“Non-compliance” is a word Dr. Sara Taylor commonly encountered during her medical training in the late 1990s.
It was a term doctors used when patients didn’t follow orders, like when patients stopped taking medication because they couldn’t tolerate the side effects, or failed to adhere to their prescribed diet, or did not quit smoking.
These days, Taylor, a family physician in Red Deer, Alta., says she rarely hears the term because it has become as passé as the paternalistic approach to medicine from which it emerged.
The patient-doctor relationship has changed profoundly over the past two decades. Patients are no longer expected to unquestioningly follow doctors’ orders. Instead, a model of patient-centered care has become the norm, where patients take a leading role in decisions about their health.
This new approach, based on mutual respect and two-way communication, isn’t just about being friendly. It can benefit patients’ health. Long assumed, but difficult to prove, a review and meta-analysis by researchers from Massachusetts General Hospital and Harvard Medical School, published in 2014 in the journal PLOS One, found the patient-doctor relationship has a small, but significant effect on health outcomes. The findings suggest trust, empathy and good communication do have a positive impact on things like weight loss, pain relief and blood pressure.
But putting patients in the driver’s seat has also introduced a new set of unwritten rules for navigating the patient-doctor relationship. Doctors may not chide patients for “non-compliance” any more, but patient co-operation is necessary. As patients become authorities of their own health, they’re also expected to take on more responsibility – to make informed decisions, to stay on top of their prescriptions and to be honest with their physicians.
Dr. Sharon Domb, a family physician in Toronto, emphasizes the majority of patients are very reasonable and her interactions with them are mostly positive, but there are times when patients can be difficult.
“It’s the usual, sort of, 90:10 rule, right? Ninety per cent of your patients cause 10 per cent of the challenges and 10 per cent of your patients cause 90 per cent of your grief,” says Domb, who works at Sunnybrook Health Sciences Centre.
If you’re among that 10 per cent, you may be undermining your relationship with your doctor and sabotaging your own health. Based on interviews with doctors who’ve experienced the gamut of patient encounters, here are remedies for six common patient faux pas.
The Shopping List Patient
Symptoms:
You’ve got more ailments than fingers: an ingrown toenail, a wonky knee, insomnia, back pain, what appears to be an ear infection, heart palpitations. And you’ve saved up all your complaints for one single doctor’s appointment.
“It’s challenging from our end,” Domb says, because when there’s a limited amount of time allotted per appointment, doctors can’t tackle a patient’s list of complaints without creating a serious logjam in their waiting rooms.
“Sometimes,” she adds, “the last issue is chest pain, so the most serious one to us is the last one on their list, but it’s the one we actually need to address.”
Cause:
A misguided attempt at efficiency.
Patients may feel they don’t want to bother their doctor with repeat visits, especially if they have several minor complaints, Domb says. Plus, it can be difficult for busy patients to find time to see their doctors. And sometimes, they may have to wait a long time to get an appointment.
Prescription:
Domb says some doctors set a limit of one issue per visit, though she doesn’t do this herself. She does, however, ask patients for the most important issues they want to address, and then asks them to come back for the rest.
It can be tough for patients to prioritize their health complaints, she acknowledges. But, she says, “If there’s a serious issue like chest pain or shortness of breath, bring it up first, rather than the wart on your foot.”
If you’re worried about troubling your doctor with multiple visits, don’t be. They’d rather see you more frequently than try to cram a year’s worth of health complaints in 15 to 30 minutes.
The Oblivious Patient
Symptoms:
You’re mentally sharp and capable of tackling everything else in your life. But when it comes to matters regarding your health, let’s face it, you’re about as attentive as a goldfish.
The Oblivious Patient doesn’t keep track of their symptoms or medications, offering doctors little or unreliable information to work with. They’re typically the ones scrambling to the pharmacy for a refill only after their prescription has run out. They fail to show up for appointments, which ends up wasting time.
Causes:
Absentmindedness or over-dependence on the health-care provider.
“Some feel the onus is on the health-care team to manage everything for them,” Domb says.
For some patients, keeping track of their health is simply low on their list of priorities. Others may be more accustomed to the old, top-down approach to medical care, deferring to their doctors for all health matters.
Prescription:
Whether you’re an Oblivious Patient or not, Taylor suggests everyone can benefit from keeping a health diary. This can take the form of a daybook, an electronic calendar or even brief notes on your mobile phone. The idea is to jot down details, such as dates and times of day when symptoms arise, the severity of symptoms, a record of doctors’ appointments and information conveyed during the visits, and test results.
A health diary can help you and your doctor find patterns for all kinds of concerns, from migraines to fertility issues to mental illnesses, Taylor says. It can provide valuable clues for identifying specific triggers, and you can look back on your records years later when a problem recurs. Moreover, pain and illness can change your perception of time; a day can feel like weeks when you’re suffering. A health diary can help you keep a more accurate timeline of what’s happening with your health, not just in the days or hours leading up to a doctor’s appointment.
The Reluctant Patient
Symptoms:
Doctors? Who needs ’em? Not you. You’re fit as a fiddle. Healthy as a horse. That pain in your chest? Blurred vision? It’ll pass. At least, you’re hoping it will…
Sure, some patients make unnecessary visits to the hospital emergency department for minor complaints like sore throats and sniffles. But Dr. James Heilman also sees patients at the opposite end of the spectrum: those who ignore their symptoms and delay seeking medical help far longer than they should. Reluctant patients may needlessly prolong their suffering, while a serious condition can become even worse.
Heilman, an emergency room physician in Cranbrook, B.C., and a clinical assistant professor at the University of British Columbia, has seen patients who’ve experienced chest pains for more than half a day before finally agreeing to go to the hospital – and often only at the urging of a concerned spouse.
“They’re like, ‘It’s just indigestion. It’s just indigestion. It’s just indigestion,’” he says. “And when they arrive, [it turns out] they’ve had a massive heart attack. That occurs not that infrequently.”
Cause:
Denial.
In Heilman’s experience, this typically affects men more than women. Women tend to have more contact with the health care system in general, he says. Many men under age 50 rarely see physicians, he explains, while women are more likely to see doctors regularly for birth control, pregnancy and health visits for their children. This lack of exposure may help explain why men can be more reluctant to seek medical help when needed.
But Heilman says many patients simply don’t want to believe a serious health problem could happen to them.
“They don’t want anything to be wrong. So, you know, they hope by ignoring it, it’ll simply go away. Some of it is simply wishful thinking,” Heilman says.
Prescription:
The tricky thing is, barring obvious scenarios like a serious fall or an anaphylactic reaction, it’s often tough to know when to go to the emergency department.
“That’s a difficult judgment call for someone who’s not a medical expert to make,” Heilman says, since people’s risk tolerance and pain thresholds vary.
Educational health campaigns can help patients recognize symptoms, Heilman says, which may make them less likely to ignore serious issues when they occur. Meanwhile, measures like not smoking, exercising regularly and avoiding excessive alcohol consumption can help prevent them from landing in the emergency department in the first place, he adds.
But Heilman says when it comes to handling reluctant patients, emergency-room physicians like himself are usually so busy tackling their underlying medical conditions, there’s not much time or opportunity to address patients’ hesitance to seek help.
Besides, he adds, “If someone comes in with a heart attack, you know, when you inform them of that fact, you don’t normally need to say anything more. … The wife usually says, ‘I told you so,’ and she usually scolds him for you.”
The Misinformed Patient
Symptoms:
Dr. Google can be a blessing and a curse. Many doctors encourage patients to do their own research and inform themselves about their health. But your Internet search can do more harm than good.
The Misinformed Patient may refuse to get vaccines, for instance, after an online search yields frightening unsubstantiated warnings. Or he or she may reject pharmaceutical drugs in favour of natural treatments, with the impression that natural substances are safer.
Cause:
Unreliable sources.
The perception that pharmaceuticals are fundamentally dangerous and natural remedies are safe is a common one that Domb wishes to dispel. Some of the most potent drugs come from natural sources, she says, noting that digoxin, a drug used to treat heart conditions, and heroin, for example, come from plants.
Pharmaceutical drugs are subject to rigorous testing and regulations, she adds. But the regulatory process for natural health products is far less stringent by comparison.
One reason people may be more inclined to believe pharmaceutical drugs are more dangerous is because they likely hear and read more about their side effects, Domb says. When you get a new prescription filled, for instance, your pharmacist typically presents you with a whole list of potential side effects. But this doesn’t often happen when you buy natural supplements, whether it’s magnesium pills or echinacea. That doesn’t mean side effects for such products don’t exist, Domb says. The bottom line: “Just because something is natural does not mean it’s safe,” she says.
Prescription:
Your doctor’s job isn’t to try to convince you of certain treatments. But he or she does want to make sure you make informed decisions about your health. Even if you decline to get those vaccines or decide quitting smoking isn’t for you, your doctor ideally will respect your choices; the aim is for you to keep coming back. (Although please don’t get huffy if they warn you about the potential risks.)
When it comes to doing your own health research, be skeptical, Heilman says.
“Any source of information can contain errors. Some of them are directly trying to mislead you,” he says, while some errors simply happen unintentionally.
To help correct flawed information, Heilman is involved in Wiki Project Med Foundation, an initiative to share and maintain accurate health material on Wikipedia.
He suggests a good rule of thumb before making important medical decisions is to look up multiple reliable resources, such as Cochrane (cochrane.org), which is a global health network, the World Health Organization (who.int/en), the U.S. National Institutes of Health (nih.gov/health-information) and the Centers for Disease Control and Prevention (cdc.gov/diseasesconditions), just to name a few.
The Overly Screened Patient
Symptoms:
When it comes to your health, you don’t want to hold back. You’d like your doctor to order the full gamut of tests available – blood tests, CT scans, MRIs, mammograms. The trouble is, these tests are not always warranted.
“Sometimes when patients push for stuff, they find things that ultimately improve their health,” Heilman says. “But other times, patients end up getting care that they do not need, which costs our health-care system money and not infrequently ends up harming themselves.”
Cause:
A misguided attempt to be thorough.
Certain private clinics offer comprehensive screening as a head-to-toe health check. But Heilman warns, if you undergo a battery of tests, chances are you’ll receive some abnormal results because “people have, you know, little discrepancies between one person or another.”
They’re known as “incidentalomas,” he says, asymptomatic bumps and lumps that are discovered incidentally.
If an unnecessary full-body MRI finds a nodule in your lungs, for instance, “the question is, what do we do next?” Further investigation by doing a biopsy could put you at risk of pneumothorax, also known as a collapsed lung, or a post-operative infection. But not doing anything can fuel your worries about what that nodule might mean.
Our medical system is designed to address specific problems that patients present to their doctors, rather than casting a wide net to pick up potential health issues, Heilman says. “Those are two very different situations,” he says, noting the benefit of ordering a mammogram for a patient who has found a lump in her breast is quite different from screening individuals with mammograms as a matter of course.
Prescription:
The first step is to try to figure out why a patient is requesting a particular test, Heilman says. Then, he says, he typically has a discussion with the patient about the potential risks and benefits.
If it’s a relatively harmless test, “it’s often easier for the physician to go ahead and do the test,” he says. But trying to dissuade someone from doing a potentially risky test can be challenging.
“You don’t want to harm the person by doing unnecessary tests, but you also don’t want to send the patient home unhappy and have them simply drive down the road to another doctor to try the whole thing again,” Heilman says.
Occasionally, patients submit complaints against their physicians, if they don’t get the tests they want, he adds. “From a physician point of view, the hard thing is to refuse to do a test to the patient who’s requesting it. The easy thing to do and the fastest thing to do is to give in.”
The Not-Entirely-Honest Patient
Symptoms:
Maybe you’re a closet smoker. Maybe you have mental-health issues you don’t wish to reveal. Maybe you use drugs surreptitiously. Or you’re having extramarital sex. We all have secrets. But if you lie or withhold information from your physician, you could put your health at risk.
Dr. Zachary Levine, an emergency physician and assistant professor at McGill University, says doctors can struggle to make an accurate diagnosis if patients aren’t honest with them.
Your doctor could also prescribe medication that has serious interactions with other drugs they don’t know you’re taking. And if you have an undetected infection that needs treating, you could wind up spreading the disease, Levine says.
“Doctors go with whatever evidence we have,” he says.
Cause:
Fear or embarrassment.
In general, people are most reluctant to be open about things when they’re worried they’ll be judged for it, Levine says.
Some patients are hesitant to bring up issues about their sexual health or discuss infidelity when they share the same doctor as their parents or spouses, he adds. Others may simply fail to see how the information they’re withholding could be relevant to the purpose of their doctor’s visit.
But, he emphasizes, the more honest patients and doctors are with each other, the better they’re able to tackle health issues together. This includes encouraging patients to speak up if they don’t feel they have enough time with their doctor, if they don’t feel comfortable taking certain medications, or need more explanation about what a diagnosis means.
Prescription:
Setting the stage for an open discussion is a doctor’s responsibility. And a good doctor will ideally convey to patients that they aren’t judging them, Levine says.
If you raise concerns about your care, and you doctor doesn’t want to hear them, “well then, maybe you’re not seeing the right doctor.”
For patients, maintaining an honest relationship involves “a leap of faith,” he says. Patients should know anything they say to their doctors, with life-threatening exceptions, is confidential by law. They should also assume that they share the same goal as their doctor: to maintain or improve their health.
“You shouldn’t be adversaries,” Levine says. “You should be working together.”