Gary Oftedahl: Non-compliant or Maximally Disrupted

September 22, 2009 at 3:16 pm 2 comments

In more than 25 years of medical practice, I was frustrated by the frequent non-compliance of my patients.  Despite my best exhortations and lengthy explanations, I was astonished and disappointed by the limited impact I had on addressing the needed behavior changes to ensure a healthier patient population. It would have made my life much simpler if those patients had only listened to my sage advice.

As my career progressed, and the complexity of the care system increased, I saw an increasing frequency of patients not following the wonderful and compassionate advice I provided.  The lack of patients following my “prescriptions” and “orders” caused frequent self examination of my capabilities as a physician.

Today, I would suggest that if there is one term which we should consider expunging from our health care lexicon, it would be “non-compliant.”  As I’ve had the opportunity to explore the concepts of patient-centered care, read further on the science and challenges of behavior change, and reflect on my own life, it’s become clear that while there are occasionally true examples of deliberate non-compliance, it is more likely an excuse we use to discuss our failures in understanding the needs and the capabilities of our patients in making life style changes, that while simple in concept, are incredibly complex in putting in place in the real world.

I often think of how my patients felt when I visit with my financial planner.  I’m the first to admit that while I’m quite astute and adept at mastering most complicated concepts, understanding the nuances and vocabulary of finances is not a strength. (OK, I’m likely as susceptible to an auto mechanic telling me my “flibberjocky” needs replacement in my car and waiting for me to respond in an intelligent fashion.)  As my planner patiently and thoroughly explains the  choices available to me in distributing my investments, outlining in great detail the depth and breadth of choices, I of course, not wanting to look stupid, nod my head, appear engaged, and contemplate carefully the beautiful graphics and spread sheets he’s using to inform me.  When asked if I understand (don’t want to appear uninformed you know) I nod appreciatively, agree to a transfer of funds, and leave–hoping I’ve not just provided him a nice vacation in the Bahamas rather than advancing my retirement.

This may be an exaggeration, but do we think our patients have any more capacity to understand the complexities of self care, behavior change, medication compliance, or diet/exercise advice, than I to understand the complexity of the finance world?  Yet, if I were to be called non-compliant by my planner, I’d rail against the label, proclaiming the unnecessary complexity, confusing language, or lack of time in making the changes requested.

As the complexity of medical care increases, and the increased need for patient involvement continues to crescendo, we need to reassess our methods of engaging patients in maintaining and improving their health.   If we in health care are unable to make simple changes in workflows or processes within our care delivery systems, how can we expect our patients to make often complex, and complicated changes, which disrupt a life-long pattern of activity.

I’ve recently had the opportunity to read a great perspective on this from Carl May, Victor Montori, and Frances Mair in the BMJ, calling on the need for Minimally Disruptive Medicine (http://bit.ly/16hDOR).  Additionally, a recent video presentation by Dr. Montori at a Mayo Clinic conference on Innovation highlighted the issues in a truly eloquent fashion. (http://www.vimeo.com/6328967).

Rather than “blaming” our patients and becoming frustrated at their lack of compliance (there’s that word again) we need to begin to reframe what we’re doing in the context of minimally disrupting their life style.  Briefly, May, et. al. call on us to address four principles in guiding our work in health care redesign:

  • Establish the weight of burden–clinicians need reliable tools which assist in identifying and addressing the amount of work and effort we’re asking of  patients.
  • Encourage coordination in practice–need to move from isolated disease approaches to addressing the complexity and comorbidity which needs careful attention and coordination of services and efforts.
  • Acknowledge co-morbidity in clinical evidence–must move beyond only using disease specific processes, and incorporate comorbidities to support the coordination efforts needed.
  • Prioritize from the patient perspective–rather than focusing  on what we think is best for the patient, work with them to identify what is their priority and work in concert with them in developing a program.

While simple in content, the transformation needed to move to this goal will be challenging.  As we hear about medical/health care homes, collaborative care, shared decision making, and patient-centered care, we need to contemplate the needed shift from compliance and adherence to minimally disruptive medicine as a construct for truly developing a value-driven, patient-centered health care system.  I applaud Drs. May, Montori, and Mair for causing a tectonic shift in my thinking. Oh, and I think I’ll tell my financial planner, I need some minimally disruptive estate planning if I’m ever going to be able to retire–but that’s another story.

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