Non-compliance explained…and what healthcare leaders can do about it

by Thomas DahlborgAn image of a nice clock with time for change

“My doctor says I’m non-compliant,” she sobbed.

This 40 year old woman had recently been diagnosed as morbidly obese and told she was at risk for heart disease and diabetes. “If I don’t change my ways I know I won’t be around to see my children grow up. But now my doctor told me I’m ‘non-compliant’ because I don’t eat according to the diet she prescribed or get enough exercise. I’m so ashamed; I don’t know what to do.”

In the mid-to-late 2000’s, as the executive director of a small nonprofit healthcare and research organization, I saw patients share this scenario with our clinicians far too often.  Patients felt desperate, shamed and alone.  This is the exact opposite of what they should expect and require of our health care system: the exact opposite of a healthCARING model.

So it was no surprise to me when, as part of the NPR seriesWhat Shapes Health?, I read the story “Can Family Secrets Make You Sick?” and made note of the impact of Adverse Childhood Experiences, or ACE on adult health. In too many cases, women and men who are considered “non-compliant” by the traditional medical system were victims of abuse as children. For example, experiencing sexual abuse as a child can lead a person to have an insecure relationship with their body and thus with food (such as the 40 year old woman noted above). Those who have been bullied by coaches and others during youth sports may end up with severe distaste for exercise. But physicians rarely hear about these experiences, and do not understand these barriers in their patients’ way.

Why don’t physicians hear about these experience? One key reason is that we have not created health care systems which allow for adequate time with each patient.  In order to recoup the cost of doing business, many physicians see anywhere between 30 and 60 patients per day. Many primary care physicians are actually triple-booked every fifteen minutes to ensure that these productivity measures are met.

This healthcare model simply does not allow enough time for a doctor and patient to create a relationship.  Without this relationship, trust is not developed.

Without time, relationship and trust, patients do not feel safe enough to tell their whole story.

Without the whole story, physicians do not understand why their patient is obese and why their patient is not modifying their nutrition plan or sticking to their exercise program.

Instead, these patients are often labelled as non-compliant which, in some cases, leads to being discharged from the practice, even though the patient was both engaged and activated (to use two healthcare industry buzzwords).

We can do better- and many are trying every day.  The Patient Centered Medical Home (PCMH) is an example of an innovation with the intention to evolve this model. The IHI Triple Aim of improving experience, quality and cost of care is also a step forward, since it focuses as equally on patient experience as it does on population health and per capita costs (which, of course, are all connected).

In 2010, I spoke with other healthcare leaders about these stories of patients’ childhood abuse and the impact on their health; the label of non-compliant we thrust upon them; and their resulting feelings of abandonment, self-loathing and shame.  I also had the opportunity to share the term “relationship centered care,” and the importance of ensuring that we build into any new care model the space for time, relationship, continuity, trust, empathy, safety and compassion. We discussed the importance of each of these components.  Together, they allow:

  • for whole stories to be told and heard;
  • for clinicians to reconnect with their own passion for healing;
  • for the socioeconomic and environmental factors impacting optimal health and healing to be identified;
  • for issues such as abuse to be raised and discussed;
  • and for the clinician and patient (and family) to co-create a care pathway that addresses the root cause of the health challenges and is aligned with patient preferences.

In doing so, we position the patient for compliance, engagement, activation and most importantly, optimal health.

While this message was not ready to be heard in 2010, I was delighted to receive an e-mail recently from a national healthcare leader with a link to the research article “Relationship-centered care: A new paradigm for population health management” and to read the authors’ conclusion:

“As we move toward value-based care, the combination of relationship-centered care and patient-centered care should be considered foundational to healthcare delivery innovation, especially when these kinds of innovations are closely tied to population health management.”

It is not too late for this model to be created; but it is long overdue.

Tom Dahlborg

Tom Dahlborg is a senior healthcare leader with extensive leadership experience building patient & family centered, empathetic, compassionate care models; analyzing and meeting patient and family expectations; optimizing strategic partnerships, ventures and teams; creating competitive advantages and ensuring a solid financial condition of complex healthcare organizations. Follow him on Twitter at @tdahlborg.