We all have patients who seem to be “noncompliant”: the patient with heart failure who misses regular checkups and only comes to the clinic when his prescriptions need renewing, the patient with diabetes who never checks her blood sugars at home, or the patient with hypertension who decides how many blood pressure pills to take each day based on whether she “feels” her blood pressure is high. Noncompliance is frequent – and frustrating.
Not too long ago, however, I began to wonder about my own noncompliance. Late in the afternoon, a middle-aged farmer came in for a 10-minute visit “just to get a checkup and get some pills.” His last visit was a year earlier. The current appointment was only long enough to check his blood pressure, do a quick review of systems and set up some blood tests, and I felt frustrated that I had no time for a discussion of preventive services, diet or exercise, all of which he clearly needed.
Reflecting later on the visit, I realized I had been more focused on complying with preventive care recommendations and my own agenda than on my patient's agenda, yet I was viewing my patient as the noncompliant one.
There are many things we doctors tell patients they should do. There are many things patients want us as doctors to do. When those expectations and desires are relatively congruent, patient care seems easy. But when patients don't do what we expect (e.g., they don't take the pills we prescribe, they skip recommended appointments or they fail to adopt a healthy lifestyle), we are quick to judge them as noncompliant.
But do patients really set out to frustrate us? Do they intentionally decide not to comply with the doctor's orders? I don't think it's as simple as that.
If we are to practice true biopsychosocial family medicine, we need to realize the picture is much more complex. We need to fully appreciate our patients' understanding of their problems, no matter how implausible. We need to understand our patients' motivations. We need to appreciate our patients' social, economic and cultural context no matter how familiar or foreign.
In short, we need to move past the idea of noncompliance. Instead, our focus should be on appreciating our patients as unique individuals, understanding who they are and what they truly are seeking, and helping them address the needs that led them to us in the first place.
So, the next time a patient's “noncompliance” frustrates me, I will try to remind myself that perhaps there is more to the situation than has met my eye. Perhaps I have not fully understood my patient, perhaps I have not successfully communicated my opinion as to what will help or perhaps my patient is affected by other constraints I have not explored.
Perhaps if I see “noncompliance” as a challenge to myself to do a better job understanding my patients, both my patients and I will be happier in the end.