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Posted on 26. January 2012

Disagreeing Without Being Disagreeable

By Carla Schick

Last week, this comment was posted on the IG Living Facebook page: When a patient does not follow a doctor’s treatment plan or discontinues medication sooner than advised, doctors refer to this behavior as “noncompliance.” Statistics show noncompliance can result in higher healthcare costs, increased hospital admissions and a breakdown in doctor/patient communication. Have you ever been noncompliant, and if so, why?

We received numerous responses from fans, most of whom felt that noncompliance was necessary because of health concerns. If they experienced severe side effects from a particular medication, or if they felt that the doctor simply gave them a prescription to get them out of the office, they were “compliant in their noncompliance.”

Let’s face it: We’ve probably all been medically noncompliant at some point in our lives. Maybe we only took seven days’ worth of our 10-day antibiotic, or perhaps we chose not to take a medication that was meant for depression because we didn’t have depression; we just live in chronic pain. I’m guilty of defying my doctor’s orders. Having recently been diagnosed with gastroesophageal reflux disease (GERD), my doctor gave me a prescription for Nexium, a once-a-day medication that works by decreasing the amount of acid made in the stomach. Not only did it not get rid of my chronic indigestion, but it caused terrible stomach pain, which I later found out was one of the long list of side effects caused by the medication. After taking only two days’ worth of my 30-day prescription, I discontinued the medication because the stomach pain was unrelenting.

Doctors throw the word noncompliance around like we’re breaking the law every time we don’t follow their instructions. So this issue of noncompliance begs the questions: How can we as patients empower ourselves while maintaining respect for our physician? How can we take control of our healthcare without feeling like we’ve just been reprimanded?

Dr. Richard Frankel, a medical sociologist at Indiana University, helped develop a training program that Kaiser Permanente uses to teach their doctors to be better listeners. He says that oftentimes appointments are not productive because physicians assume that the first symptom or concern mentioned by the patient is the one that’s the most important. However, Dr. Frankel notes: “Studies show that the most important symptom or worry… is often the third or fourth item on a patient’s list, blurted out at the very end of an appointment.”

In a scenario like the one Dr. Frankel describes, miscommunication could easily lead to what a doctor might later call noncompliance. The key, it seems, is better communication between patients and their healthcare providers.

Here are a few communication tips for patients from Dr. Frankel:

  • Put all the items on the table at the start of the visit. If the doctor interrupts to focus on the first problem, say something like: “You know that’s one concern, but maybe not my most important. Could I give you the full list before we go on so we can prioritize?”
  • If you are afraid of offending your doctor by questioning or refusing a treatment or test, you could begin the discussion with: “Could you please review the benefits of this treatment for me again so that I can write them down? Good. Now could we talk about risks, too? OK, so tell me again why you think the benefits outweigh the risks in my case?
  • Be specific and straightforward with your doctor. Instead of asking, “Is it important that I start this therapy next week?” don’t be afraid to tell the doctor: “My cousin’s wedding is next week, and I’d like to go. Would it be OK to start the therapy after that?”
  • Bring a trusted friend or family member to your appointment to help make sure that delicate questions are asked and answered.

As patients, we need to respect our doctor’s expertise. But when our gut tells us a particular medication or line of therapy isn’t working, it’s time to speak up and discuss other treatment options. If we are honest with our concerns, we stand a better chance of finding a more effective treatment plan. When all else fails, we can always disagree — without becoming disagreeable.

For further information found in this blog, please visit:
www.nytimes.com/2006/08/15/health/15cons.html?pagewanted=2&_r=1

Tell us about a time when you decided not to follow your physician’s instructions.

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Comments (5) -

Marty Schick
8:17 AM on Friday, January 27, 2012

Great post!!

Working for a major healthcare provider I see more than just a poor patient experience but the costs associated with it.

Below is a good example anaysis of what this "non-compliance" issue has resulted in. It's no wonder healthcare costs are out of control.

Direct Consequences and Costs of Noncompliance
Inadequate implementation of treatment has devastating consequences, such as causing

10-25% of hospital & nursing home admissions, resulting in 340 deaths per day
20% of unintentional pregnancies in the US at a cost of $2.6 billion
3 times as many doctor visits & $2000 per year in additional costs compared to patients who follow their treatment plan
33-69% of all medication-related hospital admissions in the US at a cost of $100 billion

It is especially revealing that estimates of the total annual healthcare costs in the US resulting from patient noncompliance vary from $100 billion to $170 billion to $300 billion. First, this range (even after adjusting for the 11 year difference between the oldest and newest figures) points to the potential risk of false precision, the dramatic influence of assumptions and methodologies in such approximations, and the difficulty of computing cost-benefit ratios of efforts to enhance compliance. Second, even the most conservative figures delineate the tremendous fiscal impact of noncompliance, fully justifying The American Heart Association’s summation that “the cost of noncompliance in terms of human life and money is shocking.”

Medical Mom
9:49 AM on Friday, January 27, 2012

WOW. I appreciate Dr. Frankel's suggestions, but I really do not appreciate the overall suggestion that when a patient refuses to follow the doctor's orders it is "wrong" -- particularly in light of the high prevalence of medical errors recently reported.   The patient knows their body and totality of symptoms best--they are actually living in that body 24/7.  

In my all-too-frequent experience, many doctors are extraordinarily thin-skinned and cannot accept disagreement no matter how softly stated.

If the patient is NOT taking responsibility for understanding and researching their own conditions, then they are necessarily ceding decision-making authority to the docs. Non-compliance in that situation could be dangerous!

However, if the patient chooses to be responsible for their own body and researchers and learns as much as possible about their condition then they should be a member of the care team.  As a member of the team, the patient is on par with the physician to determine what is appropriate care.

My child has a rare disease (incidence of 2 kids per 1,000,000)and I find that local "experts" are not up on current literature and treatments.  They have prescribed contra-indicated drugs and drugs known to reduce the AUC (area under the curve)for the vital therapeutic drugs at times when my child's condition was critical. After experiencing mistakes early-on in my child's care, I determined to learn and read as much as possible. I gather and maintain more data on my child than the doctors do.

The best doctor relationships we have are ones in which the doctor does not feel the insecure impulse to be the "expert" but works collaboratively with all of the experts on the team. Maybe the critical personality trait is humility, or lack of hubris, which makes it possible for docs to suspend judgment and truly listen (fact gathering).  

These "secure" doctors are open to conversations about all the aspects of care.  They welcome more info, more literature, more data and do not perceive that accepting more information, including from the patient/parent, diminishes their expertise.

There are still times when I refuse a suggested drug that is contra-indicated, but our current expert responds "Perfectly reasonable. Let me prescribe something else."  And, importantly, the patient is not shamed for "non-compliance."  This collaboraive team yields the best results we've had.

Brussels
11:04 AM on Friday, January 27, 2012

I have to agree with "Medical Mom's" post above.  Specifically, "The best doctor relationships we have are ones in which the doctor does not feel the insecure impulse to be the "expert" but works collaboratively with all of the experts on the team....These "secure" doctors are open to conversations about all the aspects of care."

As a simple example, if we'd followed everything the doctors had said to the letter without questioning it then I would be dead today.  I am allergic to Morphine, and a doctor prescribed and was about to inject morphine into my veins when I questioned his "authority"!!!  A "non-compliance" you shout...

From my perspective, a "non-compliance" is something that is against a legal binding law, regulation or standard. Not every human is alike and what is good for one may not be neccessarily great for another. If we wanted to start referring to Doctors as legal binding law's, regulations or standards - then Doctors in general would have to significantly change their listening, hearing, and critical thinking skills.  Also, all humans might, overnight, need to  become exactly the same in shape, form and disease occurrence.

Additionally, I would suggest the health care costs in this country and around the world would drop dramatically if ALL doctors in general could diagnose a problem (after necessary tests) the first time. Without patients needing to see multiple doctors, searching for years and years and years for the solution or atleast a diagnoses. That's where the TRUE burgeoning costs of the health care system come from.

Susangb
11:44 AM on Friday, January 27, 2012

yes, just recently I ran into an issue with medication not being covered because the physicians office needed to get preauthorization for particular med. Never heard from the office and will be following up with them next week. I tryed to not take the meds to see if I could manage without it. Didn't work. I need something for my stomach that is stronger than over the counter stuff. I tryed a bunch of different over the counter meds and they didn't work.  I am not useually non complinant as I don't want to feel sick, however, my insurance company has made it more difficult to get the meds I need which the physicians clearly recommended and the physicians office didn't follow up on it either.....I didn't hear from them and decided to wait till my appointment. Of course it is not their responsibility to babysit me either

juan zori
6:40 PM on Tuesday, March 22, 2016

I'd like to tell my doctor when a med is making me sick as hell. Problem is it is extremely hard to get through to him on the phone!  Many doctors are better at isolating themselves than most business executives.  Maybe they should have gone into other careers?  So I do what I think is best for me.

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