Compliance

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Compliance – noun
compliance with international law:
obedience to, observance of,adherence to, conformity to, respect for. ANTONYMS violation.

he mistook her silence for compliance:
acquiescence, agreement, assent,consent, acceptance; docility, complaisance, pliability, meekness,submission.
ANTONYMS defiance.

(New Oxford American Dictionary 3rd edition © 2010 by Oxford University Press, Inc.)

\”Why aren\’t you taking your cholesterol medication?\”  I asked the woman.  With the coronary disease I diagnosed a year ago, my discovery that she had not taken her medication was very troubling.

\”It made me tired,\” she replied matter-of-factly.  \”And besides, the cardiologist said the stress test was negative, so my heart is fine!\”

I ordered the stress test after her heart calcium score was significantly elevated, revealing significant atherosclerosis.  She totally misunderstood the results, and I needed to fix that problem.  So I pulled out my secret weapon: a good analogy.

\”The purpose of the calcium score test was to see if you had termites in your home\”  I explained.  \”I found them.  The negative stress test just said that the termites hadn\’t eaten through your walls.  It\’s good news that your walls aren\’t falling down, but they will if we don\’t stop the termites.\”

Her eyes opened wide comprehension: the termites were eating her walls.  She was living on borrowed time.

\”Would you take a medication if it didn\’t have side effects?\” I asked.

She quickly nodded.  Of course she would.  From now on she would be a compliant patient.

Compliance is good.  Noncompliance is bad.  It\’s something I learned very early in my training: patients who do what their doctors say are compliant (good), and those who don\’t follow instructions are noncompliant (bad).  If you are lucky as a doctor, you have compliant patients.  They are the best kind.   They obey their doctors.  They are submissive.  Noncompliant patients are bad; they are a bunch of deadbeats.

Please hold your nasty comments; I don\’t really believe my patients should obey or submit to me.*

Sadly, however, many doctors wouldn\’t flinch at that description of noncompliance, heaping all the blame of noncompliance on the patient\’s shoulders. But this woman\’s story (true, albeit changed for anonymity) illustrates one of the most common cause of noncompliance: misunderstanding. She was thrilled when her stress test was negative, grasping at the opportunity to be out from under the diagnosis of heart disease.  The cardiologist told her that her \”heart was fine,\” and that was all she needed to hear to be excused from taking her cholesterol medication.  She didn\’t understand, and the blame of that misunderstanding can be shared between me, who didn\’t adequately explain the test before sending her to it, the cardiologist, who gave her \”good news\” that didn\’t tell the whole story, and the patient herself, who didn\’t ask questions when she should have.  It wasn\’t until I gave the termite analogy that she really understood.

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I love good analogies.

In the \”good old days\” of medicine, doctors were not obligated to explain things like they are today.  Patients didn\’t have access to medical information and so would have to take the doctors at their word about what they should do.  Today, however, patients have far more knowledge at their disposal than the doctor has in his/her head.  Contrary to what some doctors think, this is (usually) a good thing.  The doctor is forced to defend and explain medical decisions, making truly bad decisions less likely.  True, some questions come from untrustworthy medical sources (websites selling \”miracle\” cures, those relying on anecdotal data, conspiracy theorists, and Dr. Oz), but if I can\’t give a convincing enough argument to counter these foes, one of two things is true:

  1. I am not on solid scientific ground.
  2. The patient doesn\’t trust me.

Either one of these is valuable for me to know.

So I have come to see compliance not as a monicker of disdain, but as a challenge to overcome.  I will never get  near 100% compliance, but I don\’t get this from my kids, my car, or my dog, so why should I expect it from my patients?  Besides, I get paid the same amount if the people ignore what I say; my job is simply to give them the best advice I have.

Once I get that taken care of I can turn my attention to more important things: compliance with \”meaningful use,\” \”medical home,\” and other fun stuff.  I need to make sure I am obeying and submitting to those wonderful Washington bureaucrats.  I never question them because they know what\’s best for me.

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*I\’m using the crazy language tool called hyperbole.  It\’s good clean fun.  You should try it some time.

7 thoughts on “Compliance”

  1. Was this patient asymptomatic? If she was, why order a calcium scan and a stress test? Calcium scans expose people to radiation, increase the risk of cancer, can lead to “incidentalomas” that have to be followed up with more tests, and add costs to our health system. A positive stress test in an asymptomatic person is likely to be a false positive and can lead to referral for a cardiac catheterization, a test that is costly and invasive and carries a certain amount of risk of complications. Better to assess her risk factors and calculate her 10-year risk and use that to engage in a discussion with the patient as to whether she should take a statin.

  2. I am aware of all of this.  I do 10-year risks on every patient above a certain risk and then do what I can to reduce that risk.  If someone is of moderate risk (over 10% 10-year risk) then I use coronary CT to decide aggressiveness of treatment.  The stress test was done only after she had a very high calcium score, and this is a standard risk-stratification of a person with known coronary disease.  A negative stress test on people with known coronary disease is a predictor of better outcomes, but it does not mean the person is without risk (as was the case here).  The point of the stress test is to identify the positives – those with critical enough narrowing of their coronaries that they are at risk for ischemia induced arrhythmias (not MI, as high-grade lesions are unlikely to clot).  
    I don’t order coronary CT scans in high-risk people either, as it does not effect their treatment.  It is only in the intermediate patients (or those with a paradox, such as high lipids but negative family history or vice-versa).  Coronary CT offers much better information than CRP and homocystine in the right population.Regarding the risk of the radiation, I have yet to see a direct connection of radiation from CT scans to cancer.  A CT of the chest actually has less radiation exposure than an abdominal CT, which we do routinely for kidney stones and possible appendicitis.  While we need to not order tests carelessly, judicious use of tests like the coronary CT is (in my opinion and that of many other clinicians) a very helpful test.

    I appreciate your concern, although I would hope that you would give me the benefit of the doubt after reading my other posts.  My goal is to keep people away from the doctor and, especially, the hospital.  

  3. The hyperbole was fun, Rob, in pursuit of an important point(s). The most radical idea in this field came from a serious ethicist, Dr. Jay Katz, in his book “The Silent World of Doctor and Patient” (c. 1984), in which he noted that “follow doctor’s orders” was actually a demand for “surrender to silent and blind trust.” For more in the same vein, see also my article, “Spock, Feminists and the Fight for Participatory Medicine”: http://bit.ly/lwLPCg

  4. Cool.  I wasn’t aware of Spock’s radical nature at the time.  I have lived on both sides of the equation, starting practice in the mid-90’s when there was still a strong paternalistic side to medicine.  The Internet enabled the leveling of the ground and kicked us docs from the perch of “special knowledge” to that of consultant, coach, and curator of information.  Thanks for sharing that.

  5. Thanks for your reply, although I continue to disagree with your position.  I don’t deny that calcium scans in some cases can move people from one risk level to another. However, even in intermediate risk patients I continue to believe that the benefits of calcium scans do not outweigh the risks, for the reasons previously stated. I also continue to think that a stress test was not necessary in this patient as you could simply have treated her with a statin and controlled whatever other risk factors she had. As previously mentioned, a positive stress test could have meant a cath, possibly even stents, even though we know stenting doesn’t improve outcomes in such a patient.

  6. Dr. Rob,
    I really wish I had an internist like you instead of the quack that I have.  He tells me that a fasting glucose of 140 is normal, tried to refer me to a pulmonologist for asthma when it’s clearly in my records that my pulmonologist (who treats me for asthma) recommended HIM to me (he asked me when I reminded him of this, “well, does he give you any medication for your asthma?” to which I replied “Advair 250/50, which is also in my file”, and whenever something comes up (i.e. anything stronger than a hangnail) instantly refers me to a specialist rather than taking care of it himself. He told me I was post-menopausal after running an FSH test, and when I told him that was impossible because I was still having periods, he actually said, “No, you’re NOT having periods”, like that proclamation would magically make them go away. My vitamin D levels are currently in the toilet, so when he said he was going to order a vitamin level on me, one would naturally assume that he checked my vitamin D, right? Nope. Came back with a Vitamin B level instead. Sorry for the rant; I’m just jealous that there are internists out there like you and I have no access to them .

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