Secrets To Facilitating Patient Adherence

By Kathleen Satterfield, DPM

     The basic question is really “How do you get someone to do something that they do not especially want to do?” The fictional Tom Sawyer was the classic king of this skill but as physicians, we are trying to do something a bit more complicated than getting someone to paint a fence. We are trying to get our patients to adhere to the instructions of given treatment regimens, such as taking a confusing regimen of pharmaceuticals or staying off an injured foot.

     Although the word “non-compliance” is not in the title of this article, be assured that the issue is here to stay and it is indeed at the center of the discussion. There are those who believe there is no such thing as non-compliance and that the problem is just an inability to communicate successfully with a patient. This remains a controversial issue but what can be agreed upon is the need to facilitate a patient’s adherence to the physician’s prescribed regimen.

Why Patients Do Not Comply

     In order to facilitate this adherence, a podiatrist needs to understand in advance why the patient may not follow his or her instructions.

     It is the rare, psychologically impaired patient who digs in and refuses to try to comply with a reasonable request. There is usually a cause behind non-compliance. Most of the reasons fall into one of the following 10 categories.

     1. The patient is not physically able to comply.
     2. The patient has difficulty remembering instructions or cannot understand complicated regimens.
     3. The patient is a “control freak” and believes he or she knows better than the doctor.
     4. The patient would truly like to comply but is unable to because of financial reasons.
     5. The patient has not yet come to grips with the illness and how it is affecting his or her life. Accordingly, he or she is “not ready” to comply.
     6. The patient is not literate and cannot understand instructions.
     7. The patient is not motivated to comply.
     8. The patient has cultural issues with the treatment or the practitioner.
     9. The patient has generational issues.
     10. The patient may be fearful of the effects of the treatment regimen.

     The secret to facilitating a treatment regimen is found in addressing the specific cause of the potential non-compliance before it has an opportunity to occur. Most of these potential causes of non-adherence are clear-cut and one can surmount them if there is open communication between the patient and physician. Indeed, there may be financial difficulties, literacy issues, motivation and/or difficulty in “coming to grips” with a diagnosis. Granted, these can be embarrassing issues for a patient and the physician may need to open up the line of conversation.

     The more trying issues are those that are related to the patient’s disease state because they are multifactorial. These include not only emotional factors but physical factors as well.

Does The Disease Make A Difference?

     Disease does make a difference, in particular, if that disease happens to be diabetes mellitus.

     The resultant neuropathy and cognitive difficulties that can accompany diabetes can impair a patient’s ability to comply. For example, if a neuropathic patient has a total contact cast, the patient may earnestly not realize that he has walked as much as he has and may be startled to discover, upon removal of the cast, that an ulceration has become worse.

     Research has shown that cognitive abilities can be affected by uncontrolled diabetes. This impairment may or may not make it more difficult for the patient with diabetes to understand instructions but it is important for the physician to keep this in mind.

     One research group studied patients with type I diabetes who chose not to come to medical appointments. They found that these patients fell into three groups: the “high fear” group, the “patient as expert” group and the “low motivation” group. They did not explore the implications of disease complications on non-adherence to the program.

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