Sunday, June 14, 2009


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.


  1. Hmm, I agree that the idea of labeling patients as non-compliant is a really bad one. What gives somebody the right to do this to another person? I understand that some patients, or perhaps a much better word would be "people!", are more difficult to work with than others, but that's generally for a reason. Perhaps the relationship isn't a good fit between the person and the provider (I've experienced that myself many times). Perhaps the doctor needs to be more forthcoming with information. Perhaps what the doctor is suggesting just isn't right for the person. Perhaps the person has some other reason for not agreeing to what the doctor has to say. In whatever circumstance it is, I think we are treading on dangerous ground if it suddenly becomes okay to limit services or insurance or whatever to somebody just because there is a clash of some sort. Not cool. Not cool at all.

  2. I'm glad to see you talking about "compliance" here, too. I left a long reply on unnecessarean's post on the same issue. I agree quite a lot with the doc you quote later in your post - his views match mine almost exactly! Letting go of the need to be obeyed and viewing adherence to treatment plans without the power aspect makes us all work together a lot easier, I think!

  3. "...feel like they own their physicians..."???!!!??!!!

    HELLO!!! I am PAYING you! YOU work for ME! So yes, I do believe that means I OWN you!

    ARRGHHHH!!!! Every time I hear more about this it just makes me more mad!

  4. Wow. Where are we going?
    Yes, the "...feel like they own their physicians..." made my eyes pop out for the same reason. Just wow.

  5. Respect is a two way street. I have seen patients treat doctors like they are dirt. And that is not right. We know it isn't right for Doctors to be rude and if they are, there are avenues of pursuit. First complain to the hospital. Second you can complain to the Department of Public Health. You can also complain to the board of registration. I have seen these complaints come in and the hospital takes them very seriously and the Doctor will be put under the microscope.

  6. I'm deeply troubled by ANY trend in the US health care industry that gives MORE power to physicians and LESS power to patients. An irritable and nasty patient might try a doctor's patience and make his life a little more difficult, but such annoyances cannot compare to a patient being screamed into accepting an unwanted treatment (like we read about over at nursing birth). @ pinky, while it's great that at your hospital, they take complaints against physicians seriously, at many they don't and some drs act like kings of their own countries, and patients suffer.

  7. i wonder if we will all need to take special Compliance classes (a la charm school) to learn just how to talk so pretty and to make sure we nod vigorously and never ever question The Word of Doctor.

    If she floats shes a witch
    If she drowns shes dead

    I dont WANT TO PLAY GAMES when i am in need of healthcare! I might be in pain, out of my mind, in labor, scared, I must behave according to an undescribed set of rules?

    good lord. send us all back to our winbox herb gardens and tarot cards. we're better off.

  8. The audacity of some doctors amazes me... I am thankful that women have a medium (the internet!) to get the word out about this. I am thankful for women who are gifted in thought and word, who can advocate powerfully for those who cannot speak for themselves. (our children, our babies, ..our future!)

  9. Great post. I love that pediatrician.

    I have to disagree with patients OWNING physicians, however. I think it is a special sort of relationship where both have autonomy over their own realms. As a physician, I should not be able to force a patient into a treatment, generally, and as a patient, I should not be able to force a physician or any health care practitioner into doing something he or she doesn't feel comfortable with, either.

    For example, I do not plan on performing circumcisions or elective, non medically indicated cesareans. I will refer with a smile, but no patient will "own" my services.

  10. this is very scary. I have had to turn down services before, and been treated differently because of it. I do hope insurance companies don't take this and run, either, as it's hard enough to get them to pay for women's health care as it is.

    what can we do? is anyone organizing a way to voice concern to the AMA?

  11. I 100% agree with the Pediatrician about lumping "non-compliant" patients with those who are violent and hostile. It sounds like a sneaky back-door effort to gain more control. Open communication with a patient seems to be the resolution to this resolution. Physicians need to communicate and educate. If the patient refuses standard of care, or insists on futile interventions, then that MD needs to document in a fact based manner without labels.

  12. What a slippery slope it is to lump people who question test and treatments and decline them as needed with the diabetic who won't modify their diet or check their sugar!!

    Some people are questioning because it's their nature, others may have suffered in the past with poor medical care and are now very suspicious of everything.

    We also have a very hurried and non responsive impersonal health care system and labeling people with enough moxie to say "Stop this train" as non-complaint takes us in a very bad direction!

  13. Hospitals not monitoring the behavior of their own Docs is why I suggested you call DPH. DPH holds power over the hospital so does Jacho. OR you can call you local newspaper. In my neck of whe woods if a patient has a complaint, they can call the local paper and they are more than willing to run the story. But I think DPH is your best bet because it is like calling DSS for an abusive parent. THey might not take the child away, but there will be an investigation and the investigation will be painful.


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