In the course of a single day, we often see frustrating patients who do not follow the seemingly simple instructions that we give to them. Treating non-compliant diabetic patients, specifically those who are dealing with issues of wound care, infections and even amputations, can be particularly challenging. When I use the term non-compliant, I am sure that everyone immediately visualizes his or her most memorable patient. You may refer to this patient as a problem patient, a troublemaker or any other choice word, but are these negative judgments of patients making the challenging cases even more frustrating? After all, non-compliance ultimately causes delays in the resolution of problems and often leads to more aggressive and costly treatments. It’s important to strive for a better understanding of non-compliant patients. Indeed, non-compliance is defined as the lack of follow through with your advice. However, non-compliance can be the intentional result of a rational decision based on personal beliefs related to the disease and its treatment. In other words, does the patient own his or her diabetes-related complications or is he or she in a stage of denial? The term compliance itself has a negative connotation. It conjures images of submission to authority, coercion and a unidirectional flow of care from doctor to patient instead of a partnership. Others who have researched this topic generally prefer the term adherence. There may also be a tendency to assume the profile of a non-compliant patient is that of a young, poor, illiterate or indigent person. However, the literature does not substantiate this. According to the literature, several key factors are linked to non-compliance, including social and family relationships, experiences with the health care system and patient perceptions about illness and medication. The barriers to compliance generally fall into one of three categories: patient factors, physician factors and factors associated with the health care system. Understanding Patient Non-Compliance Factors Patients themselves may be the true source of non-compliance. In order to get to the bottom of the behavior, there are several key questions you must ask. • Does the patient assume control over diabetes? • Has the patient accepted diabetes as a chronic illness requiring lifestyle changes? • Has the patient been educated about outcomes? • What is the patient’s attitude toward diabetes? The answers to these difficult questions may reveal the reasons your problem patient is not following instructions. Of course, obtaining the answers is a difficult process given the number of patients one may see in a given day. For a patient to feel comfortable revealing these answers truthfully, he or she must also perceive the clinician as having a genuine interest in positive outcomes. Other patient factors influencing compliance are mechanical difficulties (i.e., swallowing pills), impaired mobility, cost (i.e., medications, dressing supplies), fear, pride, religious beliefs, and the patient’s perception of whether he or she is feeling better, worse or feels there is a lack of progress. There are also factors associated with the health care system that may lead to patient non-compliance. Prolonged waiting times, impersonal service, lack of continuity of care and issues associated with transportation are just some of the issues. What You Can Do To Bolster Patient Compliance You may unknowingly be playing a role in patient non-compliance as well. It’s important to evaluate your own attitude toward patients with diabetes. Is this a population that you enjoy working with or do you view these patients as a burden? Today’s clinicians must adapt from the more traditional biomedical approach and work with patients from a biopsychosocial perspective. It is necessary to accept the patient as a fully entitled partner. Indeed, these patients respond best when there is continuity of care and consistent follow-through. As clinicians, we are often responsible for demanding complicated medical regimes such as involved and unrealistic dressing changes or treatment modalities. Most people are already squeezed for time with busy schedules and non-compliance can often be the result of poor understanding and such cumbersome requests that the patient will just simply give up. If you want to influence patient compliance, consider the following keys: • Explain the logic behind your therapeutic advice. • Understand patient perceptions about the efficacy of treatment. • Talk about the patient’s problems regarding continuation of care. • Determine if treatments may interfere with the patient’s lifestyle. • Include the patient’s family and other significant people in your education efforts. • Simplify complex wound care or drug regimens. • Be specific. • Provide pre-printed handouts with instructions. • Help facilitate patients’ search for their own solutions. Empower Your Patients Clearly, if you want a patient to be compliant with a particular regimen, there is a high level of education required. The American Association of Diabetes Educators recognizes two theories of diabetes education. The compliance-based approach maintains the health care professional is an expert and patients should comply accordingly. This theory is inherently flawed in that care is unidirectional since I am “telling” the patient what to do and often not giving the patient the “why.” The empowerment approach is generally more favored today. This theory states that when we give patients all the necessary information, they can make the best decision for themselves based on their own needs, circumstances and expectations. In this regard, patients accept responsibilities and experience their own consequences. There are a few specific patient populations in which certain influences affect patient compliance. With regard to adolescents with diabetes, the most powerful predictor of compliance is support from nurses. This group may feel less threatened by nurses. They seem to feel the greatest connection and rapport with nurses as compared to physicians. Polypharmacy is the primary influence on compliance for the geriatric population. One must establish a clear plan for adding new medications and assistance from family or caregivers may be necessary to ensure patients are taking new medications exactly as you have prescribed them. Also be aware that patients of lower socioeconomic status and specifically those of Hispanic or African-American descent may have issues associated with diets, other comorbidities, access to healthcare and religious beliefs that may influence compliance. Dr. Rothenberg (left) is a Certified Diabetes Educator who practices in Atlanta. Dr. Steinberg (right) is an Assistant Professor in the Department of Orthopaedics/Podiatry Service at the University of Texas Health Science Center.
It is a good explanation, however it is better to put more on the importance of patient compliance as well.