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The Non-Adherent Patient: How to Approach Situations When Patients Don’t Follow Your Advice

January 23, 2017

Most physicians are familiar with patients who don’t always follow the advice given to them. For example, up to 30 percent of prescriptions are never filled, and another 30 percent are taken in an inconsistent matter. Providers often order tests or make recommendations and then may not be aware of whether or not the patient is following through.

The term nonadherent may be used when describing patients who are unwilling or unable to follow the recommended treatment regimens.  Nonadherence is a challenge for the patient and the clinician and can occasionally present a liability risk.

How to have the discussion

Having frank discussions with patients and being non-judgmental can be an effective way to find out more about the patient’s perspective and reason for nonadherence.

Ask open-ended questions to explore the reasoning behind a patient’s nonadherence. Is the patient not convinced about what he or she needs to do? Or does the patient lack the confidence or ability to follow through? Patients are also likely to react more positively to treatment if they are involved in core decisions and if they understand that the advice given by their physician is personal, and not a one-size-fits-all solution to their particular health issue.

Patients should be made aware of resources available to help them follow treatment plans. Affordability is often a factor in nonadherence, especially now with many patients having high deductible insurance plans. Physicians should diplomatically ask patients if this might be an issue and can propose less expensive, but effective, alternatives. 

What to do when a patient is non-adherent

Recommendations on how you should respond and document a non-adherent patient are outlined below. While we don’t reasonably expect you to do these in all patients, your response should be commensurate with the risk involved in each patient’s situation. A patient with a suspicious mass may require all of these while an abnormal test with little risk of an adverse event may only require a chart note.

  1. Chart note—A note like “Colorectal cancer screening risk/benefit discussed,” during an annual exam is invaluable when defending allegations around such screenings. If you have a discussion exploring the reasons for nonadherence, include these reasons and what you talked about in the medical record.
  2. Documented phone call—In cases such as a positive fecal occult test or abnormal lipids in a patient with known coronary artery disease, we recommend calling the patient directly and explaining the recommended plan in easily understood language and the risk of not following through. Of course, document the discussion in the medical record.
  3. Letter/return receipt requested—In cases such as an abnormal mammogram with a high-risk interpretation or an abnormal suspicious radiologic image, you may want to make a call and then state the recommended plan and the risks of not following through. In addition, you should consider a “return receipt requested” letter and keep a copy of the letter and the confirmation of receipt by the patient.
  4. Document around tracking—Missed appointments or not following up on referrals are also forms of nonadherence. Physicians may want to implement what are commonly called “tickler” systems. A tickler system reminds the physician and staff of a pattern of missed or cancelled appointments, non-receipt of test results or consultants’ reports, or failure to follow up as directed by the physician. A physician may also want to consider creating a checklist that triggers electronic reminders, flags cancellations, initiates follow-up letters for missed appointments or tests, and monitors nonadherence so that efforts to follow up by contacting patients is documented in the medical record.
  5. Terminating the relationship—You may also consider terminating the physician-patient relationship when the nonadherence is severe.

Created by MagMutual from materials provided by COPIC as part of MagMutual and COPIC’s alliance to improve patient safety and quality of care for all of our PolicyOwners. 

Disclaimer

The information presented in this Advisory is intended as general information of interest to physicians and other healthcare professionals. The recommendations and advice published herein do not reflect or establish a standard of care and do not establish rules for the practice of medicine. The publication of this information is not intended as an offer to insure such conditions or exposures, or to indicate that MAG Mutual Insurance Company will underwrite such risks for the reader. Our liability is limited to the specific written terms and conditions of actual insurance policies issued.

Footnotes