Compliance Status Report

The most recent status report of my personal compliance case, adhering to a rehabilitation program following my July 27th hip-pinning,¹ was Contemporary Compliance Case Study Follow-up

This past week, I made my way to an appointment with my orthopedic surgeon in follow-up to my July 27th hip-pinning, all the while nurturing hopes that I would forthwith be exchanging my walker for a cane - a switch which would signal a quantum leap² along the path to full ambulation and, more to the point, represent a dramatic improvement for me in the area of fashion accessories.

Well, it turns out that forthwith falls especially late this year. One can imagine my disappointment when the surgeon opted for conservative management, decreeing that the much desired transition from walker to cane would not take place for at least another month.

In hopes of accelerating my progress, I will begin Physical Therapy next week with the attenuated incentive that, should all go well, my right leg will be able to handle “touch-down weight bearing”³ shortly thereafter. Regrettably, anticipation of that milestone does not set my heart aflutter.

Beyond Walkernastics

For now, however, I have been - emphatically and repeatedly - instructed to continue to avoid using my right hip to bear any weight. While I am a tad dejected by the medical mandate, this turn of events has at least led me to extend my repertoire of walker-assisted activities beyond Walkernastics.

Because dance has always held a certain appeal, I explored the possibilities in this discipline, but the obvious choices - the tango, clogging, and the polka - proved unworkable because of the restriction against weight-bearing on my right leg. And, while it is hardly surprising to learn that something called “The Two-Step” includes movements beyond the capacity of the walking (on one leg) wounded, even the Bunny Hop, one finds, requires a different sort of hopping than the type I’ve been executing behind my walker for the past few weeks.

Happily, I discovered that many passages in the Alvin Ailey style are walker-friendly, and intricate routines in this genre can be choreographed that do not demand weight-bearing by the right leg. An example from a quotidian daily workout is pictured below:

Footnotes

1. My hip fracture, the gory details of the hip repair, and the aftermath are reported in Sick Call II, Sick Call III, Pimp My Assistive Device, and walkernastics [back]
2. Ah, I recall with great fondness, a time when I could actually consummate leaps, even sometimes pairing them with bounds [back]
3. ”Touch-down weight” is approximately 10% of ones body weight. “Touch-down weight” should not be confused with “Touchdown wait,” which was the three and one-half quarters we typically had to endure before the University of Missouri football team to score their first touchdown. [back]

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Readers may recall from Contemporary Compliance Case Study, a post published just over a month ago, that I was concerned about my own adherence to a Physical Therapy regimen for a pulled muscle diagnosis.

Well, not to worry. As it turns out, PT, treatment with which I was, of course, fully compliant, brought about no symptomatic improvement, so a second appointment with the primary physician seemed prudent.

That clinical visit occasioned an x-ray to rule out a hip fracture prior to an anticipated referral to an orthopedic/sports specialist. It required, however, only one glance at the completed X-ray to transform the rule-out into a confirmed diagnosis.

The New Compliance Challenge

Three days and three inserted pins later, I was home, with strict orders (indistinguishable to the human ear from threats) from the surgeon to avoid weight-bearing on my right leg. Compliance with these instructions requires my constant use of a walker and, for long journeys, a wheelchair.

Rehab Report

After reading posts on Heck Of A Guy, my personal blog, about my femoral neck fracture, subsequent hip pinning, and post-op orders to use a walker to avoid weight-bearing on the pinned hip, a younger friend suggested, “Please make sure to get a few ‘action shots’ of you [using the walker] walking around and post them!”

Now, one can hardly begrudge the inherent psychological drive of the young, hale, and hearty to observe the deterioration of their elders. Ridiculing photos of the impaired is, after all, at least somewhat more sublimated than shoving the old folks onto ice floes.

Still, because I found it difficult to believe a photo of me as walker-gimp would appeal to viewers other than (1) ungrateful whippersnappers all too eager to replace the Boomer generation who currently (and rightfully) run things and (2) individuals with a strong skew toward the sadistic, I deferred any action on that idea.

Since that original suggestion, however, I’ve received enough similar requests that, in acquiescence to the wishes of the Heck Of A Guy audience, and without passing judgment on the possible motivations - regardless of how sinister and perverse those may be, I offer this shot of me on my assigned apparatus, the pommel walker.

I apologize for the low level of expertise demonstrated. Snapping the shot by first setting the camera’s self-timer and then trying to be in the requested action pose when the shudder fired complicated the procedure to the point that I had little choice other than the simple loop dismount shown here. Despite several attempts, for example, I could never get the timing right for a photo of the handstands and as for those Russian Wendeswings, well, a picture of those would have just been grandstanding.

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The Case Of The Patient Of The Woeful Countenance

Almost a month ago, I was blissfully vacationing with no more than the ordinary allotment of health hassles common to a guy in his mid-fifties. On the last full day of the one week trip, I began the same morning run I had completed each previous day. A half-mile later, a pain in my right leg became severe enough to abort the effort and limp back. Contrary to my expectations that the problem would resolve itself in a day or two, it persisted for three weeks, producing a pronounced limp and enough discomfort to make me wince whenever I had to bear weight on that leg and keep me awake at night. At that point, I was finally desperate enough to see my personal doctor who tentatively diagnosed a pulled adductor and recommended anti-inflammatory medications and physical therapy with further testing for other disorders if there was no relief on this regimen. A few days later, the physical therapist performed his examination and prescribed the exercises pictured in the graphic atop this post as well as twice
weekly PT sessions.

The Compliance Conundrum

The facts are simple:

• The exercises are routine: Three stretches and one strength move that require perhaps 20-30 minutes a day and are unlikely to cause side-effects
• The twice weekly PT sessions are similarly routine
• My injury, while hardly catastrophic does cause me pain throughout each day and significantly limits my activities
• I understand the disorder and the treatment
• After only two days, I’m convinced that the treatment is likely to help; my only pain-free periods have been the 15-20 minutes that immediately followed completion of the exercises
• I have a reasonably good relationship with the physical therapist who seems competent and invested in my care

So why is compliance a significant concern to me? After all, I already integrate a 1.5 - 2 hour workout into every day (missing perhaps 10 days a year) for health reasons. And, my schedule, while full enough, is sufficiently flexible to accommodate the exercises and appointments.

Well, knowing that approximately half of all patients don’t adhere to their treatment in almost any healthcare situation may be a factor.

And I loathe stretching.

The only other negative that comes to mind is that I’m moderately miffed that I contacted this rehab facility because they advertised a satellite office near my home, but when I requested that office I was told that no appointments were available there for over a month - although they could fit me in to the schedule of their central, much less less convenient for me facility right away. I have no way of knowing the legitimacy of these circumstances, but I do have a sensitivity to being played for a sucker so there may be some residual negativity on my part.

Otherwise, this seems a no-brainer: Do a few stretches a day and drive a few miles twice a week for an appointment in return for a high probability of eliminating a painful, restricting disorder.

Nonetheless, on only the third day of the exercises, I feel the need to force myself to start the exercises and find myself looking for excuses to postpone them.

I don’t, by the way, have a solution. I’m just impressed with the problem.

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The Midlife Midwife Returns

Readers may recall Looking At Patient Compliance From Both Sides Now, the 11 April 2007 AlignMap post that introduced The Midlife Midwife, who in Patient Compliance had compared her own resistance to following her dentist’s prescription for ongoing care of her teeth (e.g., flossing, regular exams) with the recalcitrance of her own patients to adopt her recommendations for preventive health care (such as pap smears, mammograms, and exercise).

At that time, she had also decided to undergo the necessary dental work she had deferred for seven years.

The Sequel

It turns out that, as is often the case in healthcare, the decision to undergo treatment was not the end of the story. In Patient Compliance ACT 2, we learn that efforts to prepare her tooth for a crown led to an exacerbation of problems and the necessity of a root canal. Having previously endured more than my share of ministrations by dentists of widely varying degrees of skill,¹ I am sympathetic to Midwife’s anxiety about dental work and the pain she is currently undergoing.

The good news, however, is that Midlife Midwife stubbornly persists in her determination to examine her own healthcare experiences for clues into how to better manage the patients in her practice:

Even more impressive, she has translated these considerations into behavioral changes:

Midlife Midwife’s new, more positively focused response to the belatedly compliant patient is along the lines of

And, since I couldn’t improve on her own conclusion, I’ll close my post with her final words:

Credit Due Department: Atop this post is a photo of an Iowa dentist, circa 1895, from the State Historic Society, Iowa City.

Footnotes

1. ”Dentists of widely varying degrees of skill” is, of course, code for “Some of the dentists I’ve seen were incompetent clods with more than a tad of the stereotyped sadistic streak; thank goodness the dentist I see now knows what he’s doing and is a nice guy to boot.” [back]

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Patient Compliance and Furious Seasons

Philip Dawdy has been blogging at Furious Seasons¹ since September 2005 from this perspective:

He is also an award winning professional journalist who has reported for years on mental health issues and who has interviewed doctors, researchers, and hundreds of individuals with psychiatric diagnoses, which he points out

While today’s title is lifted from The Norm, Hope And Statistics, Dawdy’s 26 April 2006 post, references to his high rate of adherence to his medication regimen are prominent and frequent throughout his posts. These posts, for example, directly address compliance:

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Commentary

The author’s disclaimers notwithstanding, Furious Seasons perhaps comes closer than any other blog to integrating the writer’s experiences as a patient and his point of view as a reporter in equal proportions. While posts can be strident,² there is much to admire in his thoughtful, clearly written prose. As an example, I suggest a careful reading of the post discussing his notions on recovery: Slouching Toward Recovery. While I do not endorse all its ideas and recommendations, this post is a brave and honest distillation of years of experience that has been successful in managing major, potentially disabling symptomatology.

I am, naturally enough, especially interested in how patient compliance is treated by bloggers and can find no better way to conclude this post than with an excerpt indicative of Mr. Dawdy’s no-nonsense approach:

Footnotes

1. Although I found no confirmation at Mr. Dawdy’s blog, my working assumption is that “Furious Seasons” references the title of Raymond Carver’s first published short story, which I once read as an assignment. I recall that it was Faulknerian by design and therefore dark and convoluted with a stream of consciousness style that constantly reshuffled chronology. Heavy handed psychosexual symbolism studded a melodramatic plot that featured incest and murder. OK, it wasn’t my favorite Raymond Chandler story. Independent of the story itself, the title effectively invokes the experience of bipolar disorder episodes. [back]
2. Other bloggers are “strident” or even “vehement;” I, on the other hand, veer toward “deeply principled.” [back]

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Life - With Diabetes - Goes On

Since I last wrote about Living With Diabetes,¹ that blog has added more posts to its conveniently categorized “Compliance” section.

As I noted previously, these blog entries provide useful insights into a patient’s perspective on compliance that are not often available to a clinician during a treatment session.

I’m especially taken with an observations on the difference between disagreeing with a treatment recommendation and noncompliance as limned in these excerpts from Patient Gripe - Bariatric Surgery Suggestions

For good measure there are a couple of comments that enthusiastically endorse this notion.

So do I.

I have long promoted, especially in How To (Correctly) Not Take Medications As Prescribed, differentiating between noncompliance (whatever that term means these days) and a communicated and acknowledged non-execution of a specific treatment recommendation.²

While all manner of humanistic, sociological, and ethical principles can be invoked in support of this idea, my primary argument is based on clinical pragmatism:

The opportunity cost (in this case, the potential loss of improvements in the patient’s health that the recommendation would have hypothetically caused) of the patient not following the recommendation is more than compensated by the elimination of (some of) the changes patients unilaterally and surreptitiously make in the treatment plan. Because these deviations from the presumed treatment plan are unknown to the clinician, they are especially likely to lead to mistaken diagnoses and erroneous evaluations of treatment outcomes (e.g., a physician may assume a patient’s infection is resistant to the prescribed medication or that the original diagnosis was wrong because of lack of response when the actual cause was the patient not filling the prescription), which, in turn, lead to delays in or prevention of improvements in the patient’s health, geometric increases in healthcare expenditures, and damage to patient and clinician morale and the patient-clinician relationship.³

Clearly, there are situations in which coerced compliance is justified; e.g., the treatment of deadly, highly communicable diseases and the treatment of patients with serious disorders who are cognitively unable to realistically appraise their condition. In the majority of cases, however, automatically categorizing a patient who refuses a treatment recommendation as noncompliant, with all the connotations that term carries, is, at best nonproductive, and is likely to inhibit - and perhaps destroy - treatment.

The Life With Diabetes posts can be found at Living With Diabetes On Compliance

Footnotes

1. See From The Patient’s Point Of View [back]
2. Yes, “communicated and acknowledged non-execution of a specific treatment recommendation is a particularly awkward construction, but a more felicitous phrase, devoid of loaded words, doesn’t come immediately to mind. [back]
3. See the “Complex, Cascading, Cumulative Costs” Section of Complex, Cascading, Cumulative Costs [back]

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Unanticipated Roles In The Drama Of Patient Compliance

In It’s what you signed up for at Codeblog, Geena explores the dilemma she and other nurses face in achieving patient compliance.

Geena describes “encouraging my post-op patient to cough and deep breathe all shift” and her frustration and disappointment when, at the end of the shift, it is apparent that, despite her provision of pain medication, proper instruction, and empathic persuasion, the treatment goal was not reached.

The post’s title, It’s what you signed up for, is derived from the point made by another nurse during a discussion about this all too common situation:

The appropriateness and effectiveness of various tactics (e.g., good cop/bad cop) are also considered. It was another standard strategy, however, dissolved the reluctance of Geena’s exemplar patient to participate fully in treatment:

Commentary

In oversimplified terms, patient noncompliance, even if transient, brings the nurse’s (or any healthcare professional’s) philosophical commitment to patient autonomy into conflict with the importance of successfully executing the treatment plan.

The clinician’s role is also, however, influenced by multiple other factors, including but not limited to the following:

• Practical matters, such as limited time, staff, and other resources
• Professional and regulatory requirements
• Personal and professional expectations
• Local and cultural mores
• Environmental modes (nursing is typically expected to intervene more directly and forcefully, for example, in the case of a noncompliant ICU inpatient than with an resistant outpatient)
• The severity of the patient’s disorder
• The patient’s age, personality, attitude, and intelligence

My modification of the title of Geena’s post from It’s what you signed up for to Who Signs Up For What in the title of this post has two referents:

1. I understand the use of It’s what you signed up for as shorthand for “the patient has the final responsibility for following or not following the treatment plan,” but it is not a trivial point that much of the time patients don’t know what they’re signing up for. Some patients, for example, are unconscious, delirious, demented, intoxicated, too young, unable to communicate, or otherwise incapable of understanding or legitimately consenting to necessary treatment. Even intelligent, educated, attentive adults, however, cannot anticipate every requirement of treatment. I’ve been present at more than a few discussions of impending operations that would require some type of postoperative chest physiotherapy similar to that described in the Codeblog post to decrease the risk of pulmonary complications; in none of those discussions was the patient told, “The day after your chest is ripped open and then sewn back together, we’ll expect you to perform some respiratory calisthenics that will result in excruciating pain - for
your own good.” And, even if a patient signs an informed consent documents with such information in the fine print, how many operative candidates who know that the proposed surgery is necessary for a cure or palliation of their disorder, who are overwhelmed by an avalanche of data, and who may be worried about survival can be said to understand the details of what they are signing up for?

2. Who Signs Up For What also makes explicit the underlying theme of Geena’s post. It’s what you signed up for applies not only to patients but also to nurses, doctors, respiratory therapists, and all healthcare professionals. Garnering patient compliance is, as the cliche has it, part of the job description. My contention is that, like the postoperative patient facing a deep breathing exercise, we healthcare professionals may not have known exactly what we were signing up for.

In any case, It’s what you signed up for offers a useful perspective on patient compliance and raises some fundamental questions every healthcare professional would do well to address.

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Compliance, the 10 April 2007 entry in the the Got Liver? blog is also the most recent addition to my informal collection of posts offering insight into treatment adherence based, at least in part, on the writer’s personal experience.¹

The author of Got Liver? explains his motivation thusly,

The Got Liver? Compliance post specifically addresses the transplant candidate’s preparations for and commitment to compliance with the medications, testing, and other portions of the pre- and post-transplant treatment plans. While this process, as seen from the transplant recipient’s point of view, is enlightening and the entire post is worthwhile reading, I found one section especially surprising.

I had been cognizant of transplant-associated compliance problems such as the economic costs of adherence, the difficulties of following the strenuous requirements of treatment protocols, and the ethical issues involved in ranking potential recipients for the too-few organs available based on the anticipated compliance capacity of the candidate (along with physiological criteria, age of the patient, and other factors). I was not aware, however, of the appqrently significant number of candidates who are openly and vehemently noncompliant, as described in this excerpt:

This post is an interesting take on a healthcare scenario in which compliance is, all too literally, a life and death matter from somebody who has been there.

Footnotes

1. Other posts in this group include the following:
   The Misdiagnosed Patient
   There is a fine line between being a Squeaky Wheel & a Pain In the Butt
   Looking At Patient Compliance From Both Sides Now [back]

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• Cash For Compliance - Benefit or Bribe?
• Payment For Medication Compliance: Incentive or Bribe?
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• A Pragmatic Consideration Of Noncompliance In Patients With (Or Without) ADHD

The Midwife’s Molars

While most AlignMap posts focus on research or articles from the medical literature about patient compliance, medication adherence programs, or clinical tactics to enhance compliance, recently I’ve been struck by the insights proffered by bloggers writing about their own experiences with healthcare compliance, either as clinicians or patients.

A few days ago, The Midlife Midwife published Patient Compliance, in which she compares the recalcitrance of her own patients to adopting her recommendations for preventive health care (such as pap smears, mammograms, and exercise) with her own resistance to following her dentist’s prescription for ongoing care of her teeth (e.g., flossing, regular exams).

Oh, and there’s that seven year history of avoiding treatment of those five molars with “deep fissures and cracks” that are on “the verge of breaking”

Her approach to the issue is thoughtful, her analysis of her own motivations candid and revealing, and her conclusions all the more heartening for her refusal to accept the easy, standard answers.

Notice: Spoiler Alert
She’s getting the molars fixed.


Link
This post can be found at ~Midlife Midwife on Patient Compliance~.

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The Devil You Know is a first person account of one patient’s perception of his problems with adherence to his HIV treatment regimen. It’s poignant and instructive. I’ve excerpted only a brief portion to give a flavor of the piece:

The entire post can be found at ~The Devil You Know~

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Because the blogger at Living With Diabetes always writes with authenticity and thoughtfulness, I find her posts enlightening even when I intuitively disagree with her conclusions - or perhaps especially when I intuitively disagree with her conclusions.

She has a written a series of a half-dozen or so posts dealing specifically with adherence, prefaced with this explanation:

These posts provide useful insights into a patient’s perspective on compliance that are not often available to a clinician during a treatment session. They can be found at
Living With Diabetes On Compliance

Update
Noncompliance and A Decision Not To Follow A Treatment Recommendation Are Not Identical

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