It all but goes without saying that treatments are more successful when patients adhere to treatment regimens. If patients aren’t taking medications, following instructions for nutrition and physical activity, or attending appointments, their conditions — chronic or acute — may fail to improve, may recur or, worst of all, may worsen. Although it’s helpful to understand why patients sometimes don’t comply with prescribed medical advice, it’s even more importance to recognize that this might be intentional and done for valid reasons. More often than not, it’s because patients haven’t been fully engaged in their care. Understanding the difference between compliance and engagement is the first step, before you can identify methods for overcoming barriers to better care.
Concordance, not compliance
Historically, adherence has been viewed in terms of patient “compliance” — the degree to which a patient follows medical advice. But this term implies the relay of an order from a medical authority figure to an obedient patient. In short: It’s one-way communication, which doesn’t provide an opportunity to identify patient-originating factors that determine how appropriate a treatment recommendation is. Patient-related factors might include:
- Capability to physically carry out instructions (e.g. patient has mobility, dexterity or pain issues), which might affect motivation to follow a treatment plan
- Socio-economic factors
- Health beliefs and health literacy
- Opinions of other people, such as relatives and friends
- Psychosocial reasons (e.g. not feeling valued in the process of care)
In addition, the clinician’s goals may differ from those of the patient, who may be experiencing social, psychological or practical effects of living with a short- or long-term condition. For example, a patient with diabetes may want to feel as if they can have the same food and drink as their friends and family, and prioritize that ahead of recommendations for managing their condition.
Communication and collaboration
Two-way communication between physician and patient about treatment priorities and realistic approaches is needed to establish an achievable regimen. And being actively engaged with the patient starts with hearing the patient — not just listening. This is where certified medical scribes come in: when scribes remove the distraction of taking notes while the patient is talking, the physician is able to look at the patient, listen to their symptoms (including the things that might not seem important at first mention), ask further questions, and make a more informed judgment about moving forward with treatment. Remember, if patients are taking some steps, it’s better than no steps — and may lead to patients more fully embracing the treatment plan over time. If the continuum starts at compliance, it ends at “concordance,” with respect for the patient’s wants and needs.
Exchange of education
Patients value the ability to make informed care choices, and the quality of patient-clinician relationships can improve self-management abilities and level of patient concordance. What’s more, health outcomes improve when people are actively involved in their own care. However, this requires a solid educational foundation, communicated in the way that works best for the patient, and that is as complete and ongoing as possible. Some hospitals are giving patients DVDs, pamphlets or internet links approved by physicians, to explain available options for treatment. This lets patients explore and learn without feeling the pressure to make a decision in the exam room or on an ER bed, particularly when the diagnosis may be an emotional one. The physician supports these methods of learning with detailed explanations and by responding to questions and concerns during patient interaction. Websites, apps and illustrated guides can help patients with the tasks they must carry out at home — providing reminders of when, how and why to continue with various aspects of treatment. As a result, patients are more engaged in the process of deciding a course of treatment that they feel comfortable with or, in the case of chronic disorders, that they can adhere to over the long term.
Reduction of barriers
Clinicians must take care to not be a barrier to patient engagement. It’s up to the clinician to give patients opportunities to choose and control aspects of care, through discussions about clinically appropriate options and flexibility for patient preferences. Clinicians should encourage beneficial approaches regardless of a patient’s reluctance; be able to pinpoint the reason for a patient’s reluctance; and use cognitive, behavioral and affective strategies to guide patient communication away from this reluctance.
Other barriers may be less directly under physician control. Resourcing obstacles can include inaccessibility of services, limited appointment times, long waiting times, and lack of privacy during discussions (e.g. in the emergency department) that might involve personal circumstances. Further barriers can concern the nature of the treatment — e.g. complexity or long-term periods of care required. In addition, some people may be incapable of self-care, for example, those with dementia or mobility issues. As beneficial self-care initiatives sometimes require voluntary patient recruitment, patients who are less likely to participate might remain the hardest to reach although, ironically, they may be the people who would benefit most. For them, it is most important to get the diagnosis or care plan right the first time, rather than going through unnecessary, repeat visits with the same patient.