Want to improve your healthcare and the healthcare system at large?
… and, in the process, decrease medical costs?
… without changing doctors, moving into an ashram, or giving up any of your disgusting vices?

The Background

First, it’s important that you understand these facts:

1. Although patients who take medications1 as prescribed will, as a group, have a statistically significant better outcome than the patients who refuse the medications altogether or patients who take the medications but not as prescribed, a significant number of patients (a 20-80% range of noncompliance would cover most cases and a 50% noncompliance rate would be a fair estimate of an overall average) will not take medications as prescribed – regardless of the disorder being treated, the severity of the potential outcome, the medication prescribed, the age, education, experience, or demographics of the patients. Patient noncompliance has been a pervasive and persistent healthcare phenomenon despite the best efforts of the healthcare community to combat it since at least the time of Hippocrates (born 460 BC; died 377 BC).

2. Most of those patients who do not take medications as prescribed do not inform the prescribing clinician of this and may even claim that they have taken the medications as prescribed. In the overwhelming majority of such cases the prescribing clinician never discovers that the medications were not taken as prescribed.

3. Clinicians cannot efficaciously deal with treatment failure caused by noncompliance if they do not know that the patient did not follow the treatment plan. At best, the physician will be less efficient in providing appropriate care; at worst, they may modify the treatment with disastrous results.

4. The currently prevalent models of noncompliance management have a final common pathway: their objective, their only measure of success, is that the patient follows the prescribed medication regimen, whether this goal is attained by coercion, persuasion, incentives, moral appeals to responsibility or concern for ones family, patient education, or other methods. Even so-called “patient empowerment” has come to mean “the patient empowered to choose to take the medication as prescribed.” Consequently, patients who do not take their medications as prescribed are powerfully but covertly encouraged to actively or passively mislead clinicians about the noncompliance, perpetuating this vicious cycle.

That wasn’t so bad, was it? Is everybody still with me? OK, now we come to

The Incredibly Revolutionary Idea

1. We quit pretending that noncompliance will disappear if patients are properly educated, persuaded, empowered, informed, motivated, coerced, bribed, threatened, influenced, or reminded. We acknowledge the obvious – that except in a few cases,2 the patient makes the final choice about following a prescribed treatment.

2. Rather than continue the unrequited efforts to eradicate noncompliance, we try, as a first step in breaking the vicious cycle, fixing that part of the healthcare system that multiplies the damage caused by noncompliance: the miscommunication between clinician and patient about noncompliance.

And How Do We Do That?

Well, the easiest and best way would be for everyone to read this post, acknowledge the wisdom and power of this idea, and change overnight.

Just in case that plan inexplicably fails, there is a Plan B, but it’s a tad more complex. Plan B involves adjusting the interaction between clinician and patient to reinforce rather than discourage open communication about noncompliance. This will require the cooperation of some significant players from the healthcare field, those who pay for healthcare, and government bureaucracies as well as patients and their families. It probably won’t happen overnight.

In The Meantime

If this concept appeals to you, you can take a baby step or two toward opening communication with your medical team on your own and at your own risk by simply informing your prescribing clinician if you didn’t take your medications as prescribed, whatever the reason (e.g., you lost track of the prescription schedule, the medication caused side-effects, it didn’t seems as though the medication was working).

Here’s the catch. While telling your physician that you aren’t following his or her prescribed treatment seems rather straightforward (after all, what objection can there be to a patient telling the doctor the truth?), the risk is that your clinician could respond to your efforts in a suboptimal manner3 because, for example, of personality conflicts, fears of malpractice lawsuits, misinterpretation of your motivation, or pressure from peers, third party payers, or administrative overseers.

The possibility of a negative outcome from this interaction, while incalculable, does exist and precludes my enthusiastic endorsement and encouragement of patients taking unilateral action.

Here’s an interesting question for your primary doctor/nurse practitioner/physician’s assistant that might help you assess his/her attitude: “Say, Dr. _______, I was wondering. If you prescribed some pills for me and I called you a week later to tell you I had taken them for a while but became convinced they weren’t going to help and quit taking them, what would happen then?”

Credit Due Department: Photo by Andy Melton

Note: Originally posted Jun 29, 2006 at 1HeckOfAGuy.com, a predecessor of AllanShowalter.com

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1. This post focuses on treatment with medication only because that is a familiar concept and one that is relatively easy to understand; the same principles apply to treatment plans featuring prescribed diets, exercise programs, screening tests, etc. [↩]
2. E.g., cases involving children or adult patients incompetent to handle their own healthcare and cases in which forced compliance with treatment is legally sanctioned and is pragmatically feasible [↩]
3. “Your clinician could respond to your efforts in a suboptimal manner” is code for “Your clinician could be a jerk,” “Your clinician could find a reason to refuse to treat you,” or “Your clinician could retaliate against what he or she sees as ungrateful, uncooperative, or crazy behavior.” [↩]