Patient Compliance

Managing Patient Compliance: What's a Doctor to Do?

By: Lynn Homisak, PRT

We have all formed our own professional opinions surrounding the "non-compliant patient" based on our individual experiences with them. No matter what the basis of our opinions, the harsh reality of it is that patients who choose NOT to comply to recommended treatment protocol put themselves at risk for achieving a good medical outcome. Not to mention quality of care and in more drastic cases...even mortality. It makes you stop and think....WHY would someone intentionally do that to themselves? Why would people go to the trouble of seeking out a healthcare provider's medical advice...if only to neglect or reject the educated information? Short of throwing your hands up in the air in dismay at this type of patient behavior...one can only relate to an old TV commercial that (paraphrased) might ask, "What's a doctor to do?"

I have not been able to find statistics that relate to reasons for non-compliance directly within the podiatric profession, but overall studies have shown that generally speaking, patients follow their doctor's advice to the "T" only half of the time. Discouraging? I should say. But unique to medicine? Not hardly.

Perhaps the term itself has undergone several name changes over the years...from negligence, non-concordance and non-adherence to the now popular "non-compliance" but the fact of the matter is, a patient's disregarding behavior is nothing new. As long as there has been a doctor-patient relationship, there has been some degree of compliance issues. Let us then not dwell on what was...but on what might be. Let's move forward and take a look at some of the reasons for non-compliance as well as some likely strategies to help diminish continuing incidents.

1. Doctor-Patient Relationship
Since we mentioned this already, let's start here. Imagine you have a patient that comes in with a fracture. You can diagnose, treat and give the best medical advice you know with regards to staying off it, wearing the boot when ambulating, elevating their foot when resting....whatever is your protocol, but if they do not have confidence in you as a doctor, you may as well be talking to a wall. Trust is one of the key ingredients in terms of patient acceptance. Make the effort to build a solid relationship with them first.....gain their respect and their trust, then move on towards recommendation of your treatment plans.

2. Patient Perception of Severity
As with other medical professions, podiatry offers services that can range from "routine" to "severe." Just as an uncontrolled Diabetic patient can present to our office with a draining, gangrenous ulceration, so too can we see a less complicated condition such as a mild interdigital eczema. Chances are, because the Diabetic patient might recognize the severity of their condition and fear a worse outcome, they MIGHT be more inclined to heed the healthcare professional's advice, whereas the patient who needs only a topical prescription to combat their condition might be less concerned and therefore less attentive. Patient perception is what it is and while the associated fear factor may play a significant role in favor of better compliance, it should not be assumed that it works positively in all cases. Sadly, it sometimes can cause a patient to stop trying.

3. Patient Understanding/Awareness
Compliance is not restricted to any particular profession....It is not gender or social biased and knows no prejudice. Whether podiatry or cardiology...the definition of compliance is only as good as the patient's understanding of it. The first question they want to ask you is "WHY?" Your patient with gout wants to know "Why do I need to take these pills?" and your ruptured Achilles Tendon patient asks "Why can't I play tennis yet?" I think the most common query is that from your one week post surgical patient who asks "Why can't I go shopping yet?" You scratch your head. It's not enough that you already told them they can't or even that you are the one holding the medical degree. They need justification and verbal reassurance that what you're asking them to do (or not do) in order to comply will be in their best interest because temporary or not...to them, it only translates as a hardship.

Patients want answers and the answers have to make sense to them. If they don't, then they don't see enough of a reason for doing it your way. Share compassion for them when they complain about not playing tennis or going shopping just yet, but also make sure they understand the implications of doing so AMA (against medical advice). Let them know that soon, they will be able to participate in all their pre-surgical activities... and by all means, praise their patience throughout the process.

As their doctor, it's up to you to help them understand the necessity of the treatment protocol as recommended as well as the consequences that come with not heeding your advice and for everyone's sake, talk in a language they can comprehend. Save the medical jargon for your colleagues. Speak only in layman's terms and if you want to be assured they understand what you are saying, ask them to repeat it back to you. By the same token, understand also what it is they are asking you so that you can offer an appropriate response. I can't help but recall the movie "Philadelphia" where lawyer (played by Denzel Washington) would beg his clients to restate a confusing question.... "But this time," he begs.... "explain it to me like I'm a four year old." Believe it or not, that strategy really works. Try it the next time you require better clarification of the question being asked. Make simplicity your goal.

One of the best methods to helping patients understand all instructions given to them in the office, whether they are pre-op, post-op, orthotics break in, re-dressings, prescription dosages, etc. is to write them down. Have pre-printed instructions for ALL types of recommended at-home care and after first reading and reviewing it with them, have them take a copy home. From a legal standpoint, it might be wise to insist that the patient signs off on them once explained and place a copy in their chart, documenting that they were so informed. Well to note...be sensitive to patients who are unable or have difficulty reading or writing. I refer in particular to some of our elderly patients, those who only speak a foreign language and those who have learning disabilities or trouble comprehending.

Patients also need direction and understanding when rescheduling for their next visit. If you notice they are not keeping recommended follow up appointments, monitor this by keeping an activity log of all patients that cancel or don't show. Document in this log (and their charts) why they didn't keep their appointment and if you find upon review that the recurring excuse is "I didn't need to come in," chances are you failed to clarify to them the significance of returning for another visit. Reconsider your current methods for recall. Perhaps you can convey the importance of their return in a more efficient manner.

Whether it is medication, surgical or orthotic compliance, addressing these concerns helps provide patients with better reasons to submit to doing it your way:

• What exactly will the treatment consist of?
• What can I expect from the treatment?
• What is the anticipated length of time?
• Are their any side affects/negatives or complications I should be aware of?
• What are the consequences if I don't follow your advice 100%?

4. Encourage open communication and always keep your "sensors" on
While you may feel it is YOU who is obligated to do all the talking in terms of offering advice, giving orders and explaining the protocol...take the necessary time to stop and listen to what it is they have to say. Patients can immediately sense YOUR unwillingness to hear their concerns and they tune you out quicker than you can say "compliance." Their logic is simple. Why should they listen to what YOU have to say...if you won't listen to them? It doesn't matter that they are the ones who stand to suffer in the end...they feel neglected and anything you say from here on in means little. Make a point of asking them if they have any questions and listen to their response intently and with both ears. At times, realize you need to listen more than you speak. Listen like there is going to be a quiz on it afterwards. Remember what we said earlier. When you gain their trust...you gain their eagerness to comply.

5. Get their friends and family on board
The support of loved ones can literally can make or break the success of patient compliance. Consider this scenario with two different potential outcomes. A patient comes in with plantar fasciitis and is escorted into the treatment room along with her husband who is offered a seat right behind her. You conduct a thorough examination of her complaint and establish your diagnosis. Given her symptoms, your recommended treatment may reflect a number of different protocols, one of which is orthotic-management. When discussing possibilities with your patient, you were careful to follow steps 1-4 above: You justified the need, listened to and answered all her questions regarding this treatment only to be faced with the patient doing a 360 degree turn to face her husband and ask his opinion. The "oh-so-knowledgeable" husband responds.... "No, my brother's foot hurt in the same place and he had orthotics, but they didn't work!" Although you have managed to convince your patient that orthotics will help her condition despite her husband's remark, the chance that this patient will faithfully adhere to the adjustment phase once dispensed will be half-followed at best because there is a good chance her husband has not "bought in" to this type of care.

On the other hand, had the patient's husband responded, "Based on your explanation, Doctor, it sounds as if my wife would really benefit from a pair of orthotics," the patient would naturally be more motivated to follow your instructions thanks to his support. With the patient's permission and taking into consideration all HIPAA rules, try to include and involve their spouse/friend/parent/child in all discussions whenever possible regarding your patient's care so they can be an encouraging factor in their compliance.

Keep in mind that your staff can also play a major role in encouraging your patient. At times, patients tend to demonstrate a closeness to staff that they do not with the doctor and will secretively open up to them about their non-compliance. Take advantage of this relationship and train your staff with proper dialogue to help the patient achieve and maintain compliance. Oh, and make sure they document the conversation in the patient's chart.

6. Excuses, excuses, excuses
Compliance can be looked at by patients as carrying a price. They may feel they have to give up something in order to comply. This could range from intentional non-compliance to nothing more than sheer forgetfulness. Warranted or not, patients who fail to follow through are not identifying with the importance and as such are negligent in following through. Consider the following examples:

"Mom! I can't change the wart bandage today...I have a basketball game right after school."

"No, I couldn't possibly take the time to elevate my foot today. I had to be in 10 different places at once and didn't have a minute to rest."

"No, I didn't wear that stupid boot to school. I didn't want the other kids to see me with it on."

"No! I never wore the night splint to bed. It was just too bulky and uncomfortable."

"No, I didn't take the pills exactly as you prescribed. Truthfully, I have so many other medications, sometimes I forget."

What can we do to help them? If it's remembering to take their medication, help them implement some kind of reminder system. Someone suggested having a medication calendar handy where patients place a red sticker (or have different colors to match different medications) every time they take their pill. There are other methods such as watch beepers or timers which can also help. Pharmaceutical companies have already made attempts to address this issue by making meds in less dosages...one pill a day instead of four. Less to forget.

If the product you dispense (for example, a night splint) is so bulky that the patient outright refuses to wear it, suggest an alternative product. What good is the night splint if it's just taking up space on the floor in the corner of the bedroom? There are various brands that can produce a similar outcome. You many not believe it is the BEST product for them...but based on the theory that "something is better than nothing" and the expectation that your patient stands a better chance to comply if he wore something a little more comfortable, it's worth the switch. The point? Keep close tabs on your patient's development. Initiate practical ways to monitor their care by encouraging them to call if they have any questions, rescheduling them in advance for follow up visits and when seen, take an interest in how they are progressing with your recommended treatment plan. Make it less painful for them to be honest with you by saying that you realize how difficult it is for them to make changes to their daily routine. Reinforce that everything you are recommending is in their best interest. If they fire an excuse for non-compliance...you may want to be more flexible and consider altering the plan a bit. Make things as easy as possible for them to comply...and they will be more likely to follow through.

Compliance can be a thorny issue, but as our friend Ziggy (of the comic world) points out, "You can complain because roses have thorns, or you can rejoice because thorns have roses." Reach out to your patients and let the thorns fall where they may.