There are few things more frustrating for us optometrists than a noncompliant patient. You offer them a treatment plan that will relieve their symptoms or even cure their condition, and they come back to you complaining that they aren’t seeing results. With a little probing, they tell you that they stopped using their eye drops. Or, they haven't been using their medication according to your dosage schedule. Even worse, they think that the treatment options you gave them are all pointless and a waste of time and/or money.
We’ve all been there. It’s hard to help someone who doesn’t want to be helped. However, delving into the psychology of patient noncompliance can provide some useful insights into how to break through that barrier and help your patients help themselves.
What is patient noncompliance?
Patient noncompliance occurs when a patient does not adhere to their treatment plan. Whether it’s prescribed medication, a treatment regimen, or another lifestyle adjustment, they just won’t do it. Or they won’t do it enough.
What are the reasons for patient noncompliance?
There are plenty of reasons why people don’t do things. They might not want to, they might be busy, or they might even just be lazy.
However, unless the patient is a true rebel, there’s probably an underlying reason. That’s why it’s crucial to establish dialogue with your patients, to avoid preventable instances of noncompliance. They might be neglecting your advice for a variety of reasons. Many don’t even realize that they’re nonadherent. These factors can be psychological, temporal, or financial.
What are the factors that may lead to noncompliance?
A lack of trust, motivated by fear
Sometimes, patients just won’t listen to you. This can be very frustrating, but it’s important to ask yourself what might be going on on the patient’s side of things.
Picture this: you’ve just given a patient the best exam of your career. You came up with an elusive diagnosis for the disease that’s been impacting their vision for the better part of a decade. Success!
However, they never return, even though you asked them to return to your clinic for further treatment and management.
This is a perplexing situation. You feel like you did everything correctly; you’ve made the diagnosis of a lifetime, but the patient doesn’t bother returning. Is it because they don’t care? Oftentimes, it is easy to fall into a pattern of self-deprecation and doubt. One thing that you must always consider, especially in these instances, is how much your patients trust you.
Trust is something that develops over time. It (or a lack thereof) is a major barrier to patient compliance. When you tell a patient that they might lose their vision, this can be quite traumatic. Fear might lead these patients to seek a second opinion.
What to do
When a patient doesn’t come back right away, it’s important to step away from the clinical side of things and look at the patient’s actions through an empathetic lens.
They might be in denial. Fear is a major underlying reason this lack of trust, and developing a strong patient-doctor relationship is one way to mitigate noncompliance.
When making a major diagnosis, it is imperative that you sit down with your patients, truly talk to them, and give them compassion and reassurance they deserve.
Misunderstanding, panic, or both
Why isn’t your patient coming in for follow-ups? Why aren’t they sticking to basic rules? They may simply be scared, or they may not understand why they need to adhere to these check-ins.
Your glaucoma suspect patient never returns for their special testing and you just can’t understand why. When you are able to get them in for an appointment, you question them about why they never return. It becomes clear that they don’t understand the seriousness of their circumstances even though you’ve explained it to them in a way you think they might understand.
An important lesson here to remember is asking yourself—how much is my patient really listening to me? How much are they understanding? Would they be able to explain this back to me?
What to do
When you start to talk about glaucoma and blinding eye disease, it can be easy for a patient to switch off and start to panic. While their condition might not seem like a big deal to you, the words “blinding eye disease” can cause high anxiety and stress in your patients.
Take your time and educate your patients to make sure that they truly understand the condition and why you want them to return. Explain that you need them to return in order to understand their situation better. Clarify that being suspect for glaucoma does not necessarily mean they have glaucoma or that they will lose their vision.
Another important thing to help patients understand is that even if they have glaucoma, it is very treatable. They just have to come in!
Many patients exhibit noncompliance because of financial issues. This is a sensitive topic for many patients, who do not want to be upfront about their financial situation. Bear in mind that every patient’s situation is different and what seems like small potatoes to you could mean a heavy financial burden for them.
What to do
It is important to be up front with your patients and ask them outright how much their medication is costing them.
Oftentimes an open dialogue is the key to getting them to be honest and give you some insight into the financial impact your treatment has on them. If you find that finances are creating problems with regards to compliance, then you can always search for alternate therapies or even surgical options that might eliminate the need for long term topical therapy.
Unpleasant side effects
If your patients don’t understand the importance of a certain treatment, they may not stick with it. Especially if it causes side effects.
How many times have you prescribed a patient a treatment for dry eye using your medication of choice only to find, upon follow-up, that it’s not working . . . at all? You drive yourself crazy attempting to understand why this treatment isn’t working only to realize that your patient has not gotten a refill for months despite them only having a one-month supply.
Upon questioning, you learn that your patient only used the medication for a week before stopping! When you ask why, you discover that they were experiencing unbearable side effects like stinging and burning. They made the executive decision to simply deal with their dry eye issues rather than use the medication you prescribed.
Think about it: if something seemed to be causing more problems that it was supposed to be solving, you’d stop doing it, right? Many patients don’t realize that their medicine is working “behind the scenes,” and a few side effects can dissuade them from sticking to their regimen.
What to do
Having an open dialogue with patients is a simple way to avoid this common cause of noncompliance. Warn them of potential side effects beforehand, and follow up with them throughout to see if they’re having any issues. You can then choose a different treatment option or alter the medication to a non-preserved formulation that might be more forgiving to their ocular surface.
And, voila! Side effects: mitigated. Noncompliance: halted in its tracks!
They just can’t stick to their regimen
The treatment is only as good as the level of compliance. If it’s taken off-schedule or not at all, then it won’t work to its fullest extent. Plain and simple.
One of your glaucoma patients, a middle-aged woman, is not getting the desired IOP lowering effect of your tried-and-true medication. You explain to her exactly how to use it and she comes to all of her appointments but it just doesn’t seem to be working. It’s time to consider external factors.
You probe a bit more and discover that she’s only using her drops three times a week. Why?
She tells you that she gets so busy caring for her terminally ill husband that she often forgets to use her drops before going to sleep. Upon learning this, you tell your patient she can put her drops in before bedtime. You tell her to leave her drops on his nightstand so she sees them and remembers them.
Yet another instance of patient noncompliance that could have been avoided by forging a better dialogue from the get-go.
What to do
It all goes back to increased dialogue with patients; both getting to know them on a personal level and understanding that some people just can’t stick to a strict schedule. In an ideal world, everyone would take their medications on-schedule and with perfect use.
But that’s not realistic. You need to work with your patients to figure out what works for them.
What should I do when I have a noncompliant patient?
Notice that many of the situations described above could have been avoided. As doctors, it’s a trap we all fall into: sometimes, we’re so focused on what we know is the best treatment that we forget to consider the other factors at play.
Our patients are complex individuals with their own busy, multifaceted, and difficult lives. Learn to consider the person behind the condition, and you’ll notice an uptick in adherence and satisfaction.
The importance of dialogue
The question, “Are you taking your medicine?” provokes a simple “yes” or “no” answer. Probe a little further, and you’ll be shocked at what’s revealed.
Ask whether they found any part of their regimen confusing. Ask, on average, how often they remember to take their meds. Ask if there’s anything preventing them from being able to follow your recommendations.
And, most importantly, listen. Try to understand the reasons for their non-adherence, and then work to find solutions. Furthermore, they’re probably doing something right, and they should be commended for that.
Additionally, remember that noncompliance is a valid reason for a physician to ask a patient to seek another physician. If you can’t seem to get your message across to the patient, they might be more motivated by another doctor. It all goes back to fear, which promotes mistrust, denial, and noncompliance.
Do you have any frustrating tales of noncompliance that really stuck with you? Share in the comments!