Ensuring Patients Follow Directions

As a doctor there’s very little you can do once a patient exits your office. You’ve diagnosed or narrowed down your differential and have either prescribed treatment or asked for investigations. What comes next is down to the patient. You may never see them again or they might be back in a few days.

Patient compliance is how well a patient follows a doctor’s instructions. These instructions can include following a prescription and adhering to the drugs prescribed, coming back a few days later for follow up, or even something as simple as avoiding certain food or exercising. It can be frustrating for a doctor to deal with a noncompliant patient. It’s not that your efforts are going to waste, because that’s not what matters, but because you care about the wellbeing of your patients and it’s really important to you that they get better. It can be sad to see a patient you’ve had for a long time keep coming back in a worse condition because they’re not doing what you’re telling them.

In medicine there are even some tests that can tell doctors whether or not a patient is compliant. For instance the HbA1c test for diabetics is one of the ways a doctor can tell if their patient has been lying about taking their treatment. All doctors think “patients first” but in order for patients to improve they need to follow instructions. There are a number of obstacles that can get in the way of that and a lot of them are really not the patient’s fault.

The major focus here should be on communication. Doctors are infamously known for their terrible handwriting and as a medical student I can say that accusation is completely justified. There’s no way it’s a good idea to simply write down instructions on a piece of paper and send the patient home with it without talking about it. Even if you actually print the instructions or prescription there’s a very small chance a patient will adhere to it. First of all you may forget to write something important and since you didn’t say it and the patient didn’t get to ask you about it during the visit the issue will only be discovered when the patient leaves. You also need to explain how certain medications are taken. Everyone knows that someone with asthma uses an inhaler, but if you’re prescribing it to someone for the first time in their life you need to show them how to use it.

Patients understanding the outcomes of the treatment will increase the chances of them following it. Telling a patient with hypothyroidism that taking their thyroxine everyday before breakfast will allow them to be perfectly normal and healthy will make them want to take the drug in time. Warning a diabetic about the complications of uncontrolled diabetes such as retinal damage, neuropathy, and atherosclerosis will make them avoid missing doses. If a patient thinks their disease has no consequences or that it will eventually get better on its own will more likely neglect treatment.

Make sure to avoid medical jargon. This won’t increase a patient’s understanding and may in fact distance them from you which will make them less likely to do what you’re telling them to. Even if a patient is highly educated there’s no benefit in using medical terms. Keep it simple and show patients you care about them in order to make them more compliant. To make sure you understand what you just told them you can ask them to repeat it back to you and make sure to encourage them to ask questions. Take your time with patients and don’t rush it.

For some patients the problem isn’t that they don’t understand you, it’s that they forget. A patient with multiple chronic diseases such as a combination of diabetes, hypertension, and gout will be taking at least 4 drugs. It would be difficult for anyone regardless of how educated they are to remember the dosage and timing of each of these drugs. Older people may forget whether or not they took a dose and repeat it or not take it at all. These problems can result in missing doses, taking additional doses, or mixing up the doses of different drugs. All of these can lead to exacerbations of the disease or the appearance of side effects of drugs.

If a patient complains to you that they have a hard time getting their treatment right don’t just tell them to try harder. Take the time to find a way to make sure they can follow the treatment plan correctly. For instance they can have a schedule where they keep all the drugs at home to help remind them. Another option is the containers that contain compartments for different drugs and can help remind patients whether or not they already took a dose.

Religious reasons are also to be considered. Jehovah’s Witnesses for instance don’t accept blood transfusions or blood products. So you need to find a suitable alternative. You can’t force them to receive a blood product or tell them it’s either that or nothing else. A hemophilic Jehovah’s Witness can be treated through other means than the transfusion of blood or fresh frozen plasma. An alternative would be synthetic clotting factors which are made artificially, another option is desmopressin. Try to find solutions that don’t clash with a person’s beliefs.

Finances are one of the reasons patients don’t get treated. If you prescribe the most expensive drug to a patient and they find out at the pharmacy that they can’t afford it they’re simply not going to buy it. They might not visit you again to ask for a cheaper alternative out of embarrassment or they might not think that there’s an alternative to begin with. Not everyone knows that there are different options when it comes to drugs.

A solution to this would be learning to assess your patients. You probably already have their insurance data so that makes it much easier. You can easily prescribe drugs covered by their plan. If you think there’s a more expensive but better drug that you’d like them to use you can let them know that their insurance doesn’t cover it and ask if they’re willing to pay for it. If they refuse then you’ll just prescribe the one covered by insurance. A simpler approach would be to prescribe drugs with low prices for everyone although some people can afford more expensive ones which have fewer side effects and may be more efficient.

Chronically ill patients might not have the motivation to follow instructions. A patient with chronic liver disease who needs a transplant might start to lose hope of ever getting one which will make them not see the point of following instructions anyway. Keep your patients motivated and help them keep their hopes up.

Some patients who have logistic problems such as transportation will have a hard time completing investigations or returning for follow up sessions. An old person who doesn’t or can’t drive won’t be able to make it back for a follow up so before they leave their office make sure that they have someone to drive them. If that’s not an option then you can ask a social worker to find ways for them to be able to come back.

Not all patients are the same. In fact almost every patient is different from the other. Each has a way of thinking, beliefs, a different financial status, and more. It’s not just your job as a doctor to treat a disease, but to treat a person which includes everything we just mentioned. You won’t treat any two patients the same way. Realize the difficulties each patient faces and find solutions that work for this particular patient.