Practitioners can lead their patients to the water of theraputic compliance and make them drink.
Although the words “compliance” and “concordance” are sometimes useful in the medical field, the term “adherence” is being increasingly used. It comes from the Latin word “adhaerere”, which means to cling to, keep close or remain constant. According to Merriam Webster’s Dictionary, it is defined as “the act of adhering; steady or faithful attachment,” a definition that appropriately conjures up the tenacity that patients need to achieve in sticking to a therapeutic regimen.
“I feel there is a huge difference between compliance and adherence,” said Holly Lucille, ND. “Compliance is doing what someone says to do, adherence is the ‘faithful attachment to something,’ and no, it isn’t easier … it is much harder unless the practitioner works really hard to get the adherence part of things. When you dwell in conventional reductionist medicine with a ‘here take this’ approach … that is easy, but dietary recommendations, dose dependent supplement regimens—lifestyle interventions—that is tough!”
Deborah Waddell, Dipl Ac, LAc, agreed: “I believe compliance is a bit harder using natural remedies because they most often require being taken two to three times a day and of course usually take longer to see results than taking Western drugs,” she said. “Patient’s need to be educated on whatever remedy they are taking and I also always encourage emailing or calling the office with questions. I have found that the most compliant of all my patients were those I was treating for fertility. They have such a strong need (I believe a genetic need to bear children) that they will do whatever they are told to increase their chances of conception.”
Many patients that don’t comply are used to getting immediate results with Western drugs even though they are only masking the symptoms not treating the root cause, Waddell added. “I always explain that it will take time before they see lasting results.”
Dr. Lucille said assessment of patient compliance should take place on the first follow-up visit. “The initial visit is best laid plans and then assessment of that is the key!” Waddell noted that as an acupuncturist, she often prescribes dietary recommendations, as well as Chinese herbal formulas. “If there is no improvement in their condition, I often asked if they are compliant with their diets and/or formula’s that I have prescribed. If they say no, I try to ascertain how I can make changes that will make compliance easier. I have found non-compliance happens most often with the dietary changes I suggest. Also, due to a high level of compliance with powdered herbal formulas or those that require cooking, I have resorted to using patent herbal formulas in pill or tablet form.”
Responding to Patient Non-compliance
Practitioners should consider a straightforward response to patient non-compliance. “I respond by telling them they will not get well if they refuse to be compliant, yet being patient with them and seeing if we can find a better way together to make compliance easier,” said Waddell. “Of course, if the patient refuses compliance then I recommend that maybe it is not the right fit and they may want to try some other form of treatment.” Dr. Lucille said its about understanding the disconnect. “When I first began practicing over a decade ago, my boundaries with my patients were flimsy at best,” she recalled. “I was so motivated and passionate about them doing well and following through with my recommendations that I would end up walking them to their cars while still educating, still explaining, well after our visit had ended,” she said. “ I think if I could have gone home with a few of them to help with implementation of the plan, I would have.
“Of course, upon the return visit, if I learned that the plan wasn’t followed or that my patient hadn’t progressed, I took it personally and wondered what I could have done better. Thankfully, with time and practice, my boundaries firmed up and I began to trust deeply in my work. It was helpful to remind myself that I truly am only part of the equation in this partnership and cannot be successful without my patients doing their part as well. However, I was still craving some re-assurance that after the visit was over and they had left the supportive, almost ‘cheerleading’ environment of my office that my patients could comply with my recommendations.”
One of the tools Dr. Lucille incorporated to assist in assessing this issue is called the “Adherence Loop.”
The Adherence Loop Model
Patient adherence can be defined as a patient playing an active and willing role in their plan of care to gain maximum benefit. In order for people to adhere to a plan, there are certain action points that they need to move through almost in a loop type fashion as described in “The Adherence Loop.” developed by Dr. Devorah Klein.
Believe: People need to believe that they have the condition, that the recommendations will work, and that they can be successful.
Frame: They need to build a mental model, or framework, of how the recommendations will work on their condition.
Know: They need to know the rules and what to expect.
Prompt: Knowing what to do is often not enough. People need cues and reminders to prompt action.
Act: Action requires resources: physical, cognitive, emotional, social and financial.
Reinforce: Feedback reinforces belief to strengthen and drive adherence.
When the Adherence Loop is Broken
If, upon the follow up visit, the practitioner notices that this loop has been broken somewhere and compliance has become an issue, there are diagnostic questions to ask to help figure out where:
• Do patients want to change or is someone else telling them they need to change?
• Do patients believe there is really a solution that will work for them?
• Do patients believe they can have success?
• Do patients have an accurate understanding of their health?
• Do patients have an accurate understanding of how the recommendation works?
• Do they know what to expect from carrying out the recommendations?
• Where are the misunderstandings? (past experience, stories, fear, hope)
• Do patients understand the rules of the regimen?
• Are patents overwhelmed by information?
• Are patients not getting information?
• Are patients getting misinformation?
• Are patients forgetting to take doses?
• Is the regimen hard to keep track of (inconsistent, not memorable, alien to the patient’s other routines)?
• Is the therapy physically hard to take (painful, difficult to administer, time consuming)?
• Is the therapy socially challenging (embarrassing, awkward, requires space or equipment)?
• Is it difficult to get (financially, logistically)?
• Does it require the help of another (caregiver)?
• Is there feedback that the therapy is working?
• Are there any negative side effects?
• Do patients notice an immediate or delayed improvement?
• Are people rewarded for action?
• Did the action meet expectations?
“I have had countless experiences where a plan was able to be exponentially more effective once I found out through this tool, where either the potential or real disconnect was,” Dr. Lucille said.
Consider a collaborative effort. Waddell said she always tells her patients that they become a team, “hence we need to work together to find what will help them best with compliance,” she said. “When it comes to diet, I will often provide the patient with easy low fat whole foods plant based recipes and even a grocery shopping this. I also recommend websites that will keep them motivated and also provide them with valuable information.” Do they give up on patients? “No,” said Waddell, “but a doctor has to understand that it takes time to spend with the patient to help them be compliant. Many patients want to be compliant but just don’t know where to begin.” Dr. Lucille also doesn’t give up. “Keep searching for ‘obstacles to cure.’”
HEALTHY TAKE AWAYS
■ Adherence to dietary recommendations, dose dependent supplement regimens, and other lifestyle interventions can be more difficult relying solely on pharmaceutical drugs.
■ Consider a straightforward response to patient non-compliance.
■ Dr. Devorah Klein developed “The Adherence Loop” to help practitioners determine where a patient has broken adherence.
■ Developing a sense of teamwork with a patient may improve adherence.
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