Sunday I wrote about a landmark paper, “Healthcare in a Land Called PeoplePower: Nothing About Me Without Me.” Here’s the next in this series. It starts:
“Physicians often complain that patients are non-compliant; they do not do what they are told. This resistance perplexes doctors. They can write prescriptions for patients, but they cannot control what the patients do with the prescriptions. … To cajole or threaten has little effect. Rapport and education have likewise had little impact. Patients continue to disobey.
The paper is “The Patient’s Right to Decide,” by Warner Slack MD. It was published in the British journal Lancet – in 1977.*
[I]n my view it may be more appropriate to focus on the problem that may well be the cause … the assumption that physicians are in charge of their patients and are therefore entitled to make decisions. … The very word compliance suggests submission to a higher authority… Suggested alternatives, such as cooperation and concordance, connote a less overt paternalism but continue to suggest that the patient is the one who must yield. (Emphasis added)
It’s striking that we’re discussing exactly the same problem thirty-three years later. Actually, we’re still discussing both the practical issue and the semantic one, the politics of language – what we should even call the issue. Orthopedist Howard Luks discussed both yesterday on his blog: Compliance vs Participation. His problem is practical, and he yearns for a more participatory view – including by the patient.
I assert that indeed the physician is not in the driver’s seat, and we get a whole lot of heartbreak when we act as if s/he is. (Slack: “Subservient patients tend to regard their physicians as omniscient and are understandably incredulous when outcomes are unfavourable.”) Two years ago on e-patients.net I wrote that Stanley Feld, MD had written “Physicians are coaches, patients are players.”
And as for the “c” word, let’s put the power where it actually is – in the “player’s” hand, as Slack suggests. The patient chooses the goal (or not), and the patient puts out the effort (or not), let’s call our shared purpose what it is: Achievement.
* Lancet 1977;2(8031):240.