Non-compliance

Within a few days of each other, two fascinating viewpoints on patient non-compliance have gained widespread attention. The first is the AMA's Resolution 710: "Identifying Abusive, Hostile or Non-Compliant Patients." Jill at Unnecesarean has posted both the full text of the AMA Resolution and ICAN's response. Here are a few excerpts from the Resolution:

Whereas, Many patients are becoming more abusive and hostile toward physicians for many reasons not limited to the economy, increasing co-pays and deductibles, unreasonable expectations and demands, a lack of instantaneous cure, arrogance and/or the belief that they “own” their physicians; and...

Whereas, The stress of dealing with ungrateful patients is adding to the stress of physicians leading to decreased physician satisfaction;...

RESOLVED: That our American Medical Association ask its CPT Editorial Panel to investigate for data collection and report back at Annual 2010 meeting: 1) developing a modifier for the E&M codes to identify non-compliant patients and/or 2) develop an add-on code to E&M codes to identify non-compliant patients. (Directive to Take Action)

The internet has been abuzz over this resolution, so much that posting all of the links would be too time-consuming for me. I have several concerns with this resolution. I agree with ICAN that it could open up doors for insurance companies to deny claims for patients labeled "non-compliant." And, at least in the birth world, I fear that the label would be applied to women who want VBACs or home births or even just wish to decline standard labor interventions such as routine IVs or continuous fetal monitoring.

This brings me to the second viewpoint about patient compliance/non-compliance. In an interview with the New York Times, Dr. Donald M. Berwick, a Harvard pediatrician, discusses his recent article “What ’Patient-Centered’ Should Mean: Confessions of an Extremist.” Some excerpts from the interview:

Q. Do you think “patient-centeredness” exists in current health care practice?

A. If you are interested in quality, you have to be interested in patient-centeredness. Good doctors and nurses do try mostly to focus on every patient as an individual. But we have built a system around clinicians that makes it impossible to customize care the way it needs to be. We don’t have a standard of services or processes that are comfortable for patients. We have built a technocratic castle, and when people come into it, they are intimidated.

Patients keep having to repeat their name because the system has no memory. We dress them in silly-looking gowns. We give them the food we make instead of the food they want. We don’t let them look into their medical records unless they have permission. Health care keeps telling patients the rules instead of asking patients about their individual needs. What is said is, “This is how we do things here,” not “How would you like things done?”

People get accustomed to this. They are trained to be passive, and passivity is not a good idea. Studies have shown that people who are trained to be proactive do better and feel stronger. They have more pride and trust in their own capabilities.

When you make someone helpless, in a funny way you make them sicker, even if all you cared about was just the body.

Q. What if a patient’s preference is in conflict with recommendations grounded in evidence-based medicine?

A. I would treat it as a challenge of information exchange. Human beings have got to have the ability and the responsibility to make their own decisions. As long as they know everything they need to know, they should be able to make the decision. If we doctors feel a person is going to make unwise choices, we have to take on the responsibility of being teachers, educators and informers. We need to give people all the knowledge and information so they can make their decisions well.

And we don’t do that well at the moment. It’s often done as a relatively pro forma matter.

Q. Tell me about your views on “noncompliance.”

A. I think “noncompliance” is a control word, a power word, and we need a slightly different one. “Compliance” means I order and you either do it or not; you obey. Patients live in their bodies and may know more than the person who prescribes or does their procedure. They may know better about what is going on in their body and about the optimization of their own life. I think people who aren’t taking their own medicine are telling us valuable information about their medications and their life, and we need to listen to them.

The notion of "patient non-compliance" is a very complex one, in large part because one person's "non-compliant" patient is another physician's dream patient. Some people refuse treatment for ethical or religious reasons. Some might refuse treatments simply because they aren't evidence-based, such as an elective primary cesarean for suspected fetal macrosomia). Some patients come to office visits with a long list of questions and preferences, behavior that might annoy one physician but delight another. I don't doubt that there are many patients who truly display hostility or abusive behavior towards their health care providers, and that is not acceptable in any setting. But grouping non-compliance in with hostile, abusive, and "ungrateful" patients? Highly problematic.