Coping with nutritional problems of dysphagia
What happens if your patient won't comply with the treatment you are prescribing? Dr Melanie Wynne-Jones offers a little practical advice
Compliance is in fact no longer the right word to use in this context. It has fallen out of favour on the basis that it is too doctor-centred. Concordance is now used to describe things such as the doctor-patient partnership and shared management plans.
Concordance is defined by the Medicines Partnership as 'a process of prescribing and medicine-taking based on partnership'. But it could also be seen as relevant to any intervention, including investigation, referral, review or just doing nothing!
Clues to non-concordance include failure of the patient to improve or progress as expected, verbal or non-verbal cues, failure to request repeat prescriptions regularly or attend follow-up appointments or a change
of doctor allegiance.
Patients may initially appear to go along with the 'plan' and then abandon it because they didn't actually agree with it at all. This can happen when they:
·Feel we haven't really listened, understood or taken their ideas, concerns or expectations into account. For example, they may have come for reassurance that their neck pain is not sinister: they may not want painkillers at all. Or they may think we should have arranged an X-ray.
·Don't like our diagnosis or treatment, either in principle or in practice. For example, many people do not like to think of themselves as depressed and are prejudiced against, or frightened of, medication. Or patients may agree to lifestyle changes but have no intention of making them.
·Can't afford the prescription, time off work and so on.
·Are afraid to mention that they are taking complementary medicines, or trust them more than our treatment.
·Misunderstand the 'plan' our fault or theirs?
·Can't or won't tell us that they disagree. They might do this out of respect, out of fear of appearing stupid or difficult, out of fear of confrontation, or because they think we won't listen.
·Don't trust us because of preconceived ideas, because of something we did or said, because we aren't their preferred/usual doctor or because they prefer the advice of a relative, friend or the media.
Other patients may sincerely try to follow the 'plan' but can't remember to take the medication, can't fit our advice into their normal routine, suffer adverse effects, or are disappointed that the 'plan' doesn't work well or quickly enough.
Things can get even more complicated when a third party is involved for example, a parent, spouse, carer or other health professional (including the pharmacist). Third parties will have their own views and may or may not expect to be included in the shared decision-making.
Concordance obviously depends on the patient believing in the 'plan' yet being able to flag up problems as they arise.
To arrive at a good 'plan' requires:
·Good communication skills including language appropriate to the patient's level of understanding.
·A discussion of the nature and consequences of the 'problem'. A discussion too of the various treatments and interventions, their perceived benefits and possible adverse effects. 'Evidence' may not convince patients and may even conflict with 'patient-centredness'. The concepts of risk is particularly tricky to convey, and product insert leaflets often cause alarm.
·As simple a regime as possible. Aids such as personalised written instructions, 'dosette boxes', alarm reminders and post-it notes can all be helpful. You may also need to involve relatives, carers or other health professionals.
·A clear signal that the patient is free to raise concerns, give negative feedback and be honest about non-concordance
·Some patients may welcome back-up literature such as patient information leaflets or direction to reputable internet sites.
Despite all your efforts, you will still encounter non-concordance; this can make you feel puzzled, offended or uneasy. You may need to review your previous actions, repeat some or all of the above steps, and revise the 'plan'. Keep the patient informed.
On rare occasions you may need to be blunt with patients and tell them they will put themselves at risk and are wasting your time if they will not engage in any sort of therapeutic partnership.
However, it's important that patients feel they can be honest with you. Otherwise your subsequent advice and decisions will be flawed. Of course the patient may not follow these either!
Medicine Partnership Concordance. Includes downloadable Powerpoint presentation.
Focus On Your Medicines A Patient Guide to Medication Review (Medicines Partnership March 2004)
·What is a 'medication review'?
·Is it for you?
·Who will you talk to?
·What will you talk about?
·How do you ask for one?
·How should you prepare?
·What happens afterwards?
·Questions to ask
·Space for patients to write down their comments and questions.
Melanie Wynne-Jones is a GP in Marple, Cheshire