The Non-Compliant Patient

What is the role of the pelvic rehabilitation provider when a patient fails to follow-through on your recommendations? This issue is addressed in the medical literature, particularly for compliance with medications or medical office follow-up appointments, and it is in the medical literature where we can find a very useful articleabout the subject. Dr. Kleinsinger, MD, writes from a clinically practical point of view, and his suggestions for dialog and re-framing a patient's compliance issues can be put into use immediately. You can access the full article here.

The term "non-compliance" has been previously criticized as sounding judgmental towards a patient who is not following orders from a physician. The term "non-adherence" has been suggested as an alternative and is one that you may see in the research as well. Dr. Kleinsinger states that "non-compliance" can be utilized as long as the patient's plan of care involves both the provider and the patient in decision-making. In pelvic rehabilitation, we may not be dealing with life-threatening issues such as a patient not taking cardiac medications, however, we are required to utilize a patient's rehabilitation resources wisely and to continuously assess the response that our treatment has on the patient's health. This is challenging when a patient chooses not to complete self-care, avoid injurious activities, or take part in an instructed home program.

The suggestions in this article are directed primarily towards medication compliance, yet the principles of communication and shared decision-making can be immediately applied to the rehab clinic as well. Dr. Kleinsinger states that trust is paramount in encouraging compliance, and the clinician must recognize the power differential between the patient and the provider. Following are some guidelines adapted from the article:

1. Pose your questions in a non-judmental manner and with a problem-solving approach. Example: "I see that you have not been completing your exercises properly. Are you having difficulty with the written program I gave you?"

2. Ensure that there is a common understanding regarding the importance of the problem, the available and effective treatments, and the risks of under-treating the condition. Example: "If your body is not moved in these first weeks after surgery, you may develop a significant loss of motion that can be very painful to recover. Do you have concerns or questions for me about your treatment?"

3. Develop a shared understanding that compliance is critical to improvement.Example: "It seems that what we are trying is not working for you, and we both want you to benefit from rehabilitation. What do you think will be more helpful?"

4. Build a more effective therapeutic partnership with your patient by being open, non-accusatory, and focused on problem-solving. Example: "What could I do differently to help you? What obstacles are we facing? How could we tackle this more effectively?"

Dr. Kleinsinger offers further, useful suggestions towards effective communication, such as using physical mirroring, using "I" statements, and reinforcing that the patient can take positive action towards health. Choosing one issue at a time or asking family or friends to help out can also be meaningful for the patient. This article offers further approaches to specific causes of non-compliant behavior that you might find beneficial for your practice. Perhaps this article could be a simple tool (for a complex problem) to share with colleagues at a meeting or inservice. The author includes a checklist of tools for working with a non-compliant patient that may also be of use. He emphasizes the importance of using non-judgmental, open language when establishing a trusting relationship with the patient. It is difficult to "listen" to ourselves when we dialog with patients, yet if you can pause to think about how you are framing your discussions, it may be helpful for maximizing patient compliance. Another strategy that I have found useful is to seek out those around you who are very effective at carrying out the behaviors described in this article and modeling those behaviors. If we based our need for improved communication on all the available relationship self-help books, we can be assured that maximizing our use of communication in the clinic and in our personal lives is something that we will be refining for years to come.