Jarrod Shapiro, DPM Practice Perfect Editor Mountain View Medical & Surgical Associates, Madras, Oregon

Is Patient Compliance Possible?

In medicine, the term “compliance” brings up a host of images to those of us tasked with dealing with patients.  I can think of any number of patients where compliance — or rather noncompliance — was an important factor in the success ( or failure) of their treatment.  Of all the topics that we hear at conferences, compliance is that one topic that receives “honorable mention.”  By this, I mean our national lecturers will gloss over noncompliance, but never discuss how they actually improve it.  The comments I’ve heard are usually with the underlying tone that we treat our patients in spite of their noncompliance; recognize it’s there, but there’s nothing we can do about.  I’m unsatisfied by this general tone of helplessness in the face of our patients’ noncompliance.  So here’s my answer to the title question “is compliance possible?”  Yes, but likely never 100%.  If I’m right, and we can improve compliance, how do we do so?  What methods are likely to work? 

	Tonight's Premier Lecture is Regenerative Tissue Matrix in Treatment of Lower Extremity Wounds by Steve Brigido, DPM, FACFAS

First, I think it’s important to understand when compliance is important. I’ve listed below a few issues to focus on, in which compliance plays a significant role.

• Office scheduling and follow-up appointments
• Conservative care recommendations
• Medication prescribing
• Postsurgical follow-up

Next, we can discuss barriers to compliance.  I use the term “barriers” specifically because, more often than not, patients are noncompliant not because they are being deliberately contrary to their doctor,  but because of some event or situation in their personal life that prevents their compliance.  Some issues include:

• Lack of education/understanding
• Physical barriers
• Behavioral issues
• Lack of support
• Lack of desire
• Language and culture
• Lifestyle
• Doctors misunderstanding their relationship with patients

Finally, we can debate methods to improve our patients’ compliance.  Some of the  ideas I’ll present below are adapted from an interesting article by Stone, et al in the journal Strategic Medicine.

1. Consider YOUR relationship with your patients.  Are you an authoritarian, telling patients what to do, expecting them to “do as you say?”  Do you consider your patients as children who “misbehave” when they’re noncompliant?  Or do you consider yourself an information resource to empower patients to help themselves?  The second type of doctor role has been found to be more successful in working with modern patients.
2. Listen carefully to your patient’s history.  Ask open-ended questions that gather not only information specific to the complaint, but that elicit modifying factors and patient understanding.  For example, does your flatfoot reconstruction patient live alone in a two storey house?  Clearly, this situation will affect your patient’s ability to comply with postoperative nonweightbearing instructions. 
3. Educate your patients to the extent they want to be educated.  Some patients are empowered by having as much information as possible.  Others want only enough knowledge to obtain a basic understanding.  No matter what level of education you provide, stay away from medical jargon.  Clear, simple explanations go a long way.  Also consider dispensing written literature. 
4. Provide understanding of the consequences of your patient’s actions.  Education also includes what will happen to your diabetic patient if they continue to put pressure on that plantar ulcer.
5. Know your patient as well as possible before operating on them.  Give them an opportunity to display their level of compliance during the nonsurgical phase of your treatment.  If preoperatively your patient can’t adhere to your instructions, how well will they comply postoperatively?
6. When prescribing medications, use daily or BID dosages if possible.  Simple regimens with less dosages increase compliance.  Be sure to educate patients on side effects and in medications that require gradual withdrawal.
7. Consider “forcing” compliance when appropriate.  For example, a below knee cast will provide greater compliance than a removable cam walker.
8. Automate reminders as much as possible.  For example, automated patient appointment reminders are available and have been shown to reduce patient no-shows.  In a similar vein, calling patients early in the postoperative phase allows the physician to not only know how his patient is doing, but also allows for reminders about nonweightbearing issues, medications, and other compliance concerns.
9. Monitor care as much as possible.  For example, consider attaching a pedometer to those BK nonweightbearing casts.  If the pedometer displays steps taken, you know your patient has been noncompliant with your nonweightbearing orders.
10. Understand that the physician never actually controls the situation.  When your patient leaves the office, whether or not they comply is completely up to them.  Understand also that there are times when you’re forced to treat in spite of a patient’s compliance status (for example, emergency situations).  Remember, though, that you are the doctor, and you should never do anything that makes you uncomfortable.

Hopefully, these suggestions will help improve your approach to patient compliance.  Follow this link for more information and an interesting analysis of methods to improve compliance.  

What do you think?
What methods work for you to improve patient compliance?  Join in on a number of live eTalk discussions, or start one of your own, at podiatry.com,

Keep writing in with your thoughts and comments or visit eTalk on PRESENT Podiatry and start or get in on the discussion. We'll see you next week. Best wishes!

Jarrod Shapiro, DPM
PRESENT Practice Perfect Editor
[email protected]

Sign up today and receive up to $60 Credit for CME

GRAND SPONSOR MAJOR SPONSORS