Why Don’t They Just Stick To What I Say?

Compliance – the ability to stick to recommended lifestyle, medication and supplement recommendations are key elements of any relationship between health care practitioner and their client or patient. Wouldn’t it be so much easier if everyone “just did what I say” – the implication being that you are correct in your recommendations and that the person listening is in full agreement – so when does that actually happen and who has the greatest impact on outcome?

Characters that make compliance hard

Most practitioners recognise the wanderer – the person seeking a solution to the myriad of symptoms they possess, but quickly moving on when your suggestions do not match their expectations or losing interest when their 20 year history of self-destructive behaviour is not resolved in the first month.

Then there is the disillusioned – the individual who has already worked their way through the local NHS and extensive private practitioner list, is now financially exhausted but disillusioned with all therapies, especially anyone that seeks to ask the questions that require honest introspection.

The reactive, here you and the client or patient just do not get on, the emotionally volatile, delusional, righteous, flaky, idealistic and cranky fit into the category, but often it boils down to a failure on behalf of the health care provider to respect the position and mind-set and adapt accordingly. Even a moon phase loyalist can be managed by a traditional reductionist if a common non judgemental language is used – but how often does that happen?

The realist seeks qualified opinion, evidence if you like, that the information you are sharing with them is based not in the shape of the solar system (unless he is an astrophysicist of course) but on a body of supportive evidence, not just the view of one opinion leader – albeit they may be correct and ahead of the pack – but collective and validated wisdom. This in most cases, means more than one or two positive anecdotes or a friend’s recommendations – but even these represent collective experiences and should be weighted accordingly.

The economist seeks extensive, mostly unpaid for support and moves on when the 20^th phone call elicits the response that your time has an economic value and that you will need to charge them. Even the alleged ‘free at the point of entry’ (NHS) is an economic behemoth in which all members have a conflicted duty between optimal use of resources (time being a key one) and outcomes. Eventually the ‘economist’ excludes all support by virtue of their inability to place equivalent value on helpers time as their own needs.

The drifter, here the patient simply forgets, loses interest or experiences events in their life that make them lose the path, and rediscover the return of symptoms. Life is complex and keeping on track with what are often challenging changes to people’s lives, plus the ingestion of medications and supplements can be a challenge – especially when no return on investment is easily defined.

The under consumer sees the option of reducing their medication in dose or time as a key objective and their direct contribution, either because of side effects – real or imagined, perception of alteration in well-being, and just wanting to be in control. They proudly state that the dose they were recommended has been reduced or occasionally increased, delayed, avoided or swopped for a cheaper, albeit incompatible brand.

The hypochondriac, whilst some practitioners actively welcome the underlying neurosis as a long term economic cash cow, most clinicians find compliance, and acceptance a battle with the person who regards every symptom – mild or otherwise as a sign of impending health collapse. Riven with the fear of missing the genuine symptom, they often apply equivalence to all, and become agitated and move on or change their recommended medication and supplements, because of the short term isolationist nature of their symptom interpretation, making management a constantly evolving, but rarely satisfying experience.

The procrastinator, finds agreeing to make a change easy, but actually applying the changes almost impossible. Fear of a mistake or going in the wrong direction, combined with transitional rationality and desire to be seen to be willing to change can make them sound compliant at first. Most will present with an agreeable face and indicate that compliance is their desired and shared goal, but will fail to disengage destructive behaviour not because they cannot see why, but because they are unable to rectify their own balance of fear.

The demographic, younger women are more likely to deviate than older ones, the same is true from men, but women overall are less compliant.[1]

I am sure that you will recognise some of these, and there are many other character traits and personalities as well as illnesses that mediate compliance and of course every now and again we meet the compliant.

This is the person, genuinely seeking change, is willing to engage in constructive dialogue, listens, answers accurately and honestly to probing but valuable questions, is respectful and always turns up for their appointments.

What to do?

The cost of noncompliance is reduced efficacy of outcome and in medication/supplementation supply, a large waste of economic resources. This includes unnecessary drug purchases, missed appointments, deteriorating health, frustration and loss of practice income.

In private practice, the most significant activity by a practitioner to have an impact on compliance is follow ups – most practitioners see their role as move in, repair and move out – most patients need rescue and management.

How to do this and maintain economic viability for both people suggests that office visits may not be the best option.

For many years through our profitable practice seminars we have explained the benefits of telephone follow ups – dedicated time (income related) to listen to and manage any changes that may have occurred, offer reassurance and modify supplementation or if able to prescribe, adjust medication. Research has confirmed that demonstrating interest, concern and care and making it easy for the individual involved to communicate and ask questions ensures a higher degree of compliance and better outcomes – whatever their character traits![2],[3]

Do you structure your appointments to permit telephone or e mail follow ups, do you cost these accordingly, do you define the scope of these transient updates, do you successfully recover the fees? If not, maybe now is the time to give this area some careful thought.

By utilising these simple management techniques and understanding the personality of the presenting patient and client, it may be possible to beneficially increase compliance and improve outcome.