Originally published in Forum, Vol 20 No 2, February 2000
By Daniel O'Connell, Ph.D. Daniel O'Connell, from Seattle, Washington, is Northwest Regional Coordinator for the Bayer Institute for Healthcare Communication.
Physicians increasingly report feeling trapped between patients who demand more autonomy in their health care decisions and health plans that reserve final approval for medical tests and treatment plans. As a result, physicians often feel they are given enormous responsibility for the medical, emotional, and functional outcomes of patients' problems but exceedingly less control over the diagnostic and treatment activities necessary to address it.
Many health insurers and medical groups are developing clinical guidelines and systems to track and encourage adherence by both physicians and patients. Increasingly, health care report cards measure proportions of plan members who have had preventive screenings and vaccinations, and track biomedical markers for chronic illness against desirable parameters. Not surprisingly, as these "best practices" become more accepted, the medical community's liability for ensuring their performance increases.
One reason why patients may not adhere to their diagnostic and treatment plans is that they did not sufficiently agree with the physician's assessment in the first place. Many patients now come to their physician with ideas about what could be causing their problem and what should or could be done about it. Physicians sometimes resent this intrusion into "their" sphere of responsibility and underestimate the extent to which a patient will hold onto an idea unless convinced otherwise.
Even when patients accept the physician's initial impressions, continued adherence is not assured. A patient may change his or her mind as new data undermines confidence in the physician's assessment of the problem and appropriateness of the plan. These contrary new data come in many forms: conversations with friends and relatives, the media, unexpected symptoms, or developments that arise after the plan is under way.
Elicit the patient's ideas about the problem and any preferences for how it should be approached early on in the interview. Answering these questions is the key to a successful visit.
Think aloud during the history taking, physical exam, and subsequent discussion to demonstrate careful consideration of the patient's ideas and expectations. Ask:
Without uncovering and resolving disagreements here, the odds for adherence plummet.
Even with agreement on initial impressions, disagreement about diagnostic and treatment approaches may occur. Physicians often use a voice tone or body language to signal that they have come to a conclusion, counting on the assumed "we" to imply agreement that may not actually be present.
Physician: So we'll go ahead and order another X-ray and blood work, start you on this new medicine, and I'll see you back in two weeks.
Chances for agreement are improved by adding, How closely does this match what you expected we would suggest? which will lead to an answer that reveals how ready the patient is to accept this approach, or the extent to which some negotiation will be needed. Patients are more willing to adhere to a physician's initial proposals if they can see that—should the hoped for improvement not occur—their own preferences and beliefs will, subsequently, be considered.
Physician: I understand that you might prefer a referral to an orthopedist right now for your injured ankle, but I think you will find that the sprain improves steadily with the plan I just outlined. Could we agree to give the plan I suggested another two weeks, after which I will gladly refer you if your ankle is are not feeling much better?
If the physician has elicited the patient's key concerns, he or she is in a better position to negotiate a mutually acceptable plan with the patient.
Physician: I can see you are very uncomfortable and need to get around more easily while this heals. Let's prescribe a pain medicine to reduce the discomfort, give you a handout that describes everything you can do to speed up the recovery from a sprain, and arrange for you to get a pair of crutches to keep your weight off the ankle for the next week as well. How does that sound to you?
Confidence in a treatment plan is an extension of the patient's confidence in the physician prescribing it. Most patients cannot assess their physician's technical competence, so they infer this competence from the behaviors that they can judge. If the physician appears to be rushed, preoccupied, dismissive, a poor listener, or too tentative, then the patient is likely to worry about the accuracy of the diagnostic process or the effectiveness of the treatment strategy.
Patients rely upon their physician's commitment and thoroughness. When a physician is genuinely uncertain of the diagnosis or best approach, he or she must still project confidence in the strategies that will eventually answer that question. When a patient or family does not develop confidence in the physician, they are more likely to question why diagnoses were not made sooner, why treatment plans did not work more quickly, why diagnostic possibilities were not realized immediately, why complication arose, and so on.
If challenges to adherence are to be uncovered and resolved, physicians should probe for their patients' confidence both by direct inquiry and by attentiveness to voice tone, facial expressions, and repeated questions and doubts.
Patients will not follow diagnostic or treatment plans that they cannot remember. If a patient tries to explain the physician's reasoning to someone else, and that person is unconvinced, motivation to adhere to the plan may be lost. Give patients material that will help them to remember the reasoning behind a treatment plan and enable them to explain key points once they get home.
Mutual agreement on next steps is usually the key outcome of the encounter. Physicians must convey the urgency and importance of these steps. Uncertainty here can undermine the usefulness of all that preceded it. Asking patients to summarize their understanding of the key points in the plan assures you both that the patient is in a position to follow through.
A plan that is phrased, Why don't you try this medicine and see if you get some relief? conveys a lack of conviction from the physician. Similarly, a plan phrased as, I don't think this lump is a cancer, but it may be helpful to get a repeat mammogram just for assurance, could be interpreted as, My physician doesn't think this is really needed and it is such a hassle to take off from work again, maybe I'll just wait and see for a while.
When multiple providers are working with a single patient, they are often uncertain about who is following up on what. If advice sounds inconsistent, adherence will be undermined. For example, pharmacies give patients printed information and counseling about the medications that are being dispensed. The patient may not feel comfortable calling a physician again to resolve new doubts and conflicting advice.
Taking into account all the factors that may emerge to undermine adherence, physicians may want to tell patients:
Many patients find that they have second thoughts or questions about the treatment plan after leaving the office. Promise me that, before you change any part of our plan, you will call my office and let us think the change through with you.
The final cause of the health and liability risk stems from inadequate office systems for detecting and intervening on non-adherence. Whether on the computer, through handwritten charts, or running lists, physicians must determine if patients have followed up on important aspects of the diagnostic and treatment plan and that they (the physicians) have noted and acted upon any abnormalities.
Refer back to the previous treatment plan in the agenda-developing stage of later appointments as another check that problems have been fully addressed. Look over your cancels and no-shows daily to determine if proactive outreach is needed to monitor and prompt adherence.
The responsibility is shifting to the health care provider and health care system to promote adherence to diagnostic, preventive, and treatment plans. Individuals who are sensitive to the topics discussed above will find that they and their office can do a great deal to improve adherence and reduce their own liability risk in the process.
