Poor adherence, non-compliant – should we label patients?


Category : Medical Rants

Almost 30 years ago I had pneumonoccal pneumonia.  My symptoms were classic – seeming viral infection, then a drenching night sweat and a rigor, then a productive cough.  My CXR should segmental consolidation.

My physician first put me on erythromycin, but we switched to Pen VK after I had severe nausea and vomiting with the 5th dose of erythromycin.

It took me 13 days to take all the penicillin.  Taking medications 4 times a day is extremely difficult.  I was poorly adherent.

A few years ago I had one toenail with a fungal infection.  I took terbinafine daily, and only took 92 days to take my 90 pills.

Danielle Ofri has written a very insightful piece on labeling patients as non-compliant – When the Patient is 'Non-compliant'

When we see patients in the hospital, or in clinic, and the patient does not comply with our wishes, then what should we do?

We must ask why the patient is not taking meds or dieting or stopping alcohol consumption.  We have a responsibility to not give up on the patient.  

Try try again.  Try to understand the patient, diagnose the patient as well as diagnosing the underlying diseases.  Sometimes the problem is financial.  Sometimes the patient has side-effects.  Sometimes the patient just does not understand.

But we must not give up on the patient.

Comments (9)

The link to the Ofri piece is broken.

Well said.  Normally I am very adherent/compliant with my chronic meds, but I currently have a dental abscess and even with some pain it is really hard to remember all of those three-times-a-day pills.

I work in an institutional setting (prison) where noncompliance is rampant.  Some patients just aren't very interested in their healthcare,  and the prison system is loathe to provide more-expensive, long acting preparations which makes the compliance problem even worse.  A factor I've run into recently is–lawyer ads on TV.  Patients see these and are "scared off" of taking their medication if someone is trying to recruit personal injury clients.  Or they just misunderstand what the television presenstation is telling them.

But your central point is valid:  ask; counsel; don't give up.

I am a medical student now in my second year. For three different issues (and 3 different doctors), I was adherent to the diagnostic/treatment plan, and it has made my life significantly worse. After getting through the anxiety of my lifelong complications of treatment for relatively benign conditions, I'm left in a hole that's difficult to deal with day in and day out. Consequently, it's really made me jaded of the whole process, and I distrust most doctors and I instruct people I know and my family to never ever trust a physician without extensively looking at what they instruct them to do.
Now my motivation in life is to be a physician who doesn't put patients in harms way. I can say for a definite fact that the majority of my classmates will be terrible doctors. It's unbelievable what power physicians have to hurt and will hurt out of incompetence or ignorance or whatever it is. There's not enough "checks" in the system to get rid of these people (the majority).
Some patients probably don't adhere for good reason. I know if I was never compliant (or if I never, ever saw a doctor in my life) then my life would be significantly more carefree. It's sad when I look at friends and family who are healthy and say that could be me …. not because of lifestyle or luck, but because of PHYSICIANS. I am not the only person who feels this way obviously. You'll be surprised by how many people do.

Link is fixed.

: – )
Good post on an important topic. I try to remember that it is human nature to be better at pursuing one's own plan than someone else's plan and then both develop and discuss the plan as 'we' rather than 'I' and 'you.'

This is a good post, db!  I would like the medical industry to go back to  shared decision making rather than the current dictatorial one.  Currently if you as a patient disagree with your doctor on anything, you are labeled as a "problem patient" and will probably be dropped from the practice.

I agree with the spirit of article and I do not think your missing a dose of antibiotics mean non-compliance/poor adherence. No one has proven that you have to take antibiotics for 10 days instead of 9 in a solid way.
Let me cite an example now – patient starts smoking again after receiving bilateral lung transplants for advanced COPD related to smoking – you can use any term here – non-compliance/poor adherence to treatment program etc etc…but thats not right. Its actually a disrespect in some ways to the donor and his family.
Isues like adherence and compliance need to be looked in a "relative" manner; Using whatever euphemistic way to express that is the choice of physician. I have no problem calling a smoker with previous lung transplant non compliant with treatment progam.
Giving up on a patient and calling him non-compliant are two different things. No doctor gives up on patient who present again and again with hepatic encephalopathy to the ICU after drinking and being poorly adherent to their lactulose. I don't give up on patient who are smoking.

Talk about a paradigm shift. There was once a time in medicine when it was part of your job to care for the noncompliant patient. That should still be the case.
It would be great if every patient did what they should or didn't have a bad reaction to their meds (quite often their noncompliance to medications is our fault, not theirs,  for prescribing that particular med). But it doesn't work like that. It would be like the baseball player who wants every pitch down the middle.
I often get the referrals of patients other doctors have refused to take care of. It's not always easy, although some of those patients have legitimate gripes and were shunted off by lazy docs. Someone has to do it. And it speaks ill of our profession if it is happening more and more   
Yes, the noncompliant patients are the most frustrating, least satisfying, and often the hardest work. But that's part of the job. Disdain should be heaped those who just "fire" patients. But in the final analysis, one of the challenging aspects of the profession is how to make that noncompliant patient more compliant. It doesn't always happen, or even happen frequently, but it does happen and it is among the most gratifying things about being a doctor when it does.  

I'm sure that my Dr. has labeled me as noncompliant. However, I have good reason to be so due to my past history with Dr.'s and medications they have prescribed to "help".  I have had essential tremor since I was a teen. My father had it, a couple of my sisters have it and also a couple of my nieces. It was a bit of an inconvenience but I had always found ways to deal with it. A little over twenty years ago a new Dr. I was seeing noticed the tremor and prescribed Zanax to "help". It did away with the tremor but it ruined my pretty much perfect life. I have since learned that Zanax is alcohol in pill form and is only to be used as needed for short terms. In retrospect I can see how it changed my personality from a nice person to a bitch. I had never used drugs and knew nothing about addiction. When I started shaking I thought I needed the Zanax…my Dr. was prescribing it after all. Well, my husband didn't like the change in me and didn't make the connection  to my medication and my 23 year marriage ended in an awful divorce. Several years later a new friend who was familiar with addiction recognized my problem and I went into treatment for 3 weeks to get off it. I had never abused it….just took as Dr. prescribed, didn't even know it could be used to get high….but now I was labeled an addict. I have never had any desire to "use" since going off.
A few years later I had a hysterectomy. Two weeks later I wound up in the psych ward and was loaded up with antidepressants and antiphycotics  (sp?) Gee…do you think it could have been hormonal…they never considered that. I became emotionally flat and over time I went off some of the meds but the essential tremor became worse and worse….to the point that I could barely feed myself and could not write at all…or work. I lived with my mom and she took care of me. I didn't have insurance and couldn't afford Dr.'s at this point. Then I went on Medicaid and finally saw a movement disorder specialist. He put me on Topamax (a horrible med). I was slowly tapered onto it…to 400mg. The tremor did improve….but again I didn't recognize the mental changes. I was barely able to communicate with people…I was like a zombie. Plus I slowly lost my appetite until I reached the point where I was sick and could no longer eat. I realized that I had to get off the Topamax….and had to do it cold turkey. My blood pressure skyrocketed and anxiety went through the roof. Of course since I was an "addict" the Dr. wouldn't give me anything for the anxiety…..so I just delt with it for weeks on end. Then the Dr. put me on Propranolol for the tremor which helped.
One of my sisters was visiting me and asked if I took any supplements. I never had and I had an awful diet…full of prepared foods.  I was living on my own now and had gotten out of the habit of cooking since I was unable to cook with the tremor. She bought me some Niacin and recommended  high doses…3000mg+…..after a week or so it was like a fog lifted….I felt really good.  I was motivated to eat better and get out and get outside and walk. I did a lot of reading on healthy eating and supplements….lost 30 lbs and my cholesterol went down by 60 points in a year. I was able to go off antidepressants and the tremor is 99% better. I am my old pre-med self…I am sociable and looking forward to moving on with my life.
So a couple of weeks ago I went for a physical and saw a Dr. that has been out of medical school for less than a year…..before he had even examined me or spoken to me he told me he wanted me to go on Lipitor…my cholesterol is still borderline. I told him no thank you….I'm handling it with diet and exercise. My step-father has taken it for years and has bad muscle aches and his levels don't go down….so what's the point? The young Dr. was very cool…did a very brief physical. Didn't address the back pain I have been having until I brought it up again and gave me a referral….but I'm going to try getting out and exercising…(even if I don't feel like it) before going to another Dr. He wanted me to get a flu shot ( I haven't had a flu in over 35 years)….I didn't want to offend him again….so I told him I had gotten one at the drug store. I'm trying to get rid of toxins in my body….so why would I get a shot that contains mercury?
So yes….I guess I am now noncompliant….I no longer trust Dr.'s….They are not trained in nutrition (you are what you eat). They prescribe meds without regard to the side-effects…which can be worse than the initial problem (I am living proof of that). I will question everything that comes out of a Dr.'s mouth from now on….they are not gods.

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