What Your Healthcare Team Needs to Know About Your Non Compliance.

Compliant |kəmˈplīənt|
1. inclined to agree with others or obey rules, esp. to an excessive degree; acquiescent : good-humored, eagerly compliant girls. See note at obedient. (From the New Oxford American Dictionary)

A picture of NON-Compliance. Only a biscuit will
motivate him for action.
It’s rare that I have the opportunity to chat with a medical student, a soon to be doctor. But this past weekend I was fortunate. Mike, a bright, articulate, and lovely guy of 28, is nearing the end of his fourth year of his medical education, currently doing his internal medicine rotation. He attends a top medical school in New York City. And you know me. I just had to ask him, this soon to be practicing doctor, a few pressing questions, while strolling along the brownstone lined streets of NYC. Here’s how it went.

LL: “So how much nutrition education do you get throughout your training?”
Mike: “About 5 hours total, in my four years.”
LL: “And what kinds of nutrition topics do you cover?”
Mike: “The greatest focus is on all the vitamins and minerals and their deficiencies—scurvy, beriberi, Wernicke-Korsakoff, to name a few.”
LL: “Wow, so the bulk of your nutrition education is spent studying conditions that we rarely see in our country.” (scurvy is a vitamin C deficiency, beriberi a thiamin deficiency rather uncommon in these parts), with the exception of Wernicke’s which we do see in severe alcoholics (also from a thiamin deficiency).

Further along in our conversation Mike shared his frustrations regarding nutrition-related illness:

“Patients tend to be non-compliant. You know, they don’t do what we tell them, what they need to do to help themselves.”

What does your doctor need to hear from you in
this limited time?
And with that comment, I had to hold back my biting tongue. (He really was a lovely fella, and a friend of my son, so I took a breath and went for the patient response.) Yes, it is frustrating to feel that people could help themselves if only they would follow what you tell them to do, if they would just do it. We discussed the fact that the average length of a typical doctor’s visit is maybe 17 minutes, start to finish; during the length of three songs on your iPod, your doctor needs to assess your medical situation, answer your questions, figure out how best to convey information to you about your condition, educate you and direct you to resources. Sounds easy, no?

Clearly something gets missed in these limited length visits. How can providers expect patients to change when they haven’t even probed to see what obstacles are keeping them stuck?
For better “compliance”, doctors need to better assess patients’ readiness for change. And then provide them with correct information and useful resources to go forward.

Laziness Keeping Her From Exercise?

Maybe there's another reason she (he?) stays where he's at?
And no, I didn't pose them when I too this picture.
You can’t tell someone, like my patient Ellen, who might benefit medically from an increase in physical activity for her blood sugar, cholesterol and blood pressure management, as well as her escalating weight, that she needs to exercise four days per week, 30-40 minutes. Why? Because she associates an increase in heart rate with anxiety, and fears it’ll result in a heart attack. Instead, I had to work on getting her to see that exercise is safe, first and foremost. So I discussed with her doctor getting a stress test done, followed by a doctor’s approval for exercise, to allay her fears. After that, she was able to slowly increase her activity. Now she exercises regularly.

Time To Change The Strategy

 Stubborn and non-compiant--
but who knows what's going on inside his head?
More than one woman I have worked with has shared that her husband has made it clear in no uncertain terms that she shouldn’t be eating what she eats, or weighing the weight she weighs. The result? An “I’ll show you” response—she eats beyond her need, when he’s not around, in part to spite him. Acting like her husband, telling her what to do, judging her by her size, will ensure that her weight continues to climb. Instead, directing such patients to work with a therapist to better communicate with their spouse (and others) and speak up for them selves can help. And enlist their suggestions, their ideas for practical change. That’s a way for providers to successfully problem solve.

And such patients need to be given permission, with practical strategies, to bring food out of the closet. I often recommend that they tell their spouse what to expect—that they will see them eating foods the spouse deems unacceptable for weight management—and they shouldn’t be surprised. And their spouse should withhold comment and judgment, thank you very much. Only then can we expect “compliance”.

Information Can Cause Slips

Health care providers need to check their facts, before being quick to disseminate information. Telling patients “cut out your carbs” is simplistic and unnecessary, including for diabetics. And you can bet it’ll lead to non-compliance. And confusion, as they get bombarded with nutritional misinformation from all ends. It is unrealistic, and not a practical change.

They need to get educated, too, in communicating information with teenage and adult, anorexic girls and young men. Statements like “great job! Your weight’s heading right up there!” or “You need to gain weight or you won’t get your period” can be traumatizing. Or “You’re perfect—don’t gain another pound!” And how many girls couldn’t care less about getting their periods? Telling a 12 year old that not getting a period will lead to osteoporosis? Who cares? They envision old, bent over, great-grandmothers—not something they believe can happen to them in their teen years. But tell them amenorrhea could cause fractures when running or engaging in their favorite sports, requiring them to end participating in sports with their friends—now that may make a difference.

What’s In It For You?

Listening to what patients really do care about, about where their concerns lie, will help motivate change. For some, it’s about hair loss in clumps, or lanugo, hair growth on their arms or face, as their weight has dropped, that concerns them. Or it’s being freezing all the time, as their body temperature has dropped. Or the fear they will not be able to return to soccer, or dance, or field hockey, to name a few.
Sure, doctors and health care providers get frustrated by non-compliance. But our patients are no less frustrated—and they’re angry, and hurt—too. Because they are not understood; because there are good reasons they stay stuck in their unhealthy behaviors. And it is rarely due to ignorance.

Advice For Fellow Healthcare Providers

Compliance shouldn’t be the goal we shoot for. Patients need to be more than puppets nodding and acting according to our commands. (See definition of compliance.) 

They need to be engaged in the process of change, participating in charting their course. We all need supports, guidance, and compassion, not just rules, to begin making change. Oh, and did I mention the need for hope? Certainly, if I don’t believe in my patients, they won’t believe in their own potential for change.

The health system isn’t going to get over-hauled any time soon. Seventeen minutes may seem like a luxury in the future. But if only doctors and other providers would take the time to ask a few key questions. And then? Give up a few minutes of the 17 to truly listen.
Then they can refer to appropriate providers—the nutritionists and therapists experienced in a behavioral approach to change. Only then can they assist their patients in making change, helping us all feel a lot less frustrated.

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