Guest column: "Why won't my patient comply?"
Ryan Dix, Psy.D.
Licensed psychologist, integrated behavioral health provider
Providence Medical Group
June is a 51-year-old professional with Type 2 diabetes. On the day of her diagnosis, her primary care provider prescribed twice-daily metformin, offered advice on diet and exercise, and enrolled her in diabetes education classes.
But six months later June's glucose levels still were high and she'd gained 7 pounds. Asked how she was managing her diabetes, June confessed that she'd ignored most of the medical advice she'd been given. "I figured the pills would take care of it," she said.
Stories such as this play out in clinics across the country, leading to life-threatening medical complications for people with chronic diseases and causing an estimated $300 billion a year in health care costs.
While it's tempting to blame the patient for nonadherence, providers bear some responsibility as well. After all, we're not just treating a disease – we're treating humans with complex social and psychological factors that influence their health decisions.
A recent study accounts for those factors with a three-pronged approach to improving adherence called the Information-Motivation-Strategy Model.1 It's based on findings from more than 100 large-scale studies and meta-analyses and advises providers to explore the "what," "why" and "how" of treatment for every patient. The model advises providing patients with:
Information. To follow a treatment plan, patients must understand what the plan is. This requires providers to:
- Forge a strong relationship with their patients – one of the strongest influences on adherence
- Communicate at the patient's level of understanding
- Establish shared decision making, which encourages patients to be a partner in their health
Motivation. Patients follow treatments they believe in, so it's important to share why adherence is important. To discover what motivates patients or what prevents them from following medical advice, try to determine if the patient:
- Understands the severity of the disease and the value of the treatment
- Is aware of the consequences of not adhering to the treatment plan
- Is influenced by cultural norms, or family and friends
Strategy. Before determining a strategy – the how of adherence – it's important to remove potential barriers to success. These may include:
- Making the treatment plan simple and easy to follow
- Helping the patient prepare for possible side effects
- Addressing any mental health concerns that might impede adherence
June, our patient with diabetes, ignored her medical advice for a host of reasons. She acknowledged later that "wishful thinking" led her to believe that her chronic condition could be managed by just taking a pill. Despite attending classes, she didn't fully understand the risks of uncontrolled diabetes. And although she and her doctor discussed medications, they never talked about what motivated her choices and behavior.
Exploring any one of these areas could have helped June get off to a better start managing her diabetes. The Information-Motivation-Strategy Model not only can lead to better health outcomes, but also to stronger, more satisfying provider-patient relationships.
Ryan Dix, Psy.D., serves on the faculty of Providence Portland Medical Center Internal Medicine Residency Program.
1. DiMatteo MR, Haskar-Zolnierek KB, Martin LR. Improving patient adherence: a three-factor model to guide practice. Health Psychology Review, 2011;(6):74-91