In brief
- Communicate clearly and frankly with patients about why a treatment plan or lifestyle change is important and how to best implement a recommended course of action. Explore patients’ fears or concerns that might pose a barrier to carrying out the plan.
- Use multi-modal communication materials to enhance your patients’ understanding and to foster patient-centered care.
- Consider using office systems with reminders to help identify patients who frequently miss or cancel appointments, or do not follow through on diagnostic tests or referrals.
- Document the treatment plan and consent discussion in the patient’s medical record. If you are recommending a surgical intervention or other significant treatment, document patient refusal.
Non-adherence may include a patient missing appointments or tests, not following up on referrals, failing to fill prescriptions, or stopping medication.
Patients may not heed the guidance provided by their physicians for many reasons. Changes may be difficult for the patient, either because of other obligations, or a lack of commitment, interest, or understanding. Socio-economic conditions may mean certain treatments are unaffordable or living conditions are difficult. Issues of language, culture, or literacy may also come into play.
It is important for physicians to document the treatment plan and the consent discussion in the patient’s medical record. The medical record should show that the patient was made aware of and understood the expected benefits of adhering to the advice. In situations involving surgical interventions or other significant treatments, the record should show that the patient was made aware of the risks of non-adherence. In the event of a College complaint or legal action in which non-adherence is a factor, proper documentation allows the physician to demonstrate that the patient was advised of the recommended approach.
Case study: Non-adherence for referral
A patient with a recent negative cardiac stress test presents to the emergency department complaining of substernal chest pain following a large meal and heavy drinking.
An electrocardiogram shows non-specific changes and a single set of cardiac enzymes is negative. Reflux esophagitis is diagnosed and the patient is discharged home.
The following day the patient is reassessed at their family physician’s office. The patient complains of intermittent substernal pain with eating. Esophageal reflux is diagnosed. The physician recommends an urgent referral to a cardiologist and gastroenterologist, but the patient refuses. The physician does not document the discussion or the reasons for the patient’s refusal.
The patient subsequently suffers an acute myocardial infarction and dies. Autopsy confirms the cause of death and reveals a 95% obstruction of the anterior branch of the left coronary artery.
Experts are critical of the physician's failure to document their advice, the referral to a cardiologist, and the patient's refusal. The case is settled in favour of the patient, in part because the physician was unable to prove that the patient was informed and understood the potential consequences of refusing the test.
Patient-centered care
Fostering patient-centered care entails being as open as possible when a patient challenges the proposed treatment plan.
When patients appear hesitant or react with skepticism to your advice, consider asking them about their reasons—what are their concerns or fears? Doing so may reveal whether a patient’s refusal is adequately informed, and can lead to a more frank discussion about the likely benefits and potential risks of the proposed treatment. Consider supplementing your advice with multi-modal education materials targeted to the patient’s health literacy level, ideally in the language they are most comfortable with. The use of shared decision-making tools may further enhance patient-centered care.
Be mindful that culture may affect a patient’s interpretation of symptoms, coping strategies, and approach to health, impacting their adherence to treatment.
Following up
Every patient will react differently to your recommended treatment plan—which may encompass lifestyle changes, diagnostic testing, or medication—and following up with the patient is key to encouraging adherence to that plan. During follow-up appointments, consider reviewing the treatment plan, the patient’s goals, progress, test results, and any barriers to adherence the patient may be encountering. If the plan includes smoking cessation, for example, ask the patient about their success to date and if more assistance or resources might be needed.
Having in place a reliable system for following up on laboratory tests, diagnostic imaging, and consultations may help to identify when a patient is non-adherent, giving you the opportunity to reach out to the patient and potentially reassess the treatment approach. See Closing the loop on effective follow-up in clinical practice for more information about using systems to track whether a patient has followed through with a recommended test.
Medication prescribing
The affordability of prescribed medication may be a factor in non-adherence. If this is an issue for a particular patient, consider proposing less expensive but equally effective alternatives—including the possible availability of generic versions rather than brand-name medications.
The availability and standards regarding the use of e-prescribing vary across the country. Generally speaking, the electronic transmission of prescriptions to a pharmacy may help improve patient adherence as this practice encourages patients to consistently use the same pharmacy over time and potentially requires the patient to spend less time there when picking up medications.
Additional reading
