Hocus Pocus: Perspective on Noncompliance

When we don’t understand behavior it is easy to oversimplify, easy to apply a label and a set of beliefs in relation to the actions. Just as we assess physical symptoms, we assess compliance and we place a value on it. Compliant patients are “good patients” and though we may not want to identify a noncompliant patient as “bad,” there is often a negative connotation. And the negative connotation is often projected onto the patient. This is especially true if the health care provider feels that the proper education and information have been conveyed. The patient’s failure to comply isn’t because they don’t know, after all multiple providers have emphasized the importance of the treatment or medication. It’s the refusal to do what we recommend, which is “wrong.”

What causes an otherwise reasonable person to reject medical advice? Certainly each situation is unique, but there is often a common theme, which is that the patient rejects the premise. Do we take the time to dig into that reason? Do we take noncompliance personally? I can only speak for myself in my practice ― sometimes I do. Especially when I feel confident, even proud, of the instruction and education I have provided. When a patient rejects my instructions I find myself feeling responsible or disappointed. Indeed, there are times when other health care providers will ask us as nurses “Why didn’t he/she take their medication?” As if we are complicit in the refusal.

How does all of this relate to the the provenance of the phrase hocus pocus? Maybe there is a little magical thinking when it comes to addressing noncompliance. Perhaps, we think, repeating the same instructions again and again will lead a patient to comply. Or the other magical thought, I will be the one to say just the right thing, use just the right words and convince them to follow instructions. Hocus pocus. We use our skills and experience when providing the knowledge basis for treatment to patients. We give statistics, rationale, even strategies. That is the knowing part. But the other part of the equation is the understanding part. Putting the information into context. We can work toward that by asking for clarification. “Tell me what you understand about this treatment.” or “Help me understand your reluctance to take the medication as prescribed.” And wait.

One patient I was working with recently had a clear understanding of why a certain medication regimen to manage his symptoms was prescribed. He could tell me back what I had said. There was no confusion on his part. My attempts to convince him to take the medication were repeatedly ignored. I could not figure out why and neither could his wife or others involved in his care. Ultimately I learned that part of this patient’s noncompliance was fatigue, physical as well as pill fatigue. He just didn’t want to follow any more instructions. Being able to control this one little aspect of his life was more valuable than complying with anything we had to offer him. There is a similarity between noncompliance and the designation of a patient as being “in denial.” But both denial and noncompliance are not end points, they are starting points. They are a place to inquire, a time to expand communication in a nonjudgmental way. An opportunity to provide clarification but also a place to advocate for a patients autonomy. It isn’t easy when we know that the treatment offered will benefit the patient and we cannot get them to endorse it. It is hard to back away and allow for that. But it is as important to keep the lines of communication open, which may be one of the ways to convert noncompliance to compliance. Or a way to find our own footing in a complex dynamic.