When Patients Say No: Recognizing and Resolving Noncompliance with Treatment Plans
By Hall B. Whitworth, Jr., MD
Noncompliance with medical recommendations is more prevalent than some realize. According to reports, more than 40% of patients may not accurately follow their doctors’ orders. When treatment requires a complex regimen, a major lifestyle change or the patient is otherwise asymptomatic, noncompliance can reach as high as 70%.
That’s a shame, because compliance with treatment plans offers many benefits to patients:
- Following medical recommendations is crucial to achieving better health outcomes.
- Non-compliance can lead to complications and erode a patient’s condition.
- Following medical recommendations can save patients time and money by reducing the need for tests, medications or hospitalizations, as well as returning them to productivity.
- Compliance builds trust between patients and healthcare providers, which is essential for effective communication and collaboration.
On the other hand, healthcare professionals treating noncompliant patients face significant liability and financial risk, including the possibility of malpractice claims, particularly as patient outcomes increasingly connect to quality indicators and reimbursement. Because of those significant benefits and risks, recognizing noncompliance and developing plans to prevent it is a win for both patient and healthcare provider.
Causes of Noncompliance
How do you know a patient may not be following a recommended course of treatment? Common signs include:
- Missing follow-up appointments
- Failure to complete recommended diagnostic testing or laboratory studies
- Lack of compliance with consultation recommendations
- Non-adherence to medication instructions and monitoring regimens
- Failure to make behavioral and lifestyle changes
Characteristics of the individual patient, the nature and symptoms related to their condition and the specifics of their treatment regimen can influence the ability and willingness of patients to comply with medical recommendations. Patients have a wide range of ability to process, understand and make appropriate decisions regarding basic health information and recommendations.
- Cognitive impairment along with conditions such as anxiety and depression may limit a patient’s ability to remember and understand medical instructions. Studies show that 40% to 60% of patients incorrectly report physician instructions as little as 10 minutes after receiving information. Another study suggested that 60% of patients misunderstood instructions after a visit.
- Language, cultural differences and age may limit a patient’s ability to understand the reasons for treatment and instructions.
- Health literacy and understanding of medical terminology varies greatly between patients and impacts their ability to understand directions. Instructions such as “take on an empty stomach” are clear to some patients, but may be confusing to others.
- Motivation to proceed with treatment can be lacking. A 30-year-old patient may have difficulty comprehending the risk of disease later in life. Furthermore, asymptomatic patients may not appreciate the benefit of therapy. Misinformation about the probability of risk with diagnostic testing or treatment, as compared with the risk of not proceeding, may be powerful factors in a patient’s decision.
The characteristics of a potential or confirmed medical condition and the treatment regimen also can affect the patient’s ability or motivation to proceed.
- Goal of therapy. In one study, when providers prescribed treatment with an intent to cure a medical condition, 77% of patients demonstrated compliance. When the intent was to prevent a medical condition, 63% of patients were compliant. Asymptomatic patients demonstrate a clear reduction in compliance.
- Complexity of treatment plan. With medications taken once each day, 81% of patients complied with the schedule. When frequency increased to four times per day, only 39% of patients complied. Furthermore, with a longer duration of therapy, the frequency of compliance reduced to 50%.
- Financial cost of treatment.
- Side effects and risks of a diagnostic or treatment plan. Patients experiencing side effects may discontinue medication without notifying and coordinating adjustments with their medical provider.
While a number of factors may cause a patient’s noncompliance, recognizing the issue and addressing it can significantly improve the patient’s response to and clinical outcome of treatment.
How to Recognize Compliance Problems
Assessing patient compliance is very difficult. Many patients may not want to disappoint their physician and don’t truthfully report their degree of compliance. Other patients aren’t able to accurately evaluate or do not know their degree of compliance. In one study, 10% of patients reported that they were 100% compliant with their medication use. Using pill count methods, however, medication use ranged from 2% to 130% of the number of prescribed pills.
Several methods may help to improve patient understanding, memory and ultimately compliance with prescribed medication or recommended diagnostic studies or treatment. One important strategy is to improve the likelihood of compliance at the very beginning. Explaining the goals and rationale for therapy using language that the patient can understand sets the stage for compliance. Educate the patient on the perceived benefits of diagnostic studies or therapy at the outset, especially if the patient is asymptomatic.
Collaborating with the patient may improve adherence to the treatment plan, including frequency and duration of medication intake. Address potential financial limitations or other barriers to lifestyle modifications. In particular, correcting misinformation regarding a medical condition or possible side effects at the beginning of treatment may help to improve compliance. Finally, explain the potential consequences of not following medical recommendations.
Additional actions to improve compliance as treatment begins include:
- Speak clearly and briefly and be aware of the patient’s health language literacy. Emphasize the most important information early, as patients tend to remember what they hear first.
- Repeat the information verbally and provide written instructions if appropriate.
- Ask patients to repeat their understanding of the instructions, and if necessary, encourage them to write them down.
- Simplify medical regimens using dosage scheduling charts and pill organizers. Try to coordinate medication schedules with the patient’s daily routine.
- Discuss potential side effects as well as the consequences of stopping a medication or not taking it properly.
- Review the optimal way to report questions or side effects so treatment can be altered while still maintaining a therapeutic benefit.
- Provide clear recommendations and expectations for follow-up and required treatment monitoring. Schedule appropriate follow-up either by telephone or through an office visit.
Develop a Plan for Monitoring Compliance
Following initial diagnostic or treatment recommendations, a plan for monitoring, continuing education and feedback helps to bolster the likelihood of patient compliance.
- Encourage open discussion with the patient regarding potential barriers to treatment or side effects. If the patient elects not to proceed with diagnostic testing, consultations or continued treatment, encourage them to report this decision so you can develop a plan for continued care.
- Seek support from nursing, social services, pharmacists and family members to reinforce compliance and follow-up instructions.
- During follow-up evaluation, communicating progress with medical conditions may help to encourage continued compliance. This is particularly important in asymptomatic conditions such as elevated cholesterol or blood glucose levels.
- Follow-up with the patient to confirm completion of diagnostic testing or outside consultation. Make a note for office staff to contact the patient at a later date to confirm completion.
In some situations (anticoagulation monitoring and treatment, for example), the patient may benefit from a medication adherence contract. This should explain how a medication is used, potential side effects of altering the dose or stopping the medication, potential for interactions with other medications, side effects to report, and instructions on proper monitoring and potential for dosage adjustments. The contract should clearly explain the follow-up and monitoring schedule and where to direct questions. The physician should give a signed copy of the contract to the patient and the patient’s family or friend and place it in the medical record.
After discussion, a patient still may elect to decline a particular treatment or test. Certainly, it is well within the patient’s right to decide not to proceed once they are aware of potential treatment options.
In that case, consider asking the patient to sign a written document indicating “informed refusal.” This document should include the indications for the procedure or the medication and overall treatment plan, the risk and benefits of a particular procedure or medication, potential alternative treatment options, the potential consequences for refusing such treatment, and, if possible, the reason the patient is declining treatment. The physician should carefully document any such discussion in the medical record and may choose to include a note from a third-party witness.
Even with concerted efforts to identify and prevent issues, noncompliance can remain a challenge, and a patient’s continued noncompliance may begin to affect the physician-patient relationship. A doctor should communicate clear expectations and conditions that a patient needs to meet to continue active treatment. In some circumstances, a decision to terminate the physician-patient relationship may become necessary.
Disclaimer: The information provided here does not constitute legal, medical or any other professional advice. No attorney-client relationship is created and you should not act or refrain from acting on the basis of any content included in this article without seeking legal or other professional advice.
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