Deconstructing noncompliance

5 tips for working with patients struggling to make lifestyle changes

Two DOs discuss what leads to patient “noncompliance” and the approaches that have helped them better assist patients in achieving their health goals.

In the medical world, when a patient fails to follow a doctor’s directives, they are sometimes considered to be “noncompliant.” It’s a word with an almost militant connotation, but on the surface level, it follows some logic. Doctors generally have their patients’ best interests at heart, so, in theory, if a patient fails to hold up their end of the bargain and do the work to improve their life, it could be thought of as disobedience.

However, this black-and-white perspective seems to fly in the face of a core tenet of osteopathic medicine: looking beyond symptoms to understand how confounding lifestyle and environmental factors impact wellbeing and a patient’s ability to make lifestyle changes. According to two osteopathic physicians, the concept of noncompliance fails to account for those factors, which doctors should always be on the lookout for when prescribing a treatment plan.

Teshina Wilson, DO, a family physician with Kaiser Permanente in Pinole, California, said she seeks to develop a rapport with her patients that allows her to step back, evaluate the full picture, and understand why a patient is struggling to make a change.

“[Those scenarios] are when it starts to become the art of medicine, and the relationship between doctor and patient starts to mature and grow over time, possibly based on getting more trust between each of the parties, to really dig a little deeper and find the core issue,” Dr. Wilson said. “When a patient has been pushing back for a long time, there’s often an underlying factor at play that the physician isn’t aware of.”

Dr. Wilson and Cole Zanetti, DO, MPH, the director for digital health at Rocky Vista University College of Osteopathic Medicine, offer the following five tips to any physician working with a patient struggling to make a change.

1. Avoid jargon. Explain in plain language how the change will impact the patient.

Dr. Zanetti said he considers the term “noncompliance” to be a misnomer altogether, and that it often can be avoided from the start by effectively translating medical information into easily understandable terms in a motivational interview setting.

“In reality, the vast majority of people struggle with taking a medication or making a lifestyle change because a physician or clinician does not take the time to explain why it matters,” Dr. Zanetti said. “Most people aren’t going to do anything different unless they have a good understanding for why it’s important to them and their quality of life.”

2. Tap into what matters to the patient.

It’s often as simple as tapping into things that matter, Dr. Zanetti said. As an example, he cited explaining to a patient with high cardiovascular risk that he wants them to continue to enjoy a high quality of life, and to be able to keep up the exercising and hiking they enjoy doing. Those ideal health outcomes don’t always come across in jargon-heavy goals that can be hard to put into context, such as lowering blood pressure by a certain number of points, he said.

3. Consider mental health and social determinants of health.

All medical students train for motivational interviews, of course, but Dr. Wilson said there are certain situations with patients, in which issues recur time and time again, that you can’t possibly be trained for. It’s at these times when it’s best to ask about other parts of a patient’s life, like how work is going, how their family is doing and how they are sleeping, she said. Sometimes this provides a safe space for patients to speak about external stressors in their lives that they would typically keep within themselves.

Whatever those stressors may be, they can play a key role in causing or worsening existing mental illnesses, which Dr. Zanetti said can also be a significant confounding factor. He said doctors should always prioritize addressing those factors when evaluating a patient’s efforts to make changes.

“We cannot focus on diabetes until we get a mental health condition under control,” Dr. Zanetti said. “If someone is struggling to find housing and you’re telling them to change their diet, that’s ridiculous. But unless we ask the right questions, a lot of people are embarrassed to admit they’re struggling with these things. It’s misinterpreted as a compliance issue, as opposed to a social determinant of health issue.”

4. Honor your patients’ intelligence. 

Dr. Zanetti and Dr. Wilson both said patients can also be hesitant due to information they’ve found online that they believe, or a general distrust of the health care system. Dr. Zanetti said in these cases, it’s important to educate in a respectful manner that honors a patient’s intelligence. Dr. Wilson echoed that sentiment, and stressed that when patients bring up information they’ve found, it’s usually not because they want to butt heads with the doctor, but rather that they have found something that makes sense or feels more natural to them.

5. It might make sense to slow down. 

Dr. Wilson’s final critique of “noncompliance” was that it presumes that changes can always be made immediately. Patients and doctors should work together at a pace that makes sense and takes into account other factors impacting patients’ everyday lives, she said.

“I tell patients, tell me one thing that you can work on or adjust and adapt every day for the next month, and let’s check back in on that, and that’s how we work, slow and steady, and keep at it,” Dr. Wilson said. “When patients learn that they can start impacting their health care in terms of small changes every day, and they see the fruits of that labor, they’re more apt to feel like, OK, I’ve gotten this taken care of, now I can work on that.”

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1 comment

  1. Wow! This article continues the narrative that it is the fault of the physician when a patient does not follow recommendations. It further places the blame on a PCP and basically excuses the actions of the patients. This is how we got into a situation of physician pay-for-performance! I cannot go to my patient’s house and put the medicine into their body! I cannot make Caresource contract with more pharmacies. I cannot make CVS contract with companies to supply needed medicine. I cannot get a school to give a child an IEP. I cannot change the tier of a needed medicine. I cannot cook a healthy
    meal for all my patients to eat! Certainly there are many times where a patient is “no -compliant” for reasons other than simply not following doctors orders. But, I feel obligated to document “non-compliance” on anyone who doesn’t fill or take medicines as prescribed or follow up with referrals; otherwise, it could mean not getting paid for a visit due to poor patient outcome. This is not how medicine is supposed to be. We should not feel obligated to accept patients lying to us as a way of human life. We should not accept that insurance companies and CMS have taken over care of patients and doctor-patient relationship. And overall, physicians should stop putting the blame on other physicians. Physicians need to stop drinking corporate kool-aid and start supporting physician-led patient care.

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