Noncompliance

The longer I practice medicine, the more I realize the power of succinct, accurate information. In the era of mile-long problem lists and medication lists in the double digits, a clinician's ability to synthesize information and accurately convey it is more important than ever.

Yet, for all the precision we dedicate to describing pathology and treatments, the very general, unprecise words “noncompliance” or “nonadherence” litter our charts. For many medical conditions, our perceptions of patients are influenced by adherence to treatment regimens. Given the importance of treatment adherence, I frequently see clinicians label their patients as noncompliant or nonadherent without describing the reason why.

Early into my intern year, I met Ms. R, a sweet older lady admitted for hyperglycemia by the overnight team. She had been admitted numerous times for hyperglycemia that quickly resolved when restarting her home medications. Her body had seen the devastation of chronic, uncontrolled diabetes, including retinopathy and severe neuropathy. As members of the night team presented her case and passed her care to me, they noted that the patient was noncompliant and suggested that I call her pharmacy, tune her up, and discharge her. Over the next day, she responded to reinitiation of her diabetes medications. Her blood sugar normalized, and as we prepared for discharge, we decided to watch her administer her lunch dose to herself. What I saw shocked me.

Her retinopathy was so severe that she was barely able to see the numbers on the syringe. She was noncompliant with her insulin because she could not see how many units she was administering.
A systematic review in Annals indicated that improving patient adherence requires a multifaceted approach with case management, pharmacy, and behavioral support (1). Working with social work, inpatient pharmacy, and a local independent pharmacy, we were able to discharge her with an updated plan: Her pens were filled by a local pharmacy “preclicked” to the right dose and then delivered to her house.

As a second-year resident, I now see the word “noncompliance” as an opportunity. An opportunity to talk to and observe my patient to try and understand why they are unable to take their medicine. Although time-consuming, I have learned more about my patients’ lives and priorities and in turn have been able to provide better more sustainable care.

References

1. Viswanathan M, Golin CE, Jones CD, et al. Interventions to improve adherence to self-administered medications for chronic diseases in the United States: a systematic review. Ann Intern Med. 2012;157:785-95. [PMID: 22964778]