Source:
Integrity outranks patient compliance
By Howard Brody. Galveston Daily News. September 11, 2007
Dr Brody’s Judgment Of Other Physicians
This article is Dr. Howard Brody’s jeremiad on the lack of ethical integrity among physicians – despite his own efforts to imbue the profession with sound moral values.1 As the sole evidence of this lamentable state of affairs, Dr. Brody points to a survey of physicians and patients attitudes undertaken by Consumer Reports earlier this year. The essence of his argument is summarized in this excerpt from the beginning of his essay:
For many years, folks like me have been teaching ethics courses in medical school. Lesson One is usually the concept of “patient autonomy.” That idea is captured in the common phrase: “Whose life (or body) is it anyway?” So long as the patient is reasonably sane and competent, it should be her choice whether to have surgery or to undergo any medical treatment. As much as we might believe that the patient is making a serious mistake, we docs should not be able to order a patient to take a treatment.
It seems that no one has been listening. The February issue of Consumer Reports had a survey of 39,000 patients and 335 docs. Each was asked what they liked, and didn’t like, about the other. The docs’ biggest gripe (59 percent) was noncompliant patients — those who wouldn’t take their medicines as prescribed.
Now, if “patient autonomy” is a core ethical value in medicine, it follows logically that there cannot be any such thing as a “noncompliant” patient. “Compliance” assumes that the patient ought to do what the doctor says. But we teach in ethics class that it should be the patient’s free choice.
My Judgment of Dr. Brody’s Judgment
Dr. Brody’s contention, as I understand it, is that the concept of a noncompliant patient and the belief in patient autonomy as a fundamental element of the philosophy of medicine are mutually exclusive because “patient autonomy” (Dr. Brody’s quotation marks) means that “it [presumably, what a patient ought to do] should be the patient’s free choice.”
This line of reasoning presupposes that every instance of a patient’s healthcare behavior that is incongruent with the recommended behavior is the result of a patient’s conscious decision not to follow that recommendation. That is certainly not explicit or implicit in the definition of noncompliance routinely used in the medical literature or, at least in my experience, in formal or informal conversations between clinical personnel.
The discussion of the meaning of compliance in Interventions to Enhance Patient Adherence to Medication Prescriptions, a review by McDonald and colleagues published in JAMA in 2002,2 is instructive. I’ve chosen this article from a plethora of pieces containing nearly identical definitions of patient compliance because its use of “compliance” and similar terms is characteristic of scores of other articles, it is extensively referenced, and the entire article is available online without cost. The following excerpt3 is relevant:
Adherence may be defined as the extent to which a patient’s behavior (in terms of taking medication, following a diet, modifying habits, or attending clinics) coincides with medical or health advice. If a patient is prescribed an antibiotic for an infection to be taken as 1 tablet 4 times a day for a week but takes only 2 tablets a day for 5 days, the adherence would be 36% (10/28). The term adherence is intended to be nonjudgmental, a statement of fact rather than of blame of the prescriber, patient, or treatment. Compliance and concordance are synonyms for adherence. [emphasis mine]
This simple definition of adherence belies the difficulties that many medical regimens present for patients. For example, the regimen described for type 2 diabetes mellitus in a previous article includes a special diet, increased exercise, smoking cessation, oral hypoglycemic drugs, and risk factor management, usually involving additional drugs. Such regimens fulfill theoretical, physiological, and empirical considerations about optimal care, while ignoring practical patient-centered concerns, such as the nature, nurture, culture, and stereotyping of the patient, and the inconvenience, cost, and adverse effects of the treatment. Indeed, low adherence with prescribed treatments is very common. Typical adherence rates for prescribed medications are about 50% with a range of 0% to more than 100%.
At a theoretical level, the nature and determinants of noncompliant behavior are complex and not well understood, although there are interesting models. The following generalizations stem from numerous studies of the determinants of adherence. Compliance has little relation to sociodemographic factors such as age, sex, race, intelligence, and education. Also, although low adherence is a problem with self-administered treatments for all disorders, patients with psychiatric problems are less likely to comply and those with physical disabilities caused by the disease are more likely to comply. In addition, patients tend to miss appointments and drop out of care when there are long waiting times at clinics or long time lapses between appointments. Finally, adherence decreases as the complexity, cost, and duration of the regimen increase.
In more informal terms, noncompliance, as the term is commonly used, takes place when the patient’s actual behavior differs significantly from the prescribed treatment plan – regardless of the reason.
A patient deciding, after pondering the doctor’s advice and weighing the pros and cons, to follow a course other than that recommended by his clinician is not uncommon but it is also not the only cause of noncompliance4 – nor is it even one of the most frequent causes. Noncompliance also takes place when the patient agrees with the doctor and intends, for example, to take the prescribed medication but forgets to do so, misunderstands the instructions (or is given unclear instructions), cannot afford the pills, … . It seems apparent that a patient who wants to follow the treatment recommendations but unintentionally falters in the execution of that intent is both autonomous and noncompliant, the exact combination that Dr. Brody claims cannot logically exist.
And there’s more.
The patients polled in the Consumer Reports survey did not, as one might predict from Dr. Brody’s article, complain in overwhelming numbers about being coerced by their doctors into following treatment orders. It appears, in fact, that none spontaneously raised this issue. Instead, the patients almost unanimously reported that they (the patients themselves) “completely” or “mostly” followed their doctor’s advice.
That the patients felt they were following instructions appropriately does not itself rule out the possibility that they were being somehow forced to do so but if the physicians observed that the patients did not follow instructions while the patients simultaneously thought they were following instructions, that disparity arose from some cause other than the patient’s explicit, conscious wish not to comply.
In short, Dr. Brody may (or may not) be correct about the lack of ethical integrity among healthcare professionals, but the frustration over noncompliance indicated by doctors on a marketing survey from Consumer Reports falls far short of proof of that assessment.
How Much Persuasion Is Enough But Not Too Much?
Later in the article, Dr. Brody writes
If the patient, for whatever reason, has chosen not to do what the doctor suggests, it shows that the advice, however scientifically accurate and well-intended, failed to fit the patient’s life in some key way. Should the doc then simply shrug his shoulders? Or is it then time to sit down and talk about Plan B or Plan C?
Isn’t figuring out what could work best — or seeing why the problem is simply not a priority for the patient at this time — more important than dithering about “compliance”?
This brings up two issues.
First, I am curious about the source of Dr. Brody’s knowledge that these physicians did not already “sit down and talk about Plan B or Plan C” – or Plan D, E, F, and G, for that matter. Perhaps an alternative interpretation would be that the doctors are frustrated over noncompliance in part because they went to the effort of offering several alternative treatment recommendations, none of which were successful. I certainly don’t know that such is the case, but I suspect Dr. Brody doesn’t know that these doctors offered, as he suggests, only one set of recommendations on a take it or leave it basis.
Or what if part of the frustration is based on the clinical knowledge that noncompliant patients are, as a group, experience higher morbidity and mortality than compliant patients? A physician who believes in a patient’s right to choose a course of action that is likely to have negative results (e.g., continuing to smoke in the face of worsening emphysema) could, it seems to me, feel frustrated without renouncing a belief in patient autonomy.
Second, some schools of bioethics argue that doctors who do more than lay out alternative treatment plans, their likely benefits, and their possible risks are violating patient autonomy by explicitly or implicitly, overtly or covertly influencing the patient to follow the recommendations. Some, indeed, would hold that a doctor who indicates a preference for one plan over another is infringing on the patient’s prerogatives – even if the patient requests the doctor’s opinion and advice.
Dr. Brody, however, seems to be suggesting that a doctor who does not respond to a patient’s noncompliance with alternatives is not doing his or her job even though continuing to push treatment options at a patient who initially refuses them could be seen as coercive (albeit not by me).
It is unclear to me how a clinician, even one with integrity out the wazoo, can invariably and precisely hit the mark of encouraging the patient without coercing the patient.
Time and Money
I find myself more in tune with Dr. Brody’s final concern:
The physicians’ complaints about noncompliant patients might have hidden another survey finding, which I believe raises compliance issues of a more serious sort.
About half of the docs said that they had been forced in recent years to speed up their practices and to cram in more patients every day to meet their target incomes. And half said that this means that they see too many patients each day to give effective treatment.
Hello? Since when did meeting a “target” income become more important than giving the patient effective treatment? No one is holding a gun to these docs’ heads, forcing them to schedule too many patients each day to do a good job. Only their professional integrity would require them not to do that.
I am, however, somewhat less confident of the interpretation of these survey findings than is Dr. Brody.
I do not know the phrasing used in the questionnaire the doctors completed for Consumers Reports,5 but I suspect the wording of the pertinent questions did not include anything on the lines of Dr. Brody’s felicitously chosen terms, such as “speed up their practices and to cram in more patients.” The Washington Post report phrases it “As for patient face time, more than half of the surveyed doctors said that had been shortened in the past five years, during which time they had had to expand their practices to meet their target income. And more than half also said they saw too many patients in one day to give effective treatment.” I happen to know that my own primary care doctor, for example, expanded his practice by increasing the number of hours he saw patient each week. The term “target income” also seems a tad vague. Seeing more patients in order to make enough money to buy that second private jet is one thing; maintaining an income adequate to pay the clinic’s staff and take care of ones family seems quite another. I would observe as well that while half expanded their practices to maintain the same income and half felt they saw too many patients in one day to give effective treatment, those two groups may not be identical. Some doctors, for example, might be salaried employees required by their employer to see X number of patients.
Those qualms notwithstanding, I agree that routinely seeing too many patients in a given time to give effective treatment is an ethical lapse that could be explained away only by the most extraordinary circumstances.
As for the article’s concluding shot, “What happened to compliance with professional integrity?” I believe Dr. Brody’s attempt to link the first issue he raises, the conflict he perceives between patient compliance and patient autonomy, with his later, more striking point, the potential impairment in physician integrity that he believes is indicated by the phenomenon of doctors knowingly seeing too many patients, through the use of the term “compliance” in two different senses only confuses and ultimately weakens his case.
Those Darn Semantics
Now, I would agree that the common definitions of compliance and noncompliance are flawed to the point that they are counterproductive. I have, in fact, previously argued that patients who decide not to adhere to a treatment recommendation and so inform the doctor should be considered compliant because they are acting in concert with the clinician.6 But I recognize that I lack the authority to change the meaning of compliance as it is routinely used simply by wishing it so.
The ethical distinction between a doctor laying out treatment options for a patient and persuading that patient to follow a specific recommendation is one deserving of exploration. I would argue, however that the compliance contretemps Dr. Brody describes is one that exists only in a rarefied universe of philosophical hypotheses rather than the day to day clinical world where noncompliance is all too often the result of cognitive errors, subtle psychological forces, or even lethargy rather than conscious decisions.
__________- This article lacks only an explicit plea to God to smite the physicians who have fallen from obedience to meet full criteria for fitting into the Books of the Minor Prophets of the Old Testament. I think that, with the addition of that appeal to a wrathful God, this story of a prophet ignored by the heathen he is trying to save could serve well positioned, say, between Habakkuk and Haggai↩
- Interventions to Enhance Patient Adherence to Medication Prescriptions, Heather P. McDonald, BSc; Amit X. Garg, MD, MA; R. Brian Haynes, MD, PhD. JAMA. 2002;288:2868-2879.↩
- Because of format conflicts, I have stripped the citations from this excerpt. The references are, of course, available in the online article, available at Interventions to Enhance Patient Adherence to Medication Prescriptions↩
- I have neither the time or energy to adequately discuss the implications of unrecognized psychological and sociological influences on decisions the patient believes were made on the basis of pure, cold logic; suffice it to say that our reasons for any decision are often not clear to us until long after the fact.↩
- I am not a subscriber to Consumer Reports. My information about the survey comes for several articles written about the report, especially Tell Me Where It Hurts By Buzz McClain. The Washington Post. February 6, 2007↩
- See How To (Correctly) Not Take Medications As Prescribed↩
