The Difference We Make
When Patients Don’t Get Better… Are They Noncompliant?
Dermatology PA news & notes
By Steven K. Shama, MD, MPH
I truly believe that most of our patients get better. Of course, we generally attribute this to our making the right diagnosis and prescribing the most appropriate treatment. Over the years I have learned that some patients get better despite us. For example, we hear about rashes that clear up without us having seen the patient. This humbles us, since had we seen patients at the onset of their rashes, we might have attributed our treatments’ positive results to our “brilliance.” But what about those patients who don’t get better despite the fact you are sure your diagnosis and treatment are correct? Why aren’t they better? Is it that they aren’t doing what we want them to do? When I am faced with such a possibility I remember an article I read long ago that stated that as many as 30% of general medical patients don’t use prescribed medications as written by their clinicians. There are a variety of reasons for this noncompliance; some people don’t fill their prescriptions, some use them less often than prescribed, or some stop too soon. All of which leads to so-called noncompliant patients. If only we knew that they weren’t following our instructions. But for a number of reasons, they don’t always tell us. Is there a way that we can increase the likelihood of our patients following our instructions or at least letting us know when they aren’t? Do patients actually not tell us the truth? Steve Feldman, MD, PhD, (Professor of Dermatology, Wake Forest Medical Center, WinstonSalem, NC) performed a study, which revealed that patients don’t always tell us that they aren’t following our instructions. Dr. Feldman gave a lid-covered jar of a potent cream to a number of volunteers in Dr. Steve Shama was practicing general dermatology for 30 years in Boston, Massachusetts until last year. He retired at that time but continues in a 20 year career as a professional speaker and enjoys speaking on topics such as, “Dealing With Difficult People and Looking Forward To It!” and “Rediscovering The Joys of Medicine and of Life.” He gives these talks at medical meetings, in private practices, and to general audiences and youth throughout the country. You can reach Dr. Shama at www.steveshama.com.
48 Journal of Dermatology for Physician Assistants
order to clear a rash but also to examine the question of compliance. His simple instructions were to use the cream twice daily and to record for an entire month the number of applications they used. Some patients using this potent cream didn’t clear their rash. In order to explain this anticipated finding, he had installed (unbeknownst to the patient) a microchip in the lid of each jar that recorded every date and time the lid was removed. He found that for a number of patients who did not get better, the micro-chip indicated that many doses of medication were missed even though the patients’ personal recordings showed almost complete adherence to the twice daily schedule. Dr. Feldman’s conclusion was that some patients simply did not tell the truth. He offered no explanation as to why this occurred, but the facts were apparent; patients were noncompliant and this was accompanied by them not telling the truth. In the face of these findings, how can we increase compliance and how can we get patients to tell us when they are noncompliant? Based on my own personal experience, on journal articles I have read, and on talks I have heard, the following suggestions may help increase compliance and honesty in patients. 1. Be convincing in your diagnosis and treatment. If you need to express some doubt, make sure patients know that you are not thinking of another more serious diagnosis and always give hope. 2. You can convey the feeling that you truly care about them getting better by taking your time when presenting your treatment ideas. Sit, make eye contact with your patients, and speak in soft tones. 3. Involve your patients in the decision making process. State what needs to be treated, why, and what could happen if not treated; if there are side effects of the treatment, mention