Saturday, December 3, 2011

What Your Healthcare Team Needs to Know About Your Non Compliance.

Compliant |kəmˈplīənt|
1. inclined to agree with others or obey rules, esp. to an excessive degree; acquiescent : good-humored, eagerly compliant girls. See note at obedient. (From the New Oxford American Dictionary)

A picture of NON-Compliance. Only a biscuit will
motivate him for action.
It’s rare that I have the opportunity to chat with a medical student, a soon to be doctor. But this past weekend I was fortunate. Mike, a bright, articulate, and lovely guy of 28, is nearing the end of his fourth year of his medical education, currently doing his internal medicine rotation. He attends a top medical school in New York City. And you know me. I just had to ask him, this soon to be practicing doctor, a few pressing questions, while strolling along the brownstone lined streets of NYC. Here’s how it went.

LL: “So how much nutrition education do you get throughout your training?”
Mike: “About 5 hours total, in my four years.”
LL: “And what kinds of nutrition topics do you cover?”
Mike: “The greatest focus is on all the vitamins and minerals and their deficiencies—scurvy, beriberi, Wernicke-Korsakoff, to name a few.”
LL: “Wow, so the bulk of your nutrition education is spent studying conditions that we rarely see in our country.” (scurvy is a vitamin C deficiency, beriberi a thiamin deficiency rather uncommon in these parts), with the exception of Wernicke’s which we do see in severe alcoholics (also from a thiamin deficiency).

Further along in our conversation Mike shared his frustrations regarding nutrition-related illness:

“Patients tend to be non-compliant. You know, they don’t do what we tell them, what they need to do to help themselves.”

What does your doctor need to hear from you in
this limited time?
And with that comment, I had to hold back my biting tongue. (He really was a lovely fella, and a friend of my son, so I took a breath and went for the patient response.) Yes, it is frustrating to feel that people could help themselves if only they would follow what you tell them to do, if they would just do it. We discussed the fact that the average length of a typical doctor’s visit is maybe 17 minutes, start to finish; during the length of three songs on your iPod, your doctor needs to assess your medical situation, answer your questions, figure out how best to convey information to you about your condition, educate you and direct you to resources. Sounds easy, no?

Clearly something gets missed in these limited length visits. How can providers expect patients to change when they haven’t even probed to see what obstacles are keeping them stuck?
For better “compliance”, doctors need to better assess patients’ readiness for change. And then provide them with correct information and useful resources to go forward.

Laziness Keeping Her From Exercise?

Maybe there's another reason she (he?) stays where he's at?
And no, I didn't pose them when I too this picture.
You can’t tell someone, like my patient Ellen, who might benefit medically from an increase in physical activity for her blood sugar, cholesterol and blood pressure management, as well as her escalating weight, that she needs to exercise four days per week, 30-40 minutes. Why? Because she associates an increase in heart rate with anxiety, and fears it’ll result in a heart attack. Instead, I had to work on getting her to see that exercise is safe, first and foremost. So I discussed with her doctor getting a stress test done, followed by a doctor’s approval for exercise, to allay her fears. After that, she was able to slowly increase her activity. Now she exercises regularly.

Time To Change The Strategy

 Stubborn and non-compiant--
but who knows what's going on inside his head?
More than one woman I have worked with has shared that her husband has made it clear in no uncertain terms that she shouldn’t be eating what she eats, or weighing the weight she weighs. The result? An “I’ll show you” response—she eats beyond her need, when he’s not around, in part to spite him. Acting like her husband, telling her what to do, judging her by her size, will ensure that her weight continues to climb. Instead, directing such patients to work with a therapist to better communicate with their spouse (and others) and speak up for them selves can help. And enlist their suggestions, their ideas for practical change. That’s a way for providers to successfully problem solve.

And such patients need to be given permission, with practical strategies, to bring food out of the closet. I often recommend that they tell their spouse what to expect—that they will see them eating foods the spouse deems unacceptable for weight management—and they shouldn’t be surprised. And their spouse should withhold comment and judgment, thank you very much. Only then can we expect “compliance”.

Information Can Cause Slips

Health care providers need to check their facts, before being quick to disseminate information. Telling patients “cut out your carbs” is simplistic and unnecessary, including for diabetics. And you can bet it’ll lead to non-compliance. And confusion, as they get bombarded with nutritional misinformation from all ends. It is unrealistic, and not a practical change.

They need to get educated, too, in communicating information with teenage and adult, anorexic girls and young men. Statements like “great job! Your weight’s heading right up there!” or “You need to gain weight or you won’t get your period” can be traumatizing. Or “You’re perfect—don’t gain another pound!” And how many girls couldn’t care less about getting their periods? Telling a 12 year old that not getting a period will lead to osteoporosis? Who cares? They envision old, bent over, great-grandmothers—not something they believe can happen to them in their teen years. But tell them amenorrhea could cause fractures when running or engaging in their favorite sports, requiring them to end participating in sports with their friends—now that may make a difference.

What’s In It For You?

Listening to what patients really do care about, about where their concerns lie, will help motivate change. For some, it’s about hair loss in clumps, or lanugo, hair growth on their arms or face, as their weight has dropped, that concerns them. Or it’s being freezing all the time, as their body temperature has dropped. Or the fear they will not be able to return to soccer, or dance, or field hockey, to name a few.
Sure, doctors and health care providers get frustrated by non-compliance. But our patients are no less frustrated—and they’re angry, and hurt—too. Because they are not understood; because there are good reasons they stay stuck in their unhealthy behaviors. And it is rarely due to ignorance.

Advice For Fellow Healthcare Providers

Compliance shouldn’t be the goal we shoot for. Patients need to be more than puppets nodding and acting according to our commands. (See definition of compliance.) 

They need to be engaged in the process of change, participating in charting their course. We all need supports, guidance, and compassion, not just rules, to begin making change. Oh, and did I mention the need for hope? Certainly, if I don’t believe in my patients, they won’t believe in their own potential for change.

The health system isn’t going to get over-hauled any time soon. Seventeen minutes may seem like a luxury in the future. But if only doctors and other providers would take the time to ask a few key questions. And then? Give up a few minutes of the 17 to truly listen.
Then they can refer to appropriate providers—the nutritionists and therapists experienced in a behavioral approach to change. Only then can they assist their patients in making change, helping us all feel a lot less frustrated.


  1. This was an amazing article...I appreciate hearing some articulate so eloquently how I feel. Your blog postings are slways so thoughtful and I love that you are able to see the wrold from your patients perspwctive while maintaining those professional lenses! Awesome!!

  2. My mother goes to the doc once a year for a physical and her blood sugar is always a tad high and they send the test results with a note that tells her to exercise more and eat fewer desserts. My mom is super tiny, definitely underweight, she has so many disordered eating habits that I can't even count them all, and she exercises like a fiend for over an hour a day. When she gets a note from her doctor that says "exercise more and eat fewer desserts" she translates that message to "lose weight fatty". She got so small she eventually went in for several other tests to rule out cancer because she was just wasting away, but when I helped her calculate how many calories she was consuming, she was averaging about 700 a day. She truly believes she was following doctors orders.

    A little extra time from the doctor would have prevented the problem, I think, at the very least he could have used more precise language.

  3. Such a brilliant post! Doctors, especially new doctors, need to remember that their patients are not naughty children. We do all sorts of funny things for all sorts of incredibly complicated reasons - most of which we don't even really understand ourselves!!
    I have always been extremely lucky with my treatment as my gp specialises in eating disorders. But I have heard enough stories about ppl being told some very unhelpful things by their gps to know that there is something really basic going wrong in their training.

  4. Thanks for your feedback! Any suggestions on spreading the message to prevent the kind of damage Kate describes would be greatly appreciated!

  5. Re: Kate's message. Eat less and move more doesn't work, full stop.I'm not a doctor but I'll bet that if people ate quality food in reasonable quantities (not starvation levels or excessive) that a great many health problems could be averted. Same with exercise-- reasonable amounts doing something you enjoy is beneficial; doing things that hurt or you dislike is not (looking at my own damaged knees in chagrin-- exercising more was not the right choice for me at least).

    Happy and healthy is far more important than body shape. Doctors need to learn to leave their charts and numbers aside from time to time and actually LISTEN to their clients. My new doctor is fantastic,she listens, she SUGGESTS (not orders), and she didn't say a word about losing more weight-- she was more interested in me maintaining my present comfortable and sustainable lifeways.


  6. As a medical student (Though in England, not America) I can say that nutritional education here isnt a whole world better. We have covered the nutritional deficiency diseases, some work on malnutrition in hospital and eating disorders.. aaand thats about it. We need to be taught more about nutrition and why people do what they do. Expecting "compliance" seems to boil down to "expecting my patients' numbers to go the direction I want them to go, and if they dont it's the patients' fault" Not terribly productive. And who really completely alters thier diet longterm just to please thier doctor? They may do it because thier doctors' advice reinforces beliefs and behaviours they already have but no doctor has that kind of control- as you say not puppets on a string.
    And it is so wrong to expect that from patients. Listening is whats needed, but that takes time, communication skills and empathy some doctors just do not have. We do get a lot more training now but you can tell who listens and who doesnt already.
    Thankyou for putting a very complex medical problem beautifully into words.

  7. Thank you thank you thank you for writing this. as a dietetic intern i feel like i'm occaisionally butting heads with those same MDs that get 5 hours of nutrition in their education. pt's don't need to just be "compliant" they need to be taught, supported and guided. change won't happen until the patient is ready-our job is to get them to that place!

  8. Woow! very wonderful!!! I've learned much about the topics about the nutrition education, the fact about this and the possible illness when you were not listening to the advice of the doctors and the benefits when you followed those steps and advice of the Doctors How to live a healthier living.