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Editorial May 2006
The Compliance
Conundrum
Ronald T. Burkman, MD
Physicians face a significant challenge in assisting patients to follow approaches that will either maintain health or treat an existing condition. While most physicians view following advice and taking medications as a straightforward matter for patients, in reality there are multiple barriers that can undermine success. Some patients may not fully understand either their condition or the proposed intervention. Thus, they may not equate failure to follow instructions with a lack of improvement in health. The physicianÍs instructions or advice may not be imparted at
a ñteachable moment,î so that the patient remembers nothing about the counseling session. This often occurs with conditions that require surgery; even though the surgeon provides a detailed description of the benefits and risks of the procedure,
a significant percentage of
patients have no recollection of the discussion.
One problem is that the physician's explanations may be
too technical for the patient to understand. Gauging the patient's
level of comprehension is critical. Many people—even those
who are highly educated—inherently have difficulty in remembering
to take daily medications. Another problem that may interfere with
compliance is the occurrence of side effects, leading the patient
to discontinue use without
notifying the practitioner.
Many clinicians care for culturally diverse populations. While
most US physicians espouse a "Western" milieu, other
cultures may not encourage free exchange in communication—particularly
with someone who is viewed as an authority. Thus, critical information
may not be solicited or shared. Finally, it may be difficult for
a patient to contact the physician, leading them to decide arbitrarily
to stop a medication.
Although many of these barriers can be removed by recognition
and appropriate attention, substantial improvements can often be
derived from focusing on communication skills. A variety of techniques
have been shown to be effective. Active listening is a simple technique,
but one that may require the clinician to alter an ingrained behavior
and allow the patient to tell her story or relate her complaint
without interruption. In an effort to “get to the point” or
expedite the visit, physicians may tend to anticipate or interrupt
patients, leading to frustration and misinformation. Of interest,
active listening in medicine has been found to add minimal time
to the encounter.
Another technique is to make the clinician-patient discussion
more interactive. This requires the use of open-ended questions
rather than questions that can be answered with a yes or a no,
allowing the clinician to gauge the patient's overall comprehension.
For example, clinicians can quiz patients regarding information
crucial to their care. Also, patients should be encouraged to raise
issues early in the encounter through the simple question, "Is
there anything else you would like to discuss?" This question
will often reveal the real reason for the visit, focusing attention
on the matter most important to the patient.
Even with use of better communication techniques, clinicians
still may not have enough time to fully educate the patient about
specific issues. The use of handouts or referral to relevant Web
sites may be of assistance. Medical information is constantly changing,
giving rise to ambiguities for physician and patient alike. In
the future, interactive Web- or compact disc-based programs may
become critical to ensuring that patients obtain enough information
to understand their conditions and manage their own care.
Ronald T. Burkman, MD
Associate Editor
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