Improve patient compliance by throwing logic out the window

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By Bill Reddy, LAc, DiplAc

Patient non-compliance, now referred to as non-adherence in the medical literature, is a major source of angst among practitioners. Early in my career, it was upsetting to find my patient wasn’t taking the supplements I had recommended or sticking to the stretching/strengthening regimen I carefully put together. Researchers agree that the most common issue is lack of buy-in, followed by—in no order—poor memory or forgetting, access barriers such as transportation or lack of finances, bad experience or side effects, poor execution or misapplication, and poor recall or misunderstanding the treatment plan. We’re going to focus on lack of buy-in or intentional non-adherence, since the others are mostly outside of a practitioner’s control.

As a clinician, logic is your friend.  It supports your development of a differential diagnosis, as well as providing a foundation to connect the dots of the etiology and pathogenesis of the disease process or condition you’re treating. Carefully explaining how you’re going to approach their treatment, why supplements and future lab work are important, and what steps are necessary for their complete recovery typically doesn’t “seal the deal” regarding their future compliance. If you don’t include an emotional component to your evaluation and treatment plan, then you’ll only retain a subset of the new patients you see in your office.

A key component to patient-practitioner rapport and their feeling of being heard is related to asking this key question, “if you could assign one word to what you’re feeling about [insert health challenge here], what would it be?”  They may reply “angry” or “scared” or “anxious.”  Studies show that when patients are asked to apply an emotion to their predicament, it has a positive correlation with patient satisfaction. Patient-centered care is multi-dimensional, and the patient playing an active role in clinical decision making also increases buy-in.

When a practitioner completes a patient’s intake, going back over it with the patient— “so, what I was hearing from you is that your knee began hurting 2 years ago…”— helps clarify any details they may have missed the first time, allows you to document the proper chronology, and demonstrates that you have a clear understanding of their chief complaints and medical history. Calling a new patient after their first appointment to answer any questions and to check in on them to see how they’re feeling, if you provided an intervention such as acupuncture, physical therapy, chiropractic, or massage, also helps differentiate you from the other busy practitioners the patient has seen in the past.

Some patients may have an established vitamin and mineral regimen while others only took a daily Flintstones chewable when they were a child. It’s of paramount importance to know if they’re comfortable taking large pills, like fish oil, and what they’re currently taking.  Those who are taking supplements regularly can usually add one or more painlessly.  It will require more of a “lifestyle change” for those folks who aren’t in the habit of taking supplements.  I also ask how they feel about liquid supplements, such as vitamin D3, or sublingual pills, like B-12, to improve compliance.

While pain scale and intensity, frequency, quality, and what makes it better or worse is valuable information for your initial intake, it won’t improve patient compliance. Like the paradigm shift in the Veterans Health Administration, which modified the physician’s question from “what’s the matter with you?” to “what matters to you?”, the critical question you need to ask is how their ailment affects their life. Let’s say it’s a 64-year-old man complaining of chronic shoulder pain, and he replies that it interferes with his golf game, and he’s afraid he may not be able to continue to play in the future. Asking more specific questions about his golf game such as how long he can play before it becomes too painful to swing, or whether the pain interferes with his sleep so he can’t get back to the club in the morning are all important pieces of information to collect.  For this man, getting to a pain scale of one or two out of 10 doesn’t matter—he wants to painlessly swing a club. 

Whatever their response, you must tie that in with any interventions you recommend because that’s what’s important to that person.  In the previous example with the 64-year-old, you can create reasonable expectations such as “I expect that in a month, you can go from playing nine holes to 18 holes,” or “you should be able to carry your golf bag again.” When they return for another treatment, make sure that you check on their golf game in terms of their score, and how long it takes them to play a round of golf, and if they had any discomfort after the game or the next day. Understanding someone’s motivation to lose weight, have less frequent headaches, reduce constipation, or lower blood pressure is the key to improved compliance.

References

Martin, L.R., Williams, S.L., Haskard, K.B. and Dimatteo, M.R. (2005) The challenge of patient adherence. Therapeutics and Clinical Risk Management. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1661624/

Shruthi, R., Jyothi, R., Pundarikaksha, H.P., Nagesh, G.N. & Tushar, T.J. (2016) A Study of Medication Compliance in Geriatric Patients with Chronic Illnesses at a Tertiary Care Hospital. Journal of Clinical and Diagnostic Research. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/28208878/