You wouldn’t think it would take much persuading to convince patients with diabetes to regularly monitor their blood sugar or stay off of a recently treated foot wound given the potentially serious consequences of not doing so. Yet the statistics tell us a different story. In an intriguing, retrospective study published in the February 2005 edition of WOUNDS, researchers found that patient compliance was poor in 79 percent of patients with diabetes that eventually succumbed to amputation.
Experts say there are things clinicians can do to identify obstacles to compliance. It starts with empathy. Instead of using a condescending or accusatory tone, one podiatric educator suggests moving in close, lowering the volume of your voice and saying calmly, “I know that you had a hard time doing what I asked of you. I know it wasn’t really fair but I appreciate how hard you have tried.” In this example, the podiatrist says you have indicated confidence in the patient’s attempt at compliance, recognition of the difficulty of the task and finally appreciation.
“After that, they often drop their guard,” she says. Accordingly, the patients are more forthcoming and candid.
Other folks cite the importance of “normalizing non-compliance” in order to get patients to open up about potential obstacles they face. One expert who lectures on patient compliance says clinicians could tell a non-compliant patient that nobody follows their regimen 100 percent of the time. By opening the door with this rapport, the clinician can subsequently ask the patient when it is most difficult to follow his or her regimen. The lecturer notes this subtle approach will likely generate more candor in contrast to asking the patient directly whether he or she is actually following the regimen.
A clinician who sees a high volume of diabetes patients in his California-based practice agrees. He says this approach facilitates candor from most patients, especially when you let them know that the hemoglobin A1c will show the last 110 days of average blood sugar. “Most patients get honest real quick when you have lab data,” he adds.
The aforementioned lecturer emphasizes working with each patient to define goals that are appropriate for the patient. Then identify barriers to those goals and help patients think about what strategies they think would be effective in overcoming those barriers. Getting patients to be actively involved in their care is crucial.
Of course, subtle reminders about the potential impact of non-compliance never hurt. One DPM cites an endocrinologist friend who often reminds her male patients about the increased risk of erectile dysfunction in patients with poor glycemic control. “She finds that extremely effective in spurring her patients toward good glycemic control.”
When all else fails, the podiatrist says nothing hits a patient between the eyes like a photo of amputated toes or a partial foot amputation. He admits it is the lowest level of intelligent reasoning but it is effective. “I reserve it for the most difficult patients but it is another tool in our tool box and I am not afraid to use it,” he maintains.
Granted, there may be a few outrageous examples of non-compliance. One doctor recalls a post-op patient who went water skiing while wearing a plaster cast. However, in the majority of cases, experienced clinicians say it is important to show empathy and be cognizant of potential barriers to non-compliance such as economic status, a lack of family support, living circumstances, etc. Indeed, perhaps the most important thing is asking the right questions so clinicians can identify the obstacles and help patients overcome the barriers.