Patient, Treat Thyself: Part I

Non-compliance. Non-adherence. Call it what you will, but it is an interesting conundrum that we face on a regular basis in health and health care. Here is a common example. A clinician sees a patient with mechanical low back pain which responds favorably to exercise and postural correction. Better yet, they experience a cause-and-effect relationship between symptoms and activity on their first visit. It all makes sense to the patient, and they leave with a sense of comfort and control. They now have the tools to solve the problem. Life is good, or so it seems.

So when the same patient returns for their second visit and says, “My back still hurts. I haven’t done the exercises, nor any of the stuff you suggested”, imagine the consternation of the clinician. The answers are all there, right in front of the patient. Why do they choose to not act upon them?

In many cases, a patient can be provided with all of the tools to solve their own problem. It could be the self-management of back pain – or diabetes, or obesity, or any one of countless acute and chronic medical complaints. It extends to the world of fitness as well with the development and self-management of an effective training program.

But there will be some that will still choose not to do so, even with all the tools within their grasp. It is admittedly one of the strangest moments in a day at the clinic, and it always begs the question: why wouldn’t a patient choose to implement solutions?

One piece of this equation is self-perception and self-efficacy.

Patients make the best decisions available to them given the context and environment in which they operate. They don’t choose to make bad decisions – they make decisions that are appropriate given their personal map of reality. If a patient perceives themselves as having high self-efficacy, then they will tend to implement the tools available because it is within their comfort zone to do so. Their behaviors are consistent with their self image. But if a patient perceives themselves as having low self-efficacy, then they will likely believe that even with all the right tools, they still don’t have the capacity to solve their own problem and need to be fixed by someone else. Again, their behaviors are consistent with their self image.

Unfortunately, the latter example falls into the anxiously-awaiting arms of plenty of clinicians who will gladly “fix” them. They will put some magical device on them, rub them this way and that way, or perhaps the worst of all, tell the patient that they are just going to have to live with it and the interminable treatments that will invariably go along with it.

Self-management involves making a series of choices. But these choices aren’t necessarily based on evidence or cause-and-effect, though as clinicians we would like to believe so. The decision may in fact come down to the patient’s self perception. If their self image screams “nope, can’t do it”, they will return on day two (and three, and four, and beyond) with the same answer. They will be the “non-compliant” or “non-adherent” patient. They will probably continue to shop for a clinician that will “do” something to them, thereby absolving them of self responsibility in their self management.

As clinicians, we need to ask ourselves some difficult questions. Are we doing a good enough job of focusing the responsibility on the patient? Are we creating a learning environment in which the patient can experience and understand the cause-and-effect relationship between symptoms and function, while allowing the patient to establish a value-added benefit to self-management?

Or will we just give the patient another label – “the non-compliant, problem patient” - that reinforces their low self-efficacy even more?

Another piece of the equation is the passive nature of the health care system itself, which I will explore in Part II.

Photo credits: DieselDemon