Communication tips for dealing with non-adherent patients

Around 125,000 people die per year in the U.S. due to failure to properly take medication, and 50 to 60 percent of those taking medications for chronic disease don’t take them as prescribed, according to the National Council on Patient Information and Education. 

Convincing patients to improve their health requires a mindset shift and changing from a transactional relationship to a partnership. 

“They have a need, and you have a need,” says Ellen L. Singer, MD, an internist with Northwest Permanente in Portland, Ore. The key, Singer says, is drawing out the patient’s story. Some of her best techniques were learned through an improv coach, including how to move the story along and connecting with a patient to keep the door open, instead of closing it.

Recognize non-adherence

Recognizing non-adherence is the first step in helping the patient stick with a plan. If noting that a patient’s blood pressure isn’t getting better, the physician should ask an open-ended question like “how is everything going with your medications?” instead of a closed-ended one with a yes or no answer, like “have you taken the medication?” 

The patient is more likely to answer a closed-ended question untruthfully, not wanting to disappoint the doctor, says Douglas Drossman, MD, an internist and gastroenterologist and president of the Drossman Center for the Education and Practice of Biopsychosocial Care in Durham, N.C.  

If a patient says they have not taken their medication, Drossman would avoid making a judgmental response, like “why not?” Instead he would tell the patient that sometimes there are challenges to taking a medication, and asking what the patient sees as pros and cons of taking it. The physician can then help address the reasons why the patient didn’t take it.

Some patients are averse to pills because they remind them they have a medical condition, they’re a nuisance to take, or they’re too expensive, says Wayne Weston, MD, a board member of the Institute for Healthcare Communication and co-author of Patient-Centered Medicine: Transforming the Clinical Method. He may ask a patient, “what do you think about taking medications for the rest of your life?” It’s a big change for patients who had a heart attack and need four different pills daily, for example. 

Whether accurate or not, patients have their own health explanatory models, where their understanding of their illness or condition is influenced by prior experiences, social or cultural contexts, and this helps them make decisions. If they believe a medication is harming them, they won’t take it.

If a hypertension medication causes erectile dysfunction, they may not take it. They may view it as treating one condition that doesn’t cause pain, but negatively impacting another part of life. Asking an open-ended question lets patients share their reasoning, allowing the doctor to find a different medication or approach, or challenge their view.

A non-judgmental approach that aims to listen to what the patient says can help make the patient feel more comfortable sharing, and not feel they have to please their doctor with the answer.

Offering medical advice without getting the patient’s permission, however, isn’t advisable, says Auguste Fortin, MD, MPH, a New Haven, Conn. internist and past president of the Academy of Communication in Healthcare. Asking permission empowers patients and puts them in the driver’s seat, he says, allowing them to feel in charge. By granting permission, a patient is more open to receiving the information. 

This has an added benefit to doctors, who may feel exhausted trying to get patients on the right path. Fortin recommends that doctors think of themselves as coaches or advisers, offering suggestions and encouragement. “It’s up to the patient, not us, to do the work,” he says. “Sometimes we hold ourselves to a higher position than we should.”

Move the needle

Weston recommends focusing on three things for a successful patient interview during a visit: what the doctor thinks the problem is, what the patient thinks the problem is, and each of their goals. The problems and goals may not be the same, he says. The doctor may realize that the patient’s problem is not going away, so the patient should find a way to comfortably live with it. Ultimately, if the patient doesn’t feel heard, they may not follow the doctor’s suggestions.

A patient will feel heard if the doctor uses reflective listening, reflecting back what the patient said and asking to hear more about it. Showing empathy-sharing the patient’s concerns-is next. 

“The patient needs to know that you really do understand what it’s like for them and that you care for them, even if you totally disagree with them,” Weston says.

Using motivational interviewing techniques, the physician can elicit what would encourage the patient to stick to a plan. Motivational interviewing helps encourage people to make positive adjustments by asking nonjudgmental questions to draw out a person’s reasons for wanting for to change. 

“The patient may be motivated by wanting to fit into a dress, or wanting to look good at the beach,” Fortin says, rather than being motivated by their hemoglobin A1C level. He’ll say to the patient: “that sounds like a good reason to make some changes. What might you be able to do?”

Even if he thinks their proposed changes are inadequate, Fortin supports them fully. “If they’re successful with that, they may want to do something else,” he says. He helps them set a SMART (specific, measurable, actionable, relevant, and time-limited) goal, asking them about contingency plans and when they want to start. 

He also asks how confident they are on a scale from one to 10 that they can carry out the plan. Instead of trying to get them to a higher number, he asks why that number so high and what makes them feel they can make the change. Research shows that if they get to seven or higher, their likelihood of making the change increases, he says.

If they’re under seven, he may ask what it would take for them to increase their confidence level. In addition, he asks how important the patient feels it is to make this change, using the same scale and the same follow-up questions about their choice.

After discussing the patient’s proposed plan and how they’ll deal with contingencies, he asks them to repeat back the plan. “When you say something out loud, you’re much more likely to do it,” Fortin says.

Tailor the discussion

Recognizing where the patient is in their journey is important, too. Patients will only make a change if they’re at the right stage, says Weston. The four stages include pre-contemplation, contemplation, action, and maintenance and identification. In pre-contemplation, the patient hasn’t thought about changing, or decided not to. 

The next is contemplation; the patient thinks it’s a good idea, but recognizes the difficulty. “People can stay in that ambivalent stage for years,” Weston says. In the action stage, the patient develops a plan and begins, though they are vulnerable to slipping back. Next is maintenance and identification, where a patient identifies with the  change. If they stopped smoking, they identify as a nonsmoker, for example.

“It’s important to tailor what you do to the stage,” Weston says. If they’re in the pre-contemplation stage, there’s no point in sharing strategies to quit smoking. Instead you can explain why you’re concerned.

The contemplation stage is the best time to develop strategies. Assessing confidence and interest are good strategies at this point, using the techniques of having the person rate his or her confidence and interest on a scale of one to 10. If a person is confident he or she could quit smoking but doesn’t want to, the discussion could focus on why it’s important.

Working with complex patients

Sometimes a person doesn’t adhere to treatment because the problem is overwhelming. 

If someone with diabetes has out-of-control blood sugar and lipids, Singer may let the patient choose their biggest concern, or she’ll suggest just one change. She might say, “I’d like to think about starting you on a statin. Are you okay talking about that, or do you want to wait two weeks?” A patient may shut down and not be able to process a lot of information at one office visit.

Singer helps the patient understand the risks in not taking care of themselves. “With diabetes, I’ll say, ‘When your blood sugar is high, you’ll be tired, and your body is inflamed. These are strategies to make you feel better,’” Singer says. 

She tells them if they take their pills once a day and are willing to exercise, they’ll feel better in 4-6 weeks. She may suggest a follow-up visit or phone call. “I don’t care about the interval-I’ll let them have some control about the time,” Singer says.

Another approach is: “I’ve seen people in your condition and they’ve really struggled with this. Then something bad happens like a stroke, and they find a new way of doing things. I’d love to prevent that,” Singer says, and then asks if they think they could commit to a specified plan of action. 

Another negative technique is to try and frighten the patient into changing, by saying “if you don’t stop smoking, you’ll die of lung cancer,” or “your kids will get asthma and it will be all your fault,” Weston says. 

Learning new communication skills isn’t easy. “There’s a sense that I should know how to do this,” Singer says. Organizations like the Foundation for Medical Excellence, the Institute for Healthcare Communication and the Academy of Communication in Healthcare offer courses in communication.