Are You Contributing to Patient Noncompliance?

Why some patients may not follow doctors’ orders.

By Kevin RR Williams

HEALTH Increasingly, “doctor’s orders” is becoming “doctor’s suggestion.” It may seem like a battle of wills. A patient has an aversion toward a treatment or recommendation offered by a physician. This can lead to bad consequences. Why did this diabetic patient require a foot amputation? Why does this patient come in monthly with congestive heart failure exacerbation? Why did this patient suffer a stroke? In the medical hallways or patient files, adverse outcomes are often attributed to patient noncompliance, sometimes with disdain. [1] Does it seem that the number of “noncompliant” patients is growing?

Are You Contributing to Patient Noncompliance?

More Empowered Patients

The plethora of online medical information has contributed to a higher number of empowered patients. They still need doctors but often supplement contact with hours of personal research. The goal is to be well enough informed to have a meaningful dialogue during the average 5-minute exam-room visit.

The state of health care in the United States and other countries is less conducive to extensive exam-room dialogue. With more patients in the waiting rooms, it's natural to adopt somewhat of a triage protocol: Nurses record vitals before the doctor enters to assess, advise, prescribe and discharge. Patients are rarely asked whether they see the wisdom in the treatment or if there are any obstacles to compliance. They may given no options or perhaps simply receive an unexpected follow-up referral notice.

Barriers to Compliance

Patients with rare disorders are commonly considered noncompliant. Environmental toxicity is often overlooked. After expending effort to find a cause of non-specific symptoms, a doctor is likely to refer patients for psychiatric evaluation. The protesting patient may be viewed as noncompliant. A patent might be told by a healthcare professional to practice yoga for increased mobility. Yoga is based on seven spiritual principles that may conflict with the noncompliant patient’s religious beliefs. The practice blends meditation, Pranayama, yoga philosophy, sun salutations, and Asana development. It is a form of worship.

Popular HSA health plans have high out-of-pocket deductibles. Budgeting a few hundred dollars for a visit can quickly turn into thousands with numerous tests and referrals. A noncompliant patient could be hindered by available funds to follow through or may seek less expensive options.

A patient’s values and beliefs about health can differ from those of the health care provider. There may be other conflicts in their relationship that work against following the advice offered. The patient may not have the financial resources, family support, physical ability, or emotional stability to perform the prescribed tasks. Poor self-esteem, negative side effects of drugs and other forms of treatment, and lack of progress after adhering to the prescribed regimen can also lead to noncompliance. [2]

A patient certainly has the right to refuse recommended treatment or tests. [3] Providers are responsible for informing the patient of any risks associated with a refusal of care and documenting this discussion in the patient’s chart. [4]

Improving Compliance

Many patients are primarily seeking a diagnosis. They then want to know if the issue can be corrected without medication (nutritional supplements; exercise; bedrest). A medical prescription is third on the list. Questions about when they might return to normal activities could be fourth. Surgical intervention is way at the bottom of the list. Leave these questions unanswered and a rift can form between doctor and patient.

It might be argued that patient noncompliance is largely a behavior learned from healthcare providers. Early on, patients attribute a relative omnipotence to doctors. At some point in their care, trust is broken. Perhaps treatment that conflicts with the patient's personal beliefs, past experience or internal sensations is advised. An adversarial doctor who attempts to minimize or disprove a patient’s complaints loses credibility as an advocate.

Good communication skills, including active listening, are essential for good patient care and compliant behavior. A provider’s choice of words, body language, and even silence all play a role in how a patient receives the provider’s information and advice. [2] Some doctors are better than others, as is the case with most professions. A patient who does not feel his physician is an advocate may be better off switching primary care doctors.

Tags: antagonistic, bedside manner, contentious, disagreements, empathetic, uncooperative

  1. Why the Phrase “Noncompliant Patient” Bothers Me, And Should Probably Bother You Too.
  2. Dealing with a patient’s noncompliant behavior.
  3. Patient Self-Determination Act.
  4. Noncompliance.