A radical view of “compliance/adherence” – from 1977

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.*

He continues:

[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.

4 comments to A radical view of “compliance/adherence” – from 1977

  • Annie Stith, e-Patient

    Hey, Dave!

    “Achivement,” eh? (; It most certainly is.

    On the physician’s part, it means giving up the “God Complex.” For patients it means giving up passivity in the relationship.

    I can see how it may be that what work gets done on Participatory Medicine will be received along generational lines. Elders, having grown up consistently with obedience (in all areas) may not be able to adjust to such a change. Baby Boomers might be more receptive because they have a history of breaking the rules in their youth. The Shadow Generation (those lost between the Boomers and Gen X) are middle age, starting to deal with the development of common problems (blood pressure, hyperlipidemia, being overweight, developing Diabetes II). They may be more open to questioning which medications, diets and exercise is best for them (including jumping on the Web to check things out). Gen Xers and younger can learn from us if we are persistent in our goals.

    That doesn’t mean I don’t think changes can’t happen now. It means that from my view, there may not be a collective system in place for quite some time. I read that one medical association (doctors, nurses and other health professionals) in one geographic area promotes changes in their hospitals, clinics or state. I see it as a kind of quilt being stitched together piece by piece, but some still don’t like or want the pattern being produced. Those who follow may be more willing to fill in the blank spots.

    I don’t think some of the major players who started the movement would be surprised at where we are now.

    Annie

  • Seriously, I don’t understand why people go to doctors and ask for prescriptions hoping the medications are magic itself. Clearly, physicians are not in control of what their patients take and do or not do. They can only do as much. It’s amazing how perspectives changed over the course of time. Great post!

  • […] This post was mentioned on Twitter by Dave deBronkart, Andrew Spong. Andrew Spong said: A radical view of “compliance/adherence” – from 1977 « e-Patient Dave: The patient chooses the goal (or not), an… http://bit.ly/dPr7mY […]

  • […] patients who don’t take their drugs, does that make medication adherence a patient problem? Patient engagement advocates like ePatient Dave have suggested that words like “adherence” and “compliance” advance a […]

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