Physicians Are Talking About…

Why Don't Patients Listen?

Brandon Cohen

Disclosures

December 01, 2017

What should be done when patients don't or won't follow directions? A recent article on Medscape examined this frustrating issue, and an accompanying poll indicated that slightly less than half of the responding physicians believed that their patients followed instructions most or all of the time. This sparked a lively set of responses from healthcare professionals. (Comments may have been edited for clarity or length.)

A wry internist was appalled by the overconfidence seen in some patients:

I love it when the patients tell me they are "self-taught," and "know everything there is to know" about their particular self-identified pathology. Apparently we are too far removed from the time in human evolution when stupidity was lethal. It appears to have worked its way into the standard curriculum.

A healthcare professional saw the inability to follow directions as rooted primarily in youth culture run amok:

Millennials are young adults who, if they went to typical public schools, were not challenged, were encouraged to get answers on tests from other students, and often cannot read above a 4th grade level. We are misinterpreting millennials as a different generation when in reality they are a separate culture.

A psychologist looked to a different demographic and a different reason for noncompliance:

Check the patient's cognitive status. Among middle-aged patients with chronic lung disease, end-stage renal disease, and chronic heart failure, rates of cognitive impairment are above 50%, causing nonadherence and readmissions.

A primary care physician reminded colleagues to investigate. "Most importantly, try to find out why your patient disagrees."

A dermatologist pointed to a valid reason why patients might not keep up with their meds, blaming it on "the problem of them not being able to afford their medications—that may be why they don't follow our advice. Sometimes they don't tell us for fear of embarrassment."

A psychiatrist added, "Patients are more likely to follow our advice when we carefully explain why we are giving that advice."

And a clinical nurse specialist spelled it out in detail:

Maybe different questions need to be asked. Do I understand what my patient values? Do I understand what motivates him/her? Have I explored his/her confidence level in making a change? Motivational interviewing puts the power and authority to change in the hands of the patient instead of the doctor. The doctor guides the patient in this discovery rather than directing the patient through the doctor's agenda.

Another healthcare professional offered some concrete actions to help ameliorate the problem:

A first step would be to increase the office visit time to at least 30 minutes. Most patients can see through hastily concocted diagnoses or advice. Fifteen minutes, with computer time added, translates into some 5, perhaps 10, minutes of paying attention to the patient. It does not inspire confidence and trust, not to mention respect.

An administrator offered a more low-impact approach, saying, "Patients have the right to ignore a doctor's advice. When this occurs, have the patient sign a waiver of medical advice; place it in their chart and move on."

A weary pediatrician agreed and offered a simple formula for self-preservation: "Document, document, document. Then live and let die."

An internist, however, saw pushback from patients as a positive thing:

I'm seeing that more and more patients become more proficient experts on their health issues than their physicians... Let's face it. We have more patients and fewer providers than before, so individuals must watch their backs, and wise MDs should embrace motivated patients rather than resisting or vilifying them.

But another internist warned that the most common sources of public information were often unreliable:

I discovered that Wikipedia had strayed badly from clinical fact on a common problem. The message a layperson would have gotten from the entry would have been completely incorrect. Every morning for a week, I posted corrections, only to see them deleted the next day. Finally an acceptable article was published.

One pharmacist questioned whether doctors' advice was all that valuable to begin with:

I would feel better about recommendations from my doctor if they weren't based on biased advice that is often written with serious conflicts of interest. Pharmaceutical companies have far too much influence on many guidelines, and I question whether their advice is in my best interest.

The final word goes to a registered nurse who used an anecdote to make a key distinction:

We need to be careful to distinguish between stubborn opposition or bravado and well-intentioned but ineffective cooperation. I have to relate a true story. A newly diabetic lady seemed to understand her insulin instructions quite well, and had demonstrated to the hospital nurse that she could draw up the correct amount and proficiently inject it into an orange for practice, as was the learning method at the time. When I saw her at home a few days after discharge, she was running high blood glucose and not feeling well at all. I asked her to show me her insulin injection technique. She proudly drew up the insulin and made a perfect subcutaneous injection into an orange.

Full discussions of these topics are available at Do Your Patients Follow Your Advice? and What to Do When Patients Don't Heed Your Advice.

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