Resource Center:

“Meshing patient and physician goals”
Strategic Medicine, January 1998

For most physicians, it is frustrating when patients do not follow our recommendations and instructions. We expect compliance, even though there is clear evidence from clinical studies that we shouldn't.* At the same time, managed care organizations are increasingly focused on empowering their members with information and self-care skills in order to help them become better utilizers of health care resources. And our patients themselves are changing. Today, depending on where we practice, active and informed patients may comprise the majority of our patients. This article is written to offer physicians an approach based on adherence rather than compliance as a way to improve patient satisfaction and clinical outcomes.

*The Task Force on Compliance lists compliance rates in the 30-60 percent range for common chronic conditions (1), and it is estimated that only 7 percent of the people with diabetes comply with all the steps considered necessary for good blood glucose control (2).

Compliance Versus Adherence

In this era of the empowered patient, it is time to think about compliance in a different way. Compliance implies an involuntary act of submission to authority, whereas adherence refers to a voluntary act of subscribing to a point of view. The difference is not just semantic; it goes right to the heart of our relationship with our patients. We need to influence our patients to become — or remain — adherents of good self-care. To do this, we need to establish three key conditions in our communication with patients: shared values, shared language, and mutual respect (3).

Listen for the Patient's Values

Doctors and patients look at compliance through very different lenses. While doctors value compliance, and take it to be a necessary factor in treatment, patients value convenience, money, cultural beliefs, habits, body image...any number of factors that may take precedence over treatment plans. "What physicians call 'noncompliance' may be a patient's expression of disagreement about treatment goals; in this sense, the patient always has the last word," writes patient-centered care advocate Moira Stewart (4). Robert M. Anderson, co-developer of the patient empowerment approach, views noncompliance as "a health care professional's term for disobedience," likening the doctor-patient relationship to that of the parent and child (5). Our expectation that the patient will "surrender" to the medical model is a central problem with the way we think about compliance, because patients are often unwilling or unable to comply with our instructions (6).

Contemporary theories of health communication no longer view the patient as a generic, rational receiver of care and information, but rather as a complex individual who constructs very personal and unique meanings about health and disease. Health communications researchers argue that we need to trust what our patients are telling us — that patients themselves are generally the best source of information about attitudes, beliefs, and lifestyle issues that affect their acceptance of medical treatments (7). Listening for your patients' meanings and values becomes the starting point for gaining your patients' adherence. Working with your patients to reach agreement on a treatment plan that makes sense in the context of their lives will facilitate their adherence to self-management when they leave your office and resume their day-to-day lives. (See Table 1).

Two contemporary models of medical care, patient-centered care, and the patient empowerment model, are founded upon this new view of the patient-provider relationship, in which doctor and patient each brings his own expertise to the medical encounter, and each respects the ideas of the other (4,5,8,9). The doctor remains a source of knowledge, but his or her role becomes more like that of a coach, teacher, or mentor. The patient visits the doctor to access technical resources, medical expertise, and psychosocial support, but maintains the responsibility for managing his or her illness. Compliance becomes less an issue of obedience and more an issue of setting and working toward realistic and relevant goals.

Table 1. Three Steps For Negotiating a Treatment Plan

1. Describe your definition of the problem, the management goals, and the potential roles for yourself and the patient in the ensuing care
2. Give the patient an opportunity, prompting her if necessary, to state her treatment goals, and to raise questions, concerns, or issues.
3. Together, discuss these questions, concerns, and issues, and agree on the problem definition or management goal being discussed. If you and the patient do not agree, be flexible and help to find common ground.

*Adapted from Stewart et al., p. 66 (4)

Speak the Language of Feelings

Medical ethicist Arthur Frank describes the process of a patient seeking care from a doctor as one of "agreeing to tell her story in medical terms" (10). This points out the importance of actively listening to the patient's experiences and using them as the starting point for gaining adherence. Before calling on the doctor for assistance, the patient has already developed her own meanings about the illness and how it is impacting her functions ("I can't have children."), perception of self ("I'm not a whole person anymore."), and the context of her life ("This is how my father began to go downhill.") (11). As you actively listen to the patient's account, ask questions to clarify details and improve your understanding of what it is that brings her to the office at this particular time. Asking an open-ended question such as "Can you help me understand what you hope I might do for you today?" can elicit the patient's concerns, fears, and expectations for the visit (4). This question gives your patient an opening to tell her story in her own language.

Using the patients' own words and language whenever possible has been shown to significantly increase patient satisfaction with the medical visit (12). Satisfaction is also increased by avoiding biomedical talk and emphasizing talk about feelings. In studying the relationship of the physician's interview style with the satisfaction of adult patients with chronic illness, researchers found that patients were less satisfied when doctors asked questions about biomedical topics and more satisfied when doctors asked about psychosocial topics (13). Patients were also more satisfied when they themselves talked about their feelings and relationships, rather than biomedical topics. These findings suggest that affective language, the language of feelings, might be the shared language through which physicians and patients can build understanding and find common ground.

Using affective language in the physician-patient encounter has also been shown to improve clinical outcomes. In a controlled trial, three factors were related to significant improvements in outcomes in patients with a variety of disease states (ulcer disease, hypertension, diabetes, and breast cancer). These factors included more patient control; more affect, particularly negative emotions expressed by both physician and patient; and more information provided by the physician in response to patient information-seeking (14). Regarding the observation that negative emotions displayed by physicians had a positive effect on patient outcomes, the authors speculate that patients may have interpreted physicians' expressions of frustration with their noncompliant behaviors as a sign of caring (14). These data suggest that patients benefit through increased satisfaction and improved outcomes when they and their doctors have an opportunity to talk about their feelings, both positive and negative.

A focus on the shared language of feelings is one of the key elements of the patient empowerment model of care (5,15). Patient empowerment is based on adherence, not compliance. Empowerment programs are designed to help the patient become an informed decision maker and to shift the responsibility for managing disease from the doctor to the patient. In empowerment training, patients develop self-awareness in the psychosocial aspects of self-care, including goal-setting, problem solving, stress management, coping, social support, and motivation. They also develop expertise about their illness by attending comprehensive disease state education programs. During medical visits, the health care provider asks a series of questions to guide patients in setting their own goals, establishing steps they can take, and identifying their own barriers to self-care. (See Table 2.)

In a controlled trial in patients with diabetes, the empowerment approach was found to result in significant improvements in patients' perceptions of their ability to provide effective self-care, their attitudes toward living with diabetes, and their metabolic control (15). The authors of this study caution, however, that the subjects in this study tended to be highly autonomous decision makers in their diabetes care, and that the empowerment approach may be most beneficial for patients who desire a high level of control in their own medical decision making (15).

• What part of living with [chronic illness] do you find most difficult or unsatisfying?
• How does that [the situation described above] make you feel?
• How would this situation have to change for you to feel better about it?
• How important is it to you for this situation to change?
• Are you willing to take action to improve the situation for yourself?
• What are some steps that you could take to bring you closer to where you want to be?
• Is there one thing you will do when you leave here to improve things for yourself?

  *Adapted from Eastman, Diabetes Interview, September 1997 (16)

Respect Patients' Expertise About Their Own Lives

"Physicians can learn to be experts in diabetes management, but only patients can be experts in the conduct of their own lives."

--- Robert M. Anderson (5)

Mutual respect is the third extremely important factor in the medical communications equation. Given the traditional role definitions of doctors as authorities and patients as passive recipients of care, it can be difficult for physicians to cultivate respect for the "life" expertise that patients contribute to the medical transaction. Asking about patients' preferences for involvement in clinical decision making and incorporating these preferences into the agenda for the visit is one of the key aspects of cultivating respect for your patients.

Today's patients vary considerably in their desire to participate in clinical decision making, but they all have particular expertise to bring to the medical transaction. At one end of the spectrum are the patients who prefer little or no involvement in the clinical dialogue. These patients, who tend to be older, sicker, and more satisfied with traditional medical care, have learned to view the doctor as the expert who prescribes the treatment plan with which they will comply as they are able or willing. Other patients who fall into this category include those from cultures in which it is considered disrespectful to ask questions or raise concerns with an authority figure such as a doctor. Such patients will be reluctant to express their concerns, and will need encouragement to bring their expertise about their own lives into the discussion. You may need to use your role as an authority figure to invite these patients to help you, with statements such as the following: "I will do my job better if you tell me what things might prevent you from following this treatment plan. I need to prescribe a treatment plan that works for you" (17).

At the other end of the spectrum are patients who prefer to be actively involved in making decisions about their health care and medical treatment. These patients, who generally are younger and better educated, or who may have been actively self-managing a chronic illness for some years, tend to be less satisfied with their medical care (18). They rely on the wealth of available printed and electronic health literature to inform themselves before they meet with their doctors, search out new doctors, and/or make decisions regarding their own care. Over 11 million Internet users in the United States routinely gather health information from on-line sources such as PubMed, the consumer version of MEDLINE, which recently became available free of charge on the World Wide Web (19). When working with these patients, ask them what other sources they have consulted for information about their condition, and help them make sense of it. Some of this information may be accurate and useful, and some of it may be misleading or just plain wrong. Listen carefully, put the information into context, and correct misimpressions as any good teacher would. And let them know you respect them for taking an active role in their own care.

Given the spectrum of patient preferences and physician styles, mismatches can occur, and mutual respect can be difficult to cultivate. Examples of mismatches in role definitions include: the patient who is seeking a medical authority and the doctor who wants to share medical decision making; the patient who wants a relationship with a parental figure and the doctor who wants to be strictly a biomedical scientist; the physician who wants to get to know her patient as a person and the patient who seeks only technical assistance (4). For doctors and patients to appreciate one another's expertise, it is essential that they clarify their roles and expectations.

How do you know where your next patient falls on the spectrum of participation? If you have a continuing relationship with the patient, you may know from your previous interactions how eager he or she is to participate in decision making and self-care. However, if the patient is new, and you're not sure, then the best approach is to ask. This way, you will understand each patient's expectations for involvement, which will enable you to better tailor your approach.

Gain Your Patients' Adherence and Loyalty

We've learned through experience not to expect patient compliance, and communications theory sheds some light on why a compliance mindset generally doesn't work. By establishing the right conditions for adherence — shared values, shared language, and mutual respect — you can enable your patients to better care for themselves, which is the true goal. The improved patient outcomes and satisfaction to be gained from an adherence approach will be worth the investment in learning to communicate more effectively. And over time, the adherence approach will help you to build stronger relationships with your patients, increasing their loyalty to you and your practice.

The following four suggestions, based on the most recent findings in health communication research, can help you establish the right conditions for adherence in your practice.

• Begin From the Patient's Perspective: Use the patient's story as the starting place. Listen for the patient's meanings, language, and values as he tells the story. Use the patient's language as much as possible. Translate biomedical terms into terms the patient understands.
• Include Feelings in the Discussion: Ask the patient how she feels about the situation. Actively listen, using the patient's terms to reflect on what she is saying. Show the patient you care by expressing your feelings about her progress, problems, etc.
• Base Treatment Goals on the Patient's Values: Ask the patient how much he prefers to participate in medical decision making. Allow the patient to participate to the extent that he is willing. Guide the patient to set goals, establish steps he is willing to take, and identify barriers to self-care based on his own needs and values.
• Support Patient Learning: Ask the patient what other sources he has consulted for information about his condition, and help him make accurate sense of it. Provide or direct the patient to the information he is seeking.

The following open-ended questions, developed by the Bayer Institute for Health Care Communications, can help you gain your patient's adherence under various circumstances (11,20).

To clarify the patient's expectations and meanings:
"What were you hoping I would be able to do for you today?"

"You have quite a bit of experience with doctors, what works best for you?"

"Why did you come to see me at this time?"

To clarify what you need from the patient:
"I'd like to be your doctor and to help you with this problem/condition. For me to be effective, though, I'm going to need your help. Would you be willing to [        ]?"

To acknowledge differences in values or points of view:
"I find it difficult to proceed knowing that you have a different view of the situation than I do."

"I'm wondering if we are working together as well as we might be able to."

To encourage problem-solving:
"I want to solve this problem we seem to be having. My thoughts about the situation are [        ]. What are your thoughts?"

"Is there something that I can do at this point to help us work together more effectively?"

To express empathy:
"That must be very difficult for you. I'm sorry."

To acknowledge the patient's difficulty:
"This appears to be difficult for you to talk about. Is there some way I can make it easier?"

"I understand that you are scared at the thought of surgery. Let's talk more about it."

To agree on a diagnosis:
"I've arrived at one explanation of what the difficulty is. [Provide the explanation.] How does that fit in with what you have been thinking?"

About the authors: Sheryl Bronkesh, President of The HSM Group; Steven Wood, PhD, former Chairman of The HSM Group (Scottsdale, AZ); and Zachary Gerbarg, President of Gerbarg and Associates, Inc. (Clayton, MO), are authors of the new book, Improving Patient Satisfaction Now: How To Earn Patient and Payer Loyalty, available from Aspen Publishers, Gaithersburg, MD. Dr. Wood is also a professor emeritus of marketing at Arizona State University.

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