- extent to which a person’s behavior coincides with medical advice. Adaptation or adherence to medical advice. Doesn’t always have to be taking pills, it could also be not accepting a life-saving treatment
Scope of Noncompliance
- increased exposure to pharmacologic agents, misinterpretation of research findings, increased health care costs, and increased morbidity and mortality. 25-50% of patients will be noncompliant.
sore throat vs. throat cancer - sore throat hurts (more compliance to sore throat treatment)
bronchitis vs. TB - bronchitis has shorter treatment so better compliance
peptic ulcer disease vs. HTN - pain in PUD, more compliance.
(2) Medical regimen - 3 pills or more, side effects, expensive Þ less compliance
(3) Patient knowledge - don’t educate too much Þ can scare patients
Health belief model (test to see if patient believes what you are telling them)
Understands risk
Problem is serious
Treatment is good
Patient is capable of treatment
(4) Patient
Age
(young or old) - Elderly will not comply due to expense, suspicious, or trade pills (will swap pills with other elderly patients and try to treat themselves); Adolescence - autonomy issue, desire to be like other kids
Personality
- a Type A person may not be so compliant because he is so busy, he tries to up dosage or not take medications because they interfere.
(5) Socioeconomic factors - poor people are less compliant concerning long-term treatment because of expense.
(6) Social support - if family members are involved Þ increased compliance
Psychosocial and Psychiatric Factors
Cultural influences
Psychiatric disorders
Psychosis, paranoid
Mood disorders
Depressed patient more likely to see doctor, but may not be compliant
Manic - feels they don’t need anything.
Dementia, delirium
Anxiety level
- mild (facilitates learning and compliance), severe (leads to denial).
Doctor Behavior Increasing Patient Cooperation
Alertness to noncompliance
Continuity of care
Biopsychosocial assessment and management: Patient education, dialogue rather than monologue, consider noncompliance as a symptom not "bad behavior," concept of patient as a colleague
Enlisting family support
Simple regimen
Doctor-Patient Relationship
Patient
-wants doctor to be knowledgeable, helpful, respectful, empathetic; generally has more hidden desire for "magic bullet" cure; has preformed desires/feelings regarding doctor based on past care, which can lead to transference
Doctor
- desires the ideal patient (accurately describes signs and symptoms that fit with a correctable biologic finding, is compliant, unchallenging and grateful); possess some hidden expectations of patient depending upon early experiences that lead to reactions called countertransference; should come into the encounter with some self-knowledge or self-understanding about the relationship.
Positive placebo effect
- patient believes that doctor will be able to help
Negative placebo effect
- patient feels that doctor may not have his/her best interest at heart; ask about relationships with other doctors
Transference
- Broad definition: patient expectation of encounter based on past experience.
Specific definition - unconscious reaction of patient to doctor based on experiences with original caretakers.
Features - patient reactions not in keeping with reality expectation, intense, inappropriate, puzzling.
Positive transference: Patient thinks you are the greatest doctor in the world, early trust can be formed, fosters compliance; however, dangers include eventual patient disappointment, patient seductiveness, and erotomania.
Negative transference: Feelings of distrust and anger at the doctor, can lead to noncompliance.
Remember that the white coat = power, transference can cut across age, status, and sexual boundaries.
Countertransference
- unconscious feelings and responses to the patient based on the doctor’s past experience.
Guilt provoking patient - patient says treatment isn’t working Þ doctor feels inadequate; doctor may try to placate patient as much as possible. May stem from the fact that the doctor could never quite please his/her parents.
dislike, intolerance to overevaluation
potential value: can help to identify with the patient.
Special Problems in the Doctor-Patient Relationship
those that harm - 87% of doctors have erotic thoughts; 12% of male and 3% of female doctors have sex with patient
vulnerable patient or vulnerable doctor
98% of hemophiliac men who got HIV through transfusion were educated on safe sex, only 50% will comply.
choices: no celibacy since it = no pleasure, no condom since it = transference of patient’s bad experiences.
Why would a woman have sex with an HIV positive man? - have a baby to remember man, fear rejection, stopping might make him angry, low self-esteem