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.

What Impact Can Non-Adherence Have?

     Other than altruism and pride, is there a reason for the physician to want a patient to comply with treatment instructions? There are more reasons than the doctor may suspect. Yes, legal and financial reasons can factor into the picture. If there is a negative outcome, the patient may believe it is the physician’s fault in spite of the fact that he or she did not adhere to a single bit of the physician’s instructions. Even if there is no legal case, a patient’s word-of-mouth about his or her experience can be equally destructive to a physician’s reputation and financial bottom line.

     However, the patient is usually on the losing end of non-adherence. A Family Practice Management article reported that about 6 percent of hospital admissions were caused by non-compliance. For instance, consider a patient who takes more medication than is safe because the prescribed regimen does not address the pain sufficiently and ends up with liver failure, on a transplant list and looking for someone to blame. A look at recent newspaper headlines tells us all this is happening more and more, both with prescription drugs and over-the-counter preparations containing acetaminophen. No physician wants this for his or her patients.

     Perhaps the group that has followed the trend with the most interest is the pharmaceutical industry. It is in the best financial interest of pharmaceutical companies that patients both fill and use their prescriptions (and refill them again). Accordingly, it is understandable that they would a href="/files/photos/adherencelead.jpg" rel="lightbox">track this information. In one survey reported by the American Academy of Family Practitioners (AAFP), Upjohn Company reported that 20 percent of respondents did not fill a prescription given to them during a one-year period. The number one reason reported was a belief that they did not actually need the medication prescribed.

     Another study discussed by AAFP reported that 21 percent of those respondents did not believe the medication prescribed was actually necessary, 22 percent feared the side effects and 14 percent cited an inability to afford the prescription.

     These outcomes are a clear indication that there is a lack of communication and trust between patient and physician.

     The cost of that mistrust and resulting non-adherence is counted in real dollars as well as in pain and suffering. The cost of needlessly incurred healthcare events is estimated at $8.5 billion by the National Pharmaceutical Council. This includes dollars spent on hospitalizations and physicians visits needed when treatment regimens were not adhered to in the first place.

     There is not a great deal of formal research data about adherence to treatment regimens among the podiatric population. However, Armstrong and Harkless did look at outcomes in their South Texas diabetic patient population and found that non-compliance can end in amputation.

     The study looked at the risk of complications when patients did not keep their clinical appointments. The authors defined non-compliance as “missing greater than 50 percent of scheduled appointments in any calendar year.” Of the 341 patients in their study, 30 fell into this group.

     They used the University of Texas Diabetic Foot Classification system and found that patients who were compliant, and in categories 0 and 1, had a zero incidence of ulceration. These patients, who retained sensation in their feet, were on top of their appointments and remained unaffected by the disease.

     Patients in the non-compliant group were over 50 percent more likely to have foot ulcerations and, with increasing underlying neuropathy and deformity, they became more than 20 times more likely than the compliant patients to have an amputation.

Other Implications Of Non-Compliance

     Not adhering to a treatment regimen can also mean not showing up for a scheduled surgery, and that can wreak havoc on schedules, impact other patients and eventually (if it is a continuing problem) impair a surgeon’s ability to have procedures scheduled at attractive times. No surgeon wants to be harnessed with the afternoon slots at the surgery centers and hospitals.

     One recently reported study found that patients who tended to not show up for scheduled surgery had also previously shown a tendency to exhibit the same behavior with other healthcare encounters like clinic visits.

     In a proactive move to fight against non-adherence, this study suggested scheduling patients identified as non-compliant later in the schedule as a cost-cutting move that would cause the least amount of disruption.

A Closer Look At Subtle Undercurrents Of Non-Adherent Behavior

     St. Luke said it first: “Physician, heal thyself,” and it is still good advice. In an article in Family Medicine in 1986, the idea of a power struggle between the patient and physician was examined along with the role this played in non-compliance.

     Every physician can probably remember at least one patient who seemed to “push all the wrong buttons” and a simple statement about a treatment escalated into a gauntlet throwing challenge.

     Ross and Phipps point to each party’s “emotional needs” as being the actual cause of this type of confrontation. In other words, it is not really about the issue at hand but is instead about the issue that remains hidden — a power play, machismo, mistrust, the patient as expert, the physician as dictator.

     Non-compliance with pediatric treatment regimens has been reported to be as high as 93 percent in one study and because of the significant and negative potential outcomes, there has been a great deal of study done about this particular group. These practitioners also have the added onus of having to “treat” the child’s caregiver as well.

A Guide To Overcoming The Non-Compliance Problem

     With medication regimens being the most problematic for all providers, the authors of “How Do You Improve Compliance?” outlined the following steps.

     1. Improve communication between the physician and patient. Time is an ever decreasing commodity with the demands of billing, supervising staff and other practice demands. Podiatrists can hand out patient brochures and instruction sheets in order to maximize information exposure and minimize hands-on time. However, studies invariably show that giving a piece of paper to a patient without an accompanying discussion — including questioning the patient about its contents after discussing it — is an exercise in futility.

     The caregiver has to connect with the patient. This involves maintaining eye contact with the patient and speaking to his or her level of education. Listening is a major part of communication with a patient, especially when it comes to clues a patient may offer as to his or her non-adherence.

     2. Be willing to make changes to a plan and negotiate regimens. This may seem entirely foreign to most physicians who are by definition the boss of their practices. However, a patient’s unwillingness to follow a plan may be backed up by a good reason for not doing so whether it is a lack of financial resources or perhaps an unyielding schedule. The physician may be able to reach a happy medium with the patient that will not compromise the treatment. Examples of this include prescribing a generic medication rather than a brand name or recommending a walker instead of a wheelchair that cannot be propelled over carpeting in a patient’s home.

     3. Try to get the patient to take ownership of his or her disease. A gentle reminder that the patient “takes his or her disease home” and doesn’t leave it with you will sometimes jar the patient’s realization.

     4. Keep the treatment regimen as simple as possible. If a medication can be dosed fewer times per day, the patient is much more likely to comply. Postoperative instructions are rife with complicated steps. Keeping it relatively basic will improve the chances of the patient following any of the instructions.

     Be cautious about potentially ambiguous language. One postoperative patient, after reading that the bandages should be kept clean, washed them in her home sink and reapplied them, exposing the surgical wound to potential infection. Adding the word “intact” might have kept the dressings in place.

     5. Consider other methods of fostering patient adherence. For those who enjoy higher technology and have access to it, computer programs may help patients to track their symptoms or disease state.

     Even something as low-tech as a pill box imprinted with the days of the week can be a tool to help the patient.

     British researchers point to other behaviors that will enhance patient compliance. They suggest creating a more patient-friendly environment; striving for minimum waiting times; developing a more conversational style; asking patients about their beliefs and fears; asking them how much they actually want to know about their condition; and/or reviewing the costs of non-compliance with them.

Final Notes

     It is difficult not to muse about the idealized perfection seen in Norman Rockwell’s classic illustrations about the doctor and his patient. There was always respect emanating from the patient to the physician and a sense of protectiveness and caring for the patient in return. It definitely is idealized though if you believe a study that revealed that patients may perceive that the physician does not even have their best interest in mind.

     That probably comes as a shock to most physicians who believe they always have their patients’ best interests at heart. It is probably also a warning to those physicians to look into their patients’ hearts as well.

     Dr. Satterfield is a Clinical Associate Professor in the Department of Orthopaedics/Podiatry Service at University of Texas Health Science Center at San Antonio.

     For related articles, see “How To Facilitate Better Patient Compliance” in the June 2003 issue of Podiatry Today.


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