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Respecting a 'non-compliant' patient's choices

A doctor can instruct and implore a patient to follow treatment guidelines. But it's up to a patient to decide.

September 27, 2010|By Steve Dudley, Special to the Los Angeles Times

I saw Margaret recently. I was happy that she came in, as she was overdue for a visit. She is a delightful, middle-age woman who has been on the receiving end of more than her fair share of health problems, including high blood pressure, diabetes and gout.

It's that pesky gout that troubles her the most, and the reason why she popped into my office. She had recently suffered another attack at the base of her big toe, and boy did it smart. Stoic by nature, she reported that it was "a little painful." A little painful? Afflicted individuals usually liken the experience to having a baby in your big toe, or having your foot smashed repeatedly with a sledgehammer, or walking on red-hot coals. I'll say it's "a little painful."

I asked Margaret if she was taking her medicine to prevent ongoing attacks. She was evasive and instead countered with the fact that she was watching her diet. I surmised that she didn't want to disappoint me by admitting that she had neglected her pills. Offering her a way out, I asked if her prescription had run out. She dodged again, telling me that her toe was a little better and that yesterday was much worse.

Oh, Margaret. As Sgt. Joe Friday used to say, "All we want are the facts, ma'am."

Flipping through her chart, I found a note from her cardiologist. As is common among those of us in the medical profession, he had made a master problem list of all the things that were wrong with her. There they were, neatly delineated in descending order of importance (at least in the mind of the cardiologist): systolic dysfunction, hypertension, Type 2 diabetes and gout, all of which I was well familiar with.

Then, at the bottom, was a new entry: "medically non-compliant."

Now that's an interesting term — non-compliant. In a nutshell, it means that our patients won't do what we, the omniscient doctors, tell them to do.

I suppose, in the strictest sense, the cardiologist was right. Margaret would let her cardiac medications lapse, for shame. She didn't exercise enough, more shame. She hadn't lost weight, shame, shame, shame. And yes, in the case of gout, she had stopped taking her medication.

Last summer, I had asked her to return in three months for a recheck. It had now been nine months, and the only reason she was here in my office was because she was in pain — not because she had any desire to wipe that "non-compliant" label off her problem list.

But I object to that whole line of thinking.

For starters, who's in charge here, the doctor or the patient? Some of my colleagues may differ with me, but in my mind, the patient is in the driver's seat. I see my role as that of a consultant, offering advice and assistance to those who seek it. But in the final analysis, the patient gets to decide whether to accept or reject it. I can be emphatic, forceful — even animated at times — but in the end, if a patient doesn't take her medication or get a needed test, that is a decision I must respect.

The reasons are many. Perhaps the drugs are too pricey and the patient is embarrassed to admit that finances are a problem. Sometimes the drugs cause unpleasant side effects. Often, it is tough to persuade a patient that they need a drug to head off a problem they don't even have. And some people just don't like to take pills.

I wouldn't say that these patients are non-compliant. They have reached a decision based on values known only to them.

The "non-compliance" label reflects a very authoritarian approach to the doctor-patient relationship. It presumes that I am in control, and it's up to the patient to toe the line. It's not a role that I'm comfortable with. What is more important to me is to try to figure out the "why" behind the non-compliance.

To this busy cardiologist, however, it was easier to tack another line on the master problem list.

I still don't know why Margaret takes such serious health problems so lightly. But with each visit, I try to probe a little deeper.

As my visit with Margaret wound down, I spoke, yet again, about the nature of gout and how she may be able to prevent future attacks. She smiled and nodded, even accepted the prescription from my outstretched hand. She told me she'd be back in a few weeks for a checkup and some lab tests. I offered my words of encouragement as she shuffled down the corridor, then reflected on the encounter I had just had.

It's my job to educate and be a health resource. I hoped that I had done that with Margaret, at least a little bit. Time will tell. I suspect I'll see her again next February.

Dudley is a Seattle physician.

doctordudley@comcast.net

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