Find out what the patient’s concerns really are—and follow up

It is my belief that all physicians want what is best for their patients. Once they diagnose the patient, physicians do everything possible to see the patient recover from the injury or illness as completely and quickly as possible. The best patient care is provided when a collective effort of the physician and patient takes place, and they both do their part to achieve the treatment goals and objectives.

Repeatedly, a breakdown occurs in this partnership between the physician and the patient. It is a common occurrence for the physician to create a treatment plan, identify frequency and duration of care, recommend nutritional protocols, or provide a home exercise program only to have the patient not comply with these recommendations.

The problem of patients not following their physicians’ recommendations also involves patients not checking their blood-sugar levels according to clinical guidelines or failing to take their medication as prescribed. Or when patients are interested and concerned enough about a health issue to seek professional help to quit smoking or lose weight and then fail because they do not follow through with the recommended actions to achieve their goal.

The question, of course, is why patients don’t comply with their doctors’ recommendations, especially when it is the patients who initiate the doctor-patient encounter and it is the patient who will realize the clinical benefit.

In the beginning of every new patient visit, the physician must be cognizant of the opportunity for intervention and influence a behavioral change in this patient toward improved health and wellness. To accomplish this, the physician must explain the problem to the patient in a way that conveys an understanding of what the patient is going through with a sense of urgent importance for the patient to change his or her behavior. Once the patient perceives that the physician understands the patient’s problem, the door is now open to strengthen the physician/patient relationship and establish the groundwork to improve patient satisfaction and compliance.

Develop Trust
David Goldman describes the physiological consequences of trust in conveying a message to a person successfully. He discusses a mechanism whereby when we hear a recommendation, the amygdala filters the message and attaches an emotional context to it. Since the amygdala is responsible for our fight-or-flight response, if the message is perceived as threatening, the incoming message is short circuited and fails to reach the prefrontal cortex. From this point on, the rest of the message is considered irrelevent and the information is not absorbed.¹

This mechanism explains at least to some degree why, after a report-of-findings consultation, the physician feels satisfied that he or she has provided the patient with a complete understanding of his or her condition and prognosis. The patient, on the other hand, not having fully heard the physician’s explanation, remains uninformed about his or her diagnosis, therapy, or prognosis.

The next step is to develop a clear perception of the patient’s needs, and to understand why the patient is in the office and what he or she wants the physician to do as a result of this encounter. The best possible role of the physician is to be perceived as a trusted partner. Most cases of patient dissatisfaction can be traced back to an inadequate discovery of the patient’s needs.

Take the time to find out what the patient’s concerns really are. This usually requires asking some questions that probe a little deeper into this patient’s history, including but not limited to work, recreation, family, and social habits. For example, I had a geriatric patient who presented with a shoulder injury that included 8–10 pain, decreased range of motion, and functional restrictions in some activities of daily living.  

The patient was disproportionately distressed over this, so I questioned her about why this injury was upsetting her so much. The patient explained that this injury prevented her from hanging the laundry on a clothesline, signified a sign of her advancing age, and brought fears of future deterioration and dependency. In addition to treatment protocols, recommendations such as lowering the clothesline were made. Although the patient was far from the point of discharge, she was able to hang her laundry and was very pleased with the treatments.

Talk To Them, Not At Them
Try not to dominate the interaction. Most patients have some degree of knowledge about their condition, either by reading, seeing other physicians, or discussing it with family and friends. Whenever possible, acknowledge this information and include the patient by discussing possible solutions you have to offer.

Don’t force or insist on a commitment from a patient. The patient must give the physician a “green light,” as it were, before we can proceed. After we have given the patient options, ask if they are acceptable and whether the patient can comply with the recommendations. If the patient has objections, find out what they are. If the patient agrees with you, then confirm the commitment by repeating the agreement.

Follow Up
Finally, be sure to follow up with the patient regarding any possible recommendations that were made. Follow-up is required so we can monitor progress, identify problems, and let the patient know we are interested and care enough to ask.²

Whenever I use acupuncture to help a patient quit smoking, I always call with previous permission to check on these patients and see how they are doing. When patients know the doctor cares enough to follow up, they seem to increase their sense of responsibility and commitment. I am convinced that follow up calls contribute to my success rate with this procedure.

One United Health Care Corporation study investigating poor compliance in patients taking their prescription medications concluded: “After decades of compliance research, very little consistent information is available, except that patients do not take their medication as prescribed.” One proposed explanation for this phenomenon is to better understand medication-taking behavior; researchers need to examine the patient’s perspective as opposed to previous studies based on physician perspective.³

There is no question that it is frustrating when patients do not follow physician instructions. We expect compliance, even though there is clear evidence from clinical studies that we shouldn’t. It is estimated patient compliance is between 30–60% for chronic conditions⁴ and only 7% of people comply with all the steps considered necessary for glucose control.⁵

Clearly, this is the time of the empowered patient. As such, the literature offers alternative ways to consider compliance.  Compliance implies an involuntary act of submission to authority, whereas adherence refers to a voluntary act of subscribing to a point of view. This implies a close relationship with our patients based on communication. Communication is based on shared values and mutual respect.⁶

It is possible that what physicians consider noncompliance is simply the patient’s expression of disagreement about the treatment goals and objections. In these terms, noncompliance is more like patient disobedience.⁷ We need to learn to trust what our patients are telling us so they can facilitate adherence to our recommendations. In the big picture of patient care, we are really discussing patient self management as they incorporate our recommendations into their day-to-day-lives. This is patient-centered care. The physician remains the source of knowledge, offering medical expertise and psychosocial support. The physician maintains responsibility for managing the patient’s illness and injuries. The physician’s role, therefore, takes on the qualities of a coach or teacher.⁸

Whether you have been in practice for many years or are a recent graduate new to the chiropractic profession, the ability to have patients adhere to your recommendations is an important consideration for success.  Patient cooperation and satisfaction with care are closely linked. If you are experiencing difficulty with patients adhering to treatment plans and your clinical recommendations, try using some of the suggestions discussed previously.

Manuel A. Duarte, DC, MS, DACBSP, DABCO, CSCS, is a graduate of National College of Chiropractic. He has extensive teaching experience and lectures on a variety of topics, including manual treatment procedures, rehabilitation, orthopedics, and sports medicine.

References
1. Goleman D, McKee A, Boyatzis RE. Primal leadership: Realizing the power of emotional intelligence. Boston, Mass: Harvard Business School Press; 2002.

2. Pawar M. Five tips for generating patient satisfaction and compliance Fam Pract Manag. 2005;12(6): 44–46

3. Morris LS, Schultz RM, Patient compliance—an overview, J Clin Pharm Ther. 1992;17(5):283–295.

4. Nelson AM, Wood SD, Brown SW, Bronkesh S Gerbarg Z. Improving Patient Satisfaction Now: How to Earn Patient and Payer Loyalty. Gaithersburg, MD: Jones & Bartlett Publishers Inc; 1977.

5. Cerkoney, KA, Hart, LK. The relationship between the health belief model and compliance of persons with diabetes mellitus. Diabetes Care. 1980;3: 594–598.

6. Segal J. Patient compliance, the rhetoric of rhetoric, and the rhetoric of persuasion. Rhetoric Society Quarterly. 1994;23(3/4):91–102

7. Stewart M, Brown JB, Weston WW, McWhinney IR, McWilliam CL, Freeman TR. Patient-Centered Medicine: Transforming the Clinical Method. Thousand Oaks, Calif: Sage Publications Inc; 1995.

8. Stone M, Bronkesh S, Gerbarg Z, Wood S. The HSM Group Resource Center: Improving Patient Compliance. Strategic Medicine, January 1998. Available at www.hsmgroup.com/info/compli/compli.html. Accessed August 14, 2006.