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I sat in the exam room with Bill, who was here for HIV treatment. Staying on medication was important. It would make HIV undetectable in his blood, reverse his immune system damage and prevent the development of resistance to medications.

“In the past month, how many doses have you missed?”

He met my gaze. “None. I take them every day.”

Bill’s labs said otherwise. His virus level remained high. His pharmacy said he hadn’t picked up his medication in two months.

I showed Bill his lab tests, then told him about the pharmacy call.

Bill sounded indignant. “They must have forgotten to write it down! I’ve picked them up every month.” I reiterated why taking his medication was important. We scheduled repeat labs and another appointment.

This happened all too often with my patients. Their excuses varied. “I had some extra in my closet.” “My friend gave me his when his medication got changed.” “The pharmacy must have given me extra pills.” These "non-compliant" patients remained my most challenging, and I struggled with how to improve their treatment.

It finally dawned on me. When starting treatment, I stressed the importance of taking “every dose, every time.” My patients knew it was important to take their medications, so if I asked about missing doses, they told me what they thought I wanted to hear. When I confronted them with contradictory information, I was essentially calling them a liar. I had painted them into a corner. They didn’t want to admit they were lying. Instead, they came up with outlandish explanations for how they really did take their pills.

So, I stopped asking about missing doses. Instead, I would say, “Bill, your labs show your virus level is high. I called your pharmacy. They said you haven’t picked up your medication in two months. What’s going on?”

My patients started to tell me about side effects, troubles affording copays, difficulties remembering pill schedules, and more. Armed with this, I could better tailor treatment for each patient.

It’s easy to label our patients "non-compliant," or to add ever more medications to their list. If we open a door for conversation with our patients, we can begin to understand barriers to care. It is only then that we can best treat chronic disease.

Mimi Emig
San Antonio, Texas

Comments   

# Asif Azeem 2018-10-11 01:06
Mimi epitomizes empathy. A great physician to work with.
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# Emilie Collins 2018-10-08 13:58
Thanks for sharing your experience and expertise Mimi. This is a wonderful essay.
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# M b tupper 2018-10-07 18:55
Excellent essay. The term non compliant is a way to blame the poor, the undereducated, or the intolerant for our own failure to understand "What's going on?" Such a simple question. Thank you, Mimi.
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# Mary 2018-10-07 09:58
Wonderful essay. Absolutely true, noncompliance is not always noncompliance. I had a patient this week in chf with probable nstemi not taking her Lasix or coreg because there was only one bathroom in the house and one of the other folks in the house was also on a diuretic...she thought coreg was a diuretic also....so, because of this, “noncompliance”
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# Mimi Emig 2018-10-07 12:10
Thanks, Mary. Most truly non-compliant patients (ie, those not interested in their health) don't show up for appointments. If they're in our office, we need to figure out what's going on and help them.
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# Tim Daum 2018-10-07 09:08
Sage advice from one of the most insightful physicians I’ve ever had the pleasure of working with!
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