Compliance.  I really hate that word!  The general impression given throughout the blogosphere is that patients:

  1. don’t take their medicine
  2. prevaricate

A few typical quotes:

  • Comp-LIE-ance:  “There are only 2 settings where compliance actually takes place; controlled substances and patients with high copays/no free ride.
  • On Your Own With Multiple Meds:  “Even though people ‘know’ they should take their pills as directed, for the most part, they don’t.

It drives me crazy to read accusations such as these.  I  am a patient.  I don’t have a high co-pay, and I’m not taking narcotics, but I’m highly motivated to do everything in my power to retain the ability to walk and dress myself, so I take those pills religiously.

It’s condescending to assert that patients have an obligation to comply with the doctor’s treatment plan.  In an attempt to avoid the word “compliance,” now patients are supposed to “adhere” to the doctor’s treatment plan.  Nomenclature is irrelevant.  It’s still condescending to dictate from on high how patients ought to go about living their lives.

The problem is that it’s the doctor’s plan.  Without buy-in from the patient, it just won’t work.  People do things when it’s to their advantage to do them, and they don’t do them when the costs outweigh the benefits.  It applies to other areas of life, and there’s no reason to think that the same philosophy doesn’t apply to medication.

If a patient says, “The doctor wants me to take all these pills, but I don’t see the need,” then it isn’t the patient’s treatment plan, it’s the doctor’s.  Patients have buy-in when their explanation becomes, “I have a medical condition that could kill me, but there are prescriptions that give me a better chance of survival.  I want to live as healthily as possible, so I’ll take these prescriptions the way they’ll be most helpful, and follow-up with my doctor to monitor my progress.”

Compliance with a treatment plan happens when it’s the patient’s treatment plan.

I am fortunate to have doctors who don’t talk down to me.  They listen to me, they answer my questions, and they don’t act like I’m too stupid to understand the basics of what’s going on with my health.  It’s not easy to take multiple medications, but my doctors have made it as easy as possible by explaining why this is a good treatment plan.

What do you think?

8 thoughts on “Compliance

  1. Great Post, WarmSocks. Physicians are too judgmental when they use the “C” word. Compliance is a one way street in medical practice. The “A” word is seen as a mutual agreement word, but weakens since there is no physician investment that makes it mutually beneficial to both patient and physician to adhere.

    One day when I was precepting a group of resident physicians in Columbus, OH, I noted that each one had presented their patient using the word non-compliant in the first sentence (e.g., this 43 year old, non-compliant white female has a three year history of low back pain…). I said, “In private practice, I don’t even think that word, can you define what you mean by non-compliance.”
    The residents all nodded agreement when a seasoned third year resident said, “That’s someone who’s just here to p… me off.”
    You’re doing patients a service to educate them about how doctors use that word. Blog on!

    • What’s really interesting (to me) is that the medbloggers who come across as the most respectful of patients are also the ones who don’t voice complaints about compliance. Anything on the topic is along the lines of figuring out how to help people find a way to take their meds. I wonder if doctors who place more value on relationships with patients see their patients have better outcomes (due to better compliance rates?), or if there’s just a different mind-set that it’s not the end of the world if someone chooses not to take pills. Thank you for your comments.

  2. Absolutely great post, Socks. I think this underscores the need for all of us to have an active role in our healthcare and be honest with our doctors about what we will and won’t do. If you’re not going to take the pills, tell the doctor, maybe there’s an alternative (instead of a week of antibiotics, maybe one injection). I told my first rheumatologist he could prescribe all the MTX he wanted, but I wasn’t going to take it because the drug didn’t appear to be working and it made me feel worse than the disease. We moved on to an alternate plan — all for the best.

  3. Inadequate patient education. Fear of side effects. Cost. Ignorance. Just don’t care. There are lots of reasons, sometimes straight forward, sometimes nuanced, for non-compliance.

  4. Speaking for myself, when I’ve been non-compliant in taking my meds, it’s happened because I felt absolutely no difference in the condition we were treating, or the meds made me feel rotten. Back when I was first diagnosed with RA, my doctor treated me only with NSAIDs and high doses of aspirin. Neither had any effect at all on my RA or the intense pain it caused in my joints, and the NSAIDs made me nauseous in spite of taking them with meals. Since they seemed to have no effect except make me sick, I’d stop taking them after a month or two. Naturally this irritated my poor doctor. This was in the mid-80s, I was being treated by a U.S. Army internal medicine doctor, and perhaps the Army formulary had no other meds to use. After a few years, we switched to plaquenil (no effect) and oral gold (no effect)except I’d have to get blood-tests done every two weeks to guard against liver damage. In the end, I stopped taking them, too.

    Today I’m compliant with my rheumatologist’s medication plan for me. The difference is that this time, he’s been able to show me how the meds have helped in lowering my inflammation levels, and my RA does indeed seem to be mostly under control. I’m compliant because I fear that if I stop taking these meds, my RA will get really bad again.

    I guess this is just a long way to say that doctors really need to be willing to SHOW the patient how the meds will help, given that so many of them can have side effects that are as bad or worse than the disease they treat. Most patients, I think, DO want to get better. It’s hard to stay enthusiastic, though, when we pop handfuls of pills each day but see no change in our condition. That causes non-compliance–and why not?

  5. I’m both a nursing professional and an RA patient. Frankly, I have been “non-compliant” many times both in the past and at the present. Reasons include all of the reasons given: cost, aren’t doing anything, make me feel worse, etc.

    But I’ve been honest with my docs – if I’m not taking the meds, I tell them. And we work around whatever the barrier is.

    Right now, I’m having repeated mild flares every couple of days – means my current regimen isn’t working well anymore. My next options involve medications I cannot afford. So I suppose I will have to limp along for the rest of my life on my current meds in varying dosages and ratios.

    Wish one or more of the organizations would work to get the drug companies to reduce the costs to something more reasonable. What’s the point of having drugs like those when the very people they are supposed to help can’t get them. We make just too much for the free plans – but what about reduced plans??

    I’m disgusted with the drug companies, and with life in general at the moment – as my fingers turn red and swell up as do my wrists – just disgusted.

  6. Thanks for this post! I am both a medical professional and a rheumatology patient, so I’ve been on both sides of this. I agree that patient education is a must so that the patient can make an appropriate decision about whether to take my advice or not. I try very hard to work with my patients/clients to find out why they cannot follow my recommendations, and then work around/with the barrier to get the best result possible.

    On the other hand, if the patient truly is not able to “comply” to the extent that the visits with me are a waste of time, co-pays and insurance money then we stop treatment. I always leave the door open though, for the person to return if circumstances change. I view myself as a facilitator. The treatment belongs to the patient, not to me.

  7. One thing that I have learned about myself is that I have to feel comfortable with the recommendations suggested by my physician or it isn’t going to happen. I think we are all very individual, even with the same diseases, and when I feel that a physician or altnerative healthcare physician has adequately listened to me and considered me as an individual in their recommendations, then I will comply. There are a lot of choices out there and we have to listen to our individual selves in making the choice that feels best for us. When I have a health care practitioner that respects that, we generally work well together.

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