Wednesday, October 28, 2009

Compliance, Adherence, and Rush

Despite the protestations of the right, I really do believe Rush Limbaugh is an entertainer. I believe this because entertainers make hay with political correctness is order to provoke, amuse, and grow rich. So while Rush, the Reverend Al Sharpton, and Glenn Back are crazier than loons (and that's a very grave insult to the loons, one of America's finest community waterfowl), at least they never struggle with the language of the PC crowd.

One of the hallowed terms in clinical medicine is "non-compliance." A patient is non-compliant when they fail to follow a prescribed course of care. The non-compliance may be overt, as in a patient who simply tells you there's no way he's going to rehab for his alcohol problem; or it may be covert, like when the patient tells you they're taking their blood pressure pills when the prescription actually never got filled. The term suggests an active and conscious effort to resist the suggested plan of medical care. It's a term that over the years we've applied broadly to any patient who doesn't do exactly as we say. (I would put in a real-world caveat here that it shouldn't apply to those who have legitimate religious reasons for refusing certain aspects of care, but technically the term would apply to them as well.)

However, in my own personal nod to the PC culture (and putting yet another nail in the coffin of my nascent career in stand-up comedy), I'm consciously trying to use a different term when I see patients in the ED. While many people do not follow through with their plan of care, in many cases it's not their choice. Sometimes they truly don't have the money to afford their medications. Sometimes they may not qualify for any assistance program that allows them access to a physician. Sometimes they lack transport to the doctor's office. Sometimes their medical condition prohibits their compliance with aspects of care. Sometimes they may be confused and take too much or too little of their medications. And sometimes they may simply be acting like human beings and just forget. Researchers have proposed the term "non-adherent" to these patients who would actually like to comply with care but for reasons other than their own are unable to do so. And while the term smacks of political correctness it actually makes clinical sense.

I think some of my colleagues in the ED would say that I give patients a harder time about compliance than some of my peers. Despite the attitude I consciously try to project, I take seriously the role of "fighting the good fight" to use our health care resources wisely. (It's a leftover of a public health career I'm still working to shake off.) So while I have no problem with the system caring for you at taxpayer's expense...if fact, I believe it's the morally right thing to do...I also believe that the individually has a responsibility to take the benefit offered by the system and use it appropriately in order to achieve the end goal of health. So I think that as we look at health care reform, and recognize that the primary way to achieve the simultaneous goals of quality, cost constraints, and access to care is to place some limits on benefits, it's important to try to ferret out the differences between patients who are non-complaint and those who are inadvertently non-adherent. The former group may lose access to care; the latter should be facilitated to maximize their chances of following the medical plan. The trick for policymakers, of course, is how to accomplish this on a national level. The trick for me is to keep the difference in mind in the middle of the night.

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