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The Noncompliant Patient

Few patients present more of a clinical challenge to a physician than those who fail to follow a treatment regimen. Some ignore orders for bedrest, cast care, dressing changes, or limiting activity. Others fail to make or keep follow-up appointments. Still others are a persistent "no-show" in the practice. And a fair number never appear for needed tests or consults with other physicians. The largest number, however, are most likely those who fail to take their prescribed medication correctly. The prevalence of this problem is staggering. According to figures published by the Food and Drug Administration (FDA) and the National Council on Patient Information:

• 14-21 percent of patients never fill their original prescription
• 60 percent cannot name all the medications they are taking
• 30-50 percent fail to follow the instructions for taking a medication
• 12-20 percent take other people's medications²

With the government, the news media, and the members of the medical community increasingly focused on patient safety, these figures cry out for both explanation and attention. The explanation may include any or all of the following, which may be applied not only to situations involving medications but also to other situations in which "noncompliance" is an issue:

The patient does not understand the seriousness of his/her condition. The issue may be one of vocabulary, denial, or physician emphasis. The patient who believes a positive biopsy result is good because "positive is always better than negative" is unlikely to be able to process the need for a rigorous course of chemotherapy unless it is explained to him/her in the simplest possible lay vocabulary. On the other hand, the patient who wants or chooses to know nothing about his/her illness may be hard pressed to take medication for a condition he/she doesn't admit having. And in another scenario, the physician, in an attempt not to overwhelm a frightened patient, may underplay the potentially serious consequences of not taking a prescribed medication as directed. Alternatively, he/she may fail to convey the importance of an issue by never mentioning it after an initial question or statement.

The patient does not understand the instruction. Language or hearing difficulties may be issues, the patient may be confused by directions that include two or more steps or that are different for two medications, or the patient may not understand the reason for taking a medication. How many patients, for example, stop taking an antibiotic when they "feel better" rather than completing the prescribed course?

The patient forgot verbal instructions. Patients who are tense in a physician's office are likely to forget at least some of what is said. Others may feel intimidated by the physician and fail to ask the questions that arise during a discussion. Written instructions, possibly pre-printed, presented in easy-to-follow steps, and written with minimal words and in simple language should always accompany oral instructions.

The patient has difficulty taking the medication. The patient who consistently chokes on a pill, gags on a liquid, or suffers nausea, dizziness, or another side effect is likely to believe that the negatives of the medication outweigh the positives. Some will report the problems to the physicians; some will cut the dose of the medication to try and "make it work"; others will simply stop taking the medication.

The patient finds a drug (or treatment) regimen too complex. Multiple medications taken at different hours, some requiring an empty stomach, some needing to be accompanied by food, some requiring abstinence from certain foods, and some negatively interacting with other drugs may exact too much of a toll on the patience of a patient who is trying to live a life, not simply a drug regimen.

The patient cannot afford the medication. With many prescriptions now costing well over $100, some patients cannot afford the medications they need. Patients trying to stretch limited resources may skip doses, halve pills, dilute liquids, or even share medications with others. And in some financially stretched households where two people are taking medication, the patients may decide whose needs are the most critical and whose prescriptions get filled.

The patient is angry at or depressed about the chronic condition that necessitates the medication. Those with chronic illnesses often long to be "normal" and tire of the treatment or medication routines that continually remind them of what they may perceive as weakness, failing, stigma, or even mortality. The reason behind the failure to take a needed medication for such debilitating conditions as multiple sclerosis and amytrophic lateral sclerosis (ALS) may be as simple as denial. It may also be as complex as a death wish.

The patient may have religious or cultural beliefs that prohibit a certain treatment or medication. Some groups refuse blood and blood products. Others reject immunizations. A few refuse antibiotics. Some may have taboos relating to medical treatment or medications during pregnancy and the menstrual cycle while others may eschew medications made from animal parts. The list goes on. These beliefs are not mere adjuncts to a person's life; they often lie at its very core. If treatment is to be successful, they need to be explored, understood, and, to the extent possible, accommodated.

The patient may not have transportation to get to the physician's office or a pharmacy. For some patients, particularly those in rural areas, this may be a major factor in "noncompliance."

The patient may not feel comfortable with the physician or the medication. A patient whose family or friends strongly discourage the use of a prescribed treatment or medication because of their own negative experience is unlikely to share his or her concerns with a physician who explains little, exhibits no interest or empathy, and belittles complaints.³

The patient wants attention. For some lonely people, their physician may be the only person listening to them and treating them with dignity and respect. noncompliance ensures repeated visits.

The patient and physician may have different goals. Occasionally noncompliance is about defiance. It is sometimes about ignorance. In the case of skipped invasive tests such as colonoscopies, it may be about fear. Often, it is about misunderstanding. Most frequently, however, it is about miscommunication. The physician and the patient may have differing expectations of, or goals for, a prescribed treatment.^4,1 The physician may simply want improvement; the patient expects cure. The physician may want to rule out a medical possibility; the patient may expect an exact diagnosis. When these goals are not communicated, the patient may be labeled "noncompliant."

1 Stein, R. Noncompliance in the Treatment of Chronic Disease. LeNurse, Inc. Available at www.lenurse.com/articles/article6/. Accessed 30 Sept. 2003.

2 The Food and Drug Administration and The National Council on Patient Information. Healthy Living: Be a Good Patient and Follow Directions. Available at www.healthlink.com/health_good_patient.asp. Accessed 30 Sept. 2003.

3 David Karp Associates. Avoiding Liability When Patients Are Noncompliant. ProNational Insurance Company Medical Risk Management Advisor. Available at www.pronational.com/news/advisor/Noncompli1Q1997.htm. Accessed 30 Sept. 2003.

4 Funnell, M. Helping Patients Take Charge of Their Chronic Illnesses. Family Practice Management. March 2000. Available at www.aafp.org/fpm/20000300/47help.html. Accessed 30 Sept. 2003.

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