncompliance with taking medication is roughly 50 percent,” says Jacqueline Dunbar-Jacob, dean of the University of Pittsburg School of Nursing, who has investigated patient adherence for 25 years. “Where lifestyle changes are recommended, that figure is probably higher.”

Why don’t they listen?

There are countless reasons why patients ignore healthcare advice. Older patients, in particular, may believe the treatment will be ineffective, or they worry about unknown side effects. Or, says Dunbar-Jacob, they may simply forget. “The ‘forgetting’ phenomenon seems to be a real one,” she says. “The person who gets into the routine of taking medication every morning becomes so habitual that they don’t notice if they’ve missed it on any given day.”

Sometimes noncompliance is purely a financial issue, as some patients - particularly those on fixed incomes - may not be able to afford the out-of-pocket cost of what you’ve ordered. What can you do to help mitigate this problem? “A lot of times the recommendations for a specific lab test or treatment may be fairly expensive and if it’s not covered by their insurance they may not have it done,” says Jim King, a family physician in Selmer, Tenn., and president of the American Academy of Family Physicians.

Give out samples of high-priced drugs if you can, or help put patients in touch with pharmaceutical companies that provide medication for free to those in need. “If it’s a pill that can be broken in half, we’ll also sometimes write a prescription for a stronger dose so the patient can break them in half - which is cheaper for them,” says King. “If it’s a test that we feel the patient really needs, we’ll also try to discount our own costs or negotiate with a hospital for a reduced rate.”

Finally, says David Hunt, president of Critical Measures, a Minneapolis-based consulting firm that specializes in cross-cultural healthcare, consider the demographics of your patient population. Do you have patients with limited English proficiency? Certainly, this makes comprehension of medical terms that much more challenging.

“Physicians should use qualified interpreters,” he says. “Using family members and friends or even children to interpret is not safe or quality practice.” Why? Because physicians often assume incorrectly that the adult child not only is going to speak English, but is able to speak their parent’s native tongue at a level that allows them to translate complex health terminology. Many hospitals have interpreters on staff who can be called to come in, or at least translate remotely via telephone.

Reading your patients

Unfortunately, it’s virtually impossible to know for sure if your patients are putting your advice into action. But there are signs that suggest noncompliance, the most obvious of which is that the patient’s condition remains the same, says David Dale, president of the American College of Physicians. “You may have an adherence issue if the patient still has high blood pressure, but you’ve been prescribing powerful drugs, the patient does not lose weight under a recommended diet plan, or he is still having chronic headaches in spite of the medication you prescribe,” he says.

Body language in the exam room is another important cue. “Sometimes silence speaks louder than words,” says Hunt. “When the patient looks at you with a pained expression, or there’s a lengthy silence after you ask them to do something, you need to encourage further discussion.”

Also, be on the lookout for patients who nod in agreement to everything you say during an exam. Nodding does not necessarily mean compliance; it may in fact just be a form of etiquette. “Physicians need to understand that sometimes, yes means no - not just for culturally diverse patients, but for lots of older adults, too, who have been taught to respect, if not revere, physicians,” Hunt says. “Many would consider it insulting to disagree with a doctor.”

Upping the odds

With noncompliance so widespread, and the causes so varied, you may be tempted to think, “Well, I did my job by recommending a treatment; it’s theirs to follow it,” and concede defeat. But, in fact, this is a battle worth fighting. Adherence to treatment protocols is the single most important factor in the success of most therapies. The trick is getting your patients to assume a more active role in their own healthcare.

Fortunately, there are a number of strategies that you can employ right in the exam room.

Ask if the patient understands the directions given before you end each visit. “I ask them if this is something they understand they need to do, and I also ask if they have any other questions,” says King. “That way, if they say, ‘Well, I don’t like taking pills’ or ‘Do I really need this?’ you can continue the dialogue.”

Use the “repeat back” method. Another effective strategy is to ask patients to repeat back your instructions. “Ask that patient to repeat what you have asked them to do, which is particularly important when you’re prescribing medication,” says Hunt. “Ask the patient to play back what they heard you say. Ask them what the correct dosage is and if they’re using a medicine dropper, ask them to show you how much they need to take.”

Use the power of pictures. A 2006 study by the Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center (LA BioMed) found that patients who saw the build-up of plaque in their own arteries were far more likely to comply with doctor’s orders. The study of more than 1,000 patients found that those who saw more plaque after undergoing an electron beam tomography (EBT) scan of their heart were more likely to stay on statin therapy than those who did not see visual proof.

Compliance among those whose scans found the most plaque exceeded 90 percent, compared with patient compliance of less than 50 percent among the general population prescribed statins. “Being able to see the buildup of plaque is one of the best and easiest methods to improve patients’ compliance, not only with cholesterol medications, but with diet and exercise as well,” says Matthew Budoff, a principal investigator at LA BioMed.

Assign “homework,” meaning your patients keep logs of whatever is ailing them - blood pressure, blood sugar, caloric intake. “I ask them to write down what they’re eating, which not only means they’ll come closer to eating the right food, it makes sure that when they come back for a check-up you have something to go over,” he says.

Electronic capturing devices make monitoring that much easier. Many systems transmit data on blood pressure, blood oxygen, temperature, blood glucose, weight, and electrocardiograph results directly to a central home health office via telecommunications.

Get tough. If you have to - and for some patients you will - don’t be afraid to bear down a little. Dunbar-Jacob says that “ongoing follow-ups with patients, either by phone or through regular office visits, seem to be an important dimension” to solving the problem. You might consider instituting a practice policy that requires your patients (at least your noncompliant ones) to bring in their medications at each check-up; Dale does this. “That way you can say, ‘It’s been a month or two and it looks like you still have a lot of pills here,” he says.

In the case of patients with a serious disease such as tuberculosis, which presents a public health risk, feel free to take an even harder line. “With noncompliant patients, you can instruct them to come into the office each day to take their pill in front of a nurse,” he says. The point here, of course, is to send the message that you care about your patients’ welfare, not that you’re related to Big Brother, so try to keep an aura of active concern out front and your parental fisheye in check.

Mutual accountability

Is compliance 100 percent the patient’s responsibility? No. You play a critical role, too. Are you giving a peak performance in this area? “A lot of times the physician doesn’t do a good job of explaining why the patient needs this particular treatment,” says King. “If the patient doesn’t understand the importance of taking a test, they leave the office thinking it’s optional.”

That’s especially true for patients who take medication to prevent problems with no visible symptoms. “Taking medication for osteoporosis or high blood pressure doesn’t make you feel any different,” says King. “If you don’t have any symptoms, it becomes easy to decide you didn’t really need that anyway.”

Dunbar-Jacob agrees. “One of the problems is that [physicians and nurses] may be spending inadequate amounts of time with patients in educating them about how to carry out their treatment,” she says. Most patients with chronic disease see their doctor three times a year, spending roughly 18 minutes with the doctor per visit. “That’s less than one hour a year the physician is spending with that patient who may be on a very complex treatment regimen,” she says.

There’s nothing like a trusting relationship to help promote treatment adherence. To help with this, the AAFP recommends physicians embrace the skill of inquiry. In other words, rather than simply treating patients for their health problem, ask open-ended questions that encourage them to share their values and concerns. Such dialogue helps establish trust, making the patient more likely to disclose critical information that will not only affect the recommended therapy, but significantly increase their likelihood of sticking with the plan.

At the same time, King says, there’s never just one way to do things, so be willing to work with your patients to explore alternatives. “Often, a patient comes in expecting one form of treatment and you prescribe another,” he says. “There are some medications that you need to take four times a day, for example, and that’s impossible for most people. In some cases, you may be able to tell them that if they make some lifestyle changes they may not need to take medication at all.” Similarly, if a patient with severe arthritis needs to lose weight for medical reasons, understand that it may be painful to exercise. “It’s up to the physician to come up with alternatives,” says King.

Remember that promoting patient adherence is as much about understanding your patient’s needs as it is about changing the way you communicate. With the growing population of aging Americans, the tendency to self-educate through online Web sites, and the influx of immigrants with mixed backgrounds and healthcare beliefs, the days of blind compliance are quickly coming to an end. But if you take the time to encourage dialogue, educate patients about their diagnosis, and consistently follow up on their treatment plans, you will not only build a foundation of trust, but you’ll help your patients view themselves as active partners in their own healthcare - one of the best ways to encourage compliance.

Shelly K. Schwartz

is a freelance writer in Maplewood, N.J., who has covered personal finance, technology, and healthcare for 12 years. Her work has appeared on CNNMoney.com, Bankrate.com, and in

Healthy Family

magazine. She can be reached via editor@physicianspractice.com.

This article originally appeared in the March 2008 issue of

Physicians Practice.