The Noncompliance Epidemic

Why Are So Many Patients Noncompliant?

Neil Chesanow

Disclosures

January 16, 2014

In This Article

Physicians' Role in Noncompliance

Once upon a time, patients followed the doctor's orders. Not anymore. The very notion of the doctor paternalistically telling the patient what to do is now politically incorrect. The term compliance, while still used interchangeably with adherence in the medical literature, is no longer preferred in white papers that think tanks churn out for healthcare decision-makers and policymakers in Washington.

"Compliance" implies that patients are passive actors in managing their chronic conditions. "Adherence," according to the World Health Organization (WHO), suggests just the opposite: that doctors and patients team up to help patients actively engage in maintaining their health.[25]

In reality, though, the teamwork concept isn't working out too well. One reason is a chronic lack of time. The mean duration of a primary care visit ranges from 7.6 to 17.6 minutes.[26] To be efficient, the doctor must control the conversation, with less time for listening and discussing topics such as medication reviews and preventive care.

Even if more time were available, it's not what every patient wants. In one study of doctor-patient relationships, behavioral economists used game-theory techniques to identify the factors affecting treatment decisions in patients with a life-threatening disease -- in this case, breast cancer -- who were considering adjuvant therapy.[27] They found that when patients disregarded their doctors' treatment recommendations, the doctors responded by telling them in more detail about the benefits of treatment. However, this produced a perplexing result: The more information the patients received, the less likely they were to be compliant.

"Patients want more specific disease and treatment information," the researchers conceded, but "the provision of this information might lead to therapy decisions which diverge from the physicians' recommendations."

But the larger problem is that too little information is offered to patients who want and need more. The average time that a doctor spends discussing all aspects of a newly prescribed medication is a mere 49 seconds.[28] Surveys show that no medication instructions are given by physicians in 19%-39% of prescriptions; in observational studies, 17%-25% of prescriptions are not accompanied by instructions from the doctor.[29] For a new prescription, doctors discuss dosing directions in fewer than 60% of cases, and they review potential adverse events -- a major reason why patients quit taking their drugs -- only 33% of the time.[29]

Nor do busy doctors typically have the time or skill to sit down with a patient and tease out his or her unique personal barriers to compliance, which is why so much of their advice goes in one ear and out the other, contends behavioral psychologist Kim Lavoie, PhD, Associate Professor at the University of Quebec at Montreal, Co-Director of the Montreal Behavioral Medicine Centre, and an expert on motivating patients to stick to their regimens.

"Health is not necessarily the patient's main priority," Lavoie observes. "If you have a 40-year-old woman who smokes and you want to get her to quit, what's likely to be her number-one concern? The answer," she says, "is weight gain. If the conversation doesn't address that obstacle, my prediction is that she's not going to quit."

"Doctors' communication style can positively influence [patient] beliefs and therefore lead to better adherence to recommendations," note the authors of a paper that analyzes the doctor-patient interaction.[30] "However, they are often unable to understand differences in patient preferences regarding information and participation during consultations. They often fail to listen to patients and explore their views on their disease and medication."

Explore their views? Who has the time for that? But doctors' failure to listen may not be just a function of time. Doctors, after all, are also psychological beings, who may at times act irrationally in counterproductive ways.

"The doctor, just as the patient, also experiences feelings during the consultation such as anxiety or anger, which have been shown to decrease the overall satisfaction of both parties with the consultation and also the patient's adherence to recommendations," researchers have discovered.[31]

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