Patients usually have reasons for being noncompliant

Commentary. By Charles Atkins, MD, amednews contributor. April 9, 2001.

COMMENTARY

Observations on the state of medical practice and medical life

SEE ARCHIVES

I recently listened to myself describing potential side effects of a medication to a patient.

"Well, you could gain weight, might experience some hair loss, and there's a chance that your thinking won't feel as crisp." Sounded like a winner to me.

As I approach my 40s, I can just imagine what my response would be to a physician trying to push a drug that would make me fat, bald and stupid. Yet if I were to be recommended such a pill, in this case for manic depression, and then neglected to take it, I would be branded as noncompliant.

In my current position, where I oversee systems of care, I spend a great deal of time reviewing medical records for individuals who have severe and prolonged mental illness. Repeatedly I come up against the term noncompliance. The more I see it, the less I like it.

So I start with Stedman's Medical Dictionary to ascertain whether this is even a word. I find compliance: "The consistency and accuracy with which a patient follows the regimen prescribed by a physician or other health professional. Adherence."

Still, I don't care for the sound of noncompliance -- as if not following the doctor's advice is a sign of moral turpitude. The term hides a bigger issue: Why is this person not doing what the doctor said?

It's not because they're being naughty. This is why the term makes me see red.

If we dig below the surface of noncompliance, we get to elements of real meaning, such as, the person can't afford the medication or tolerate the side effects or deal with the illness for which the medication is prescribed.

Let's not forget that denial is a dandy response to all sorts of bad news. If I don't take the pill or the injection, then maybe I don't really have hypertension, diabetes, etc.

For those clients on sedating medications, noncompliance might be the manifestation of iatrogenic memory loss. It's not that they don't want to take the pills -- they just can't remember. Or if not a side effect of medication, noncompliance has led me to more than one diagnosis of early dementia. But again, if we can't see beyond the term, we don't assess for the possibility of short-term memory impairment affecting the ability to take a medication as prescribed.

Then I think about my own history with medication. Every few years I'll get a cold that will progress to my hacking up green and nasty gobs. Armed with a plastic cup of sputum, I'll knock on my primary care physician's door. He'll look in the cup and prescribe 10 days' worth of the antibiotic du jour, while sending the specimen for culture and sensitivity.

Within a day or two I'll feel much better and will no longer be expectorating phlegmy goo. Somewhere around day four I'll miss my first dose of antibiotic; I'll remember later and will either double up the next dose or do without. Yes, I can hear you all reading this and making a collective tsking sound: It's bad, it's naughty, it's not how we were taught. Still, by day seven all traces of the green goo are gone, and the remaining three days' worth of antibiotics will find their way to the bathroom drawer, where they'll keep company with vintage pills from years gone by.

It's true. I confess. I am a noncompliant patient.

As I go through charts, I've developed an admiration for people who are actually able to keep on top of multiple medications taken multiple times a day; it's not easy. Years back, when I was working in a geriatric setting, I took part in a performance improvement project that looked at medication accuracy. It was a simple study that had patients write down their medications, dosage, frequency and why they were taking them.

The results were sobering. Across the board there were errors, some of them quite serious. In response, we launched a campaign involving various strategies to help improve accuracy: weekly pillboxes, medication alarms, three-by-five cards that got updated every time the patient saw the doctor, and bringing in additional supports such as family members and visiting nurses.

I've since developed what some might consider a jaundiced view of medication accuracy. There are so many variables that figure into whether patients will take a pill; I never assume they take it. Instead, I ask if they've been taking the medication and also how they've been taking it. I try to be open to any response.

At least this way I'm operating with more reality-based data. If my client is hallucinating, I'm not about to increase the medication if I learn he or she has been taking only half the prescribed dose.

"How come you're not taking the whole pill?" I'll ask.

"I thought I was taking the right amount."

"I only had to take half when it was green."

"I was trying to make them last because I'm on a Medicaid spend down."

"The whole pill makes my hands shake."

Depending on the answer, I'll be better clued in to the next step in treatment. But noncompliance tells me very little. When I see it in a chart, all it really tells me is that the patient is not doing what he or she was told, and no one is willing to spend the time to find out why.

Dr. Atkins is the director of psychiatry at Waterbury (Conn.) Hospital and a member of the Yale clinical faculty. His latest thriller is "Risk Factor" (St. Martin's Press).