The Mystery of Noncompliant Behavior
Nothing in life is ever straightforward. Either a habit of reading medical journals, or a familiarity with live patients, could lead a person to wonder what is going on in this topsy-turvy world. While some people can’t get seen at all about their health problems, and suffer for it, others have excellent access to care, and then mess it up by not following doctors’ orders.
As Dr. Fred Kleinsinger has pointed out, the term “noncompliance” has been abandoned by some, in favor of “nonadherence.” The latter is “less value-laden and does not imply a rigid hierarchical relationship between physician and patient.” In other words, in the minds of some patients, it’s all about a primal emotion: “You’re not the boss of me.”
But resentment toward authority is not the only obstacle to communication. A lot of patients have not had much formal education. They may be struggling with English as their second language, or be native speakers who just do not have very high comprehension of the language or enough native intelligence to “get it.” Many people are prone to be influenced by family members, their own unsatisfactory past experiences with the medical establishment, or the most recent television show they watched.
Patients may feel too intimidated to ask questions when they don’t fully understand what is going on. And with an aging population, Dr. Kleinsinger points out, progressive dementia is sometimes difficult to spot. People have been socialized into certain behaviors that reassure others, when they actually don’t have a clue. They may come from cultures where any hint of disagreement with a doctor is seen as serious disrespect.
The necessity of dealing with all these variables can sometimes turn a clinician into a genius intuitive diagnostician… and sometimes not. Overall,
The greater the discordance between the cultures of the practitioner and of the patient, the greater the opportunity for miscommunication and misunderstanding.
In his paper on noncompliant behavior, Dr. Kleinsinger points out that intellectual ability is not the only potential stumbling block. There is the whole realm of psychology, which he stretches to include “biological, environmental, cultural, and patient-specific factors,” some of which are denial, depression, and severe psychiatric illness. He also mentions that some patients experience material gain from their classification as medically disabled. But this may be a far-from-conscious process, especially when being ill earns extra respect and care from family members.
In addition, there is psycho-social stress. Dr. Kleinsinger writes,
Many of our patients face complex and stressful living situations. Realities such as poverty, long hours working in multiple jobs, difficult parenting problems, or troubled relationships can leave people exhausted, feeling besieged, and simply unable to cope with the added time and energy required to fully manage a chronic illness. Feeling trapped and hopeless destroys that sense of optimism for the future that usually helps motivate good self-care for chronic illness.
Also — and this is a big enough problem to comprise a whole separate category — if any type of addiction is an element of the picture, the problems multiply exponentially. The author says, “Treating the addiction is often prerequisite to treating comorbidities, but the denial that these patients usually have impedes effective medical care.”
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Source: “Understanding Noncompliant Behavior: Definitions and Causes,” NIH.gov, Fall 2003
Image by r. mial bradshaw/CC BY 2.0