When patients don’t follow orders

Getting patients to adhere to the doctor’s advice has always been one of the struggles in medicine. Sometimes patients don’t truly understand what’s expected of them or why they would benefit from, say, taking a prescription drug or receiving physical therapy. Sometimes there’s just honest disagreement between doctor and patient about the best course of action.

It can be easy to write off these nonadherent patients as stubborn, misguided or self-destructive. A rather intriguing new study suggests, however, that patients’ own beliefs about their ability to manage their health play an important role in adherence – and that health outcomes tend to be better when the doctor and patient have compatible beliefs. The study appeared in the May issue of the Journal of General Internal Medicine.

Eighteen primary care physicians and 246 patients at the VA Iowa City Medical Center and affiliated clinics were involved in the study, which queried both the doctors and the patients about their beliefs in personal control over health outcomes. Doctors and patients then were assessed for how closely their beliefs matched and how well this match corresponded with the likelihood that the patients filled their prescriptions and had well-controlled blood pressure and blood sugar measurements.

According to the findings, health outcomes were best when physicians and patients shared similar beliefs. This seemed to hold true not only for patients and physicians who both had a strong belief in personal control over their health but also for those who shared a weaker belief in this control. Patients fared less well, though, when there was a gap between their beliefs and the physician’s beliefs.

It should be noted that this study only involved VA patients who had both high blood pressure and diabetes, so the findings can’t necessarily be generalized to the rest of the population. It raises some interesting issues, though, about doctor-patient dynamics, especially when it comes to advising the patient what to do.

Does it matter whether the patient’s values are considered? Maybe it does, the study’s lead author, Alan G. Christensen, explained in an article this week in American Medical News. For instance, patients who place a high importance on control might react negatively – perhaps by not filling a prescription – if they perceive the doctor doesn’t take their values into account. On the other hand, patients who don’t have a strong sense of personal control over their health might feel pressured or overwhelmed if they’re dealing with a doctor who believes in greater empowerment. 

“The nonadherence itself can be a way for the patient to restore some sense of control,” said Christensen, chair of the University of Iowa Dept. of Psychology and senior scientist at the Center for Research in the Implementation of Innovative Strategies in Practice.

Patients don’t all have the same views of how they want to manage their health, he said. “One patient’s empowerment is another patient’s burden.”

Indeed, patients’ values and beliefs influence their actions to a greater extent than many health care professionals realize. Stephen Wilkins, a specialist in health care communication, explored this issue awhile back on his blog, Mind the Gap:

One of the basic tenets of the patient-centered care model is getting to know the “person behind the patient label,” i.e. their health motivations, attitudes, beliefs and so on. Why? It is because people that show up in the doctor’s office each have their own pre-existing set of experiences, knowledge and beliefs about their health and the health care system.

A patient’s motivations, attitudes and beliefs are shaped by a variety of experiences. Maybe they had a family member or friend with the same health condition. Maybe they saw or heard a TV or radio commercial. Or maybe they had a previous bad experience with another provider. Regardless of where this thinking comes from, or whether it is “right or wrong,” patient thinking plays an important yet often overlooked role in patient adherence.

A commenter on Wilkins’s blog brought up another point: Perhaps health care professionals unintentionally encourage nonadherence by what they convey, verbally or nonverbally, to the patient. The commenter writes: “Lack of empathy, focus on the numbers of lab results, threats of complications, judgment, etc., during an office visit (or over the phone) often sets a patient up to feel he/she has already failed (so why bother?), and has an enormous impact on how a patient may or may not manage a chronic disease.”

Whether busy physicians are willing or able to take the time to uncover their patients’ beliefs is a separate question. The authors of the Iowa City VA study suggest a good first step would be to develop a quick assessment tool that could be used to help better understand the patient’s values and motivation, and presumably help tailor the doctor’s recommendations more effectively.

Nonadherence is a tough problem to solve. And it’s not just about the physician; at some point patients have to take responsibility too. Knowing what makes a particular patient tick, however, and gaining insight into why the patient might not be adhering to the doctor’s orders can be a critical step toward addressing it constructively.

Update, May 20: Here’s another look at patient nonadherence, specifically nonadherence to prescription drugs, that appeared today in the New York Times.

Photo: Wikimedia Commons

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