American College of Physicians: Internal Medicine — Doctors for Adults ®

Thursday, May 19, 2016

Noncompliant patient-centeredness

I was talking with a few friends not long ago. Our conversation somehow got to the issue of authority, and what exactly respect for authority looks like. One of them, trying to make a point, turned to me and asked: “So you surely deal with people who don't listen to what you have to say. What do you do when your patients don't take the medications you prescribe?”

I think he was expecting me to be like the movie superhero character Mr. Furious and lash out against the patients who don't give proper respect for my authority. Most people have heard how irritated many doctors get when patients are non-compliant.

“Well,” I said, hesitating, “I guess I just ask them why they aren't taking them. There's got to be a reason for it, and I try to figure out why. It could be that the prescription costs too much; it could be that they are afraid of side effects; it could be that they heard something bad, or have some other bias against the medication for a reason I don't know; or it could be that they just don't understand why I think they should be on it in the first place.”

I totally wrecked his point, which made me glad because I didn't agree with it anyhow.

Since I am in the midst of a series of posts on patient-centeredness in health care, I need to take a quick (1,200-ish word) detour to an important related question: What happens when the patient doesn't cooperate? What does patient-centered care look like with non-compliant patients?

If you look up the word “compliance” in a thesaurus, the first synonym (at least in my thesaurus) is “obedience to.” This implies that non-compliant patients are, at least to some degree, equivalent to disobedient patients. This is borne out by the reaction many patients seem to expect of me when they “confess” they haven't taken prescribed medications: they look guilty, like they are expecting to be scolded. I guess scolding is what they've had in the past. Certainly hearing my colleagues complain about “those non-compliant patients,” I am not shocked that they scold their patients. It's as if the patient is not taking their medication with the express intent of irritating their doctor.

But this is a very doctor-centered view of things, not patient-centered. It assumes the doctor is the one who should be in control, and the patient's job is to “obey” what they've been told. It is a “prescriptive” type of healthcare, telling people what they should do. Doctors, after all, give “orders” for things, and the Rx on our prescriptions translates to “take thou.” We are the captains of the HMS Health Care, aren't we?

Perhaps this was the case when we held on to our “special knowledge” that others had little access to. Before the Internet, doctors were often the only source of medical information. People could go to the library and look things up, but most didn't take the time to do so, and there was still an air of awe given to doctors, who should never be questioned. Things have changed. Now all of the information I've got and knowledge I gained in my training and during my practice is available to everyone any time. Sure, people lack the context in which to use much of that information, but they can (and usually do) check their medical questions with Dr. Google.

This changes the whole dynamic of the relationship between doctor and patient. Many would say this is for the worse, but I disagree. My father has recently (as I've documented) been going through significant problems with his back. While it's my normal practice to avoid being a meddler in the care my family gets, I've had significant cause over the past six months to worry over that care in respect to Dad's back. By my urging, my parents (who grew up in the age of the high priesthood of doctors) have asked far more questions and have gotten better care as a consequence. “Yeah, but you're a doctor,” some might argue. So then are only doctors able to question care they (or their loved ones) are getting?

No, we should welcome questions from our patients, as they may just point us in a direction we hadn't considered. Since I've been more engaged with my patients in this practice, I have seen them open up to me much more about things because they perceive that what they say matters to me. I respect what they have to say about things, so they talk to me and don't hold back on their fears or concerns. This means that people are much less scared to talk to me about things, much more likely to confess their alcoholism, their depression, or their concerns about medications they are taking. All of these things allow me to give better care.

So what does patient-centered care look like in a world where the patient is a participant? Here are the rules I follow:
• The patient always deserves my respect, and should always perceive that respect. It's not enough to respect them, I've got to show that I do.
• It's their body, not mine. I can think it makes sense to get a surgery or take a medication, but they are the ones who have to get cut on or put the foreign substance in their body. I have to approach them with this in mind, asking about their fears and concerns, and not assuming the fact that I prescribe or recommend something that they will not question it.
• I may know more about medicine than they do, but they know more about their own bodies. There is an old saying in medicine, “the patient will always tell you what is wrong with them.” In other words, it is our job to listen, to ask questions, and to discuss things with them so that we can know what is going on. Many docs are far too quick to disbelieve symptoms the patient reports, and so many patients are afraid to tell of symptoms that “don't make sense.” This can lead to misdiagnosis.
• It's more important to get it right than to be right. If the patient comes up with the diagnosis then hooray. I don't care how we come up with it. Who cares if they looked it up on Google. I look up my non-medical problems on Google. Should plumbers, electricians, or geologists be mad at me when I look up information in their areas? I could care less. It's my pipes, my wires, and my … rocks.
• I want my patients taking responsibility for their health. As I said before, what happens between appointments is far more important than what happens in them. This means that my job is now one of teacher, interpreter, and encourager. If I can't explain why they need a medication, they shouldn't take it. If they have questions, fears, or concerns, I want to hear about them. Most of all, I don't want people worrying about being scolded when they come to my office. I'm not their mom.
• In the end, it's their choice. If after explaining, listening, educating, and even warning, people don't follow my instructions, I'm OK with that. My job is to let them know the risk of their choices. Once I've done my part, I don't lose any sleep about their choices.

As it stands, I feel my patients are quite compliant with what I recommend. They comply as long as I've done my side of the agreement, and they tell me if they don't do as I recommend. I wish other docs would lighten up and stop thinking we are in the Marcus Welby world of prescriptive medicine.

We aren't, thank goodness.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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