Looking after patients who won't look after themselves
BMJ 2000; 320 doi: https://doi.org/10.1136/sbmj.000217 (Published 01 February 2000) Cite this as: BMJ 2000;320:000217
- Gavin Yamey, editorial registrar1
- 1BMJ
“To write prescriptions is easy, but to come to an understanding of people is hard.”
Franz Kafka, A Country Doctor
There is nothing more frustrating in medicine than caring for “heartsink” patients who ignore all of our medical advice. We watch in horror as they refuse to take their life enhancing medicines and continue to adopt risky practices. Up to one fifth will never take their prescription to the pharmacist,1 up to a half will delay or omit doses,2 and many will never turn up at specialist outpatient clinics.3 Their behaviour contributes to their illness and premature death. It causes us irritation, confusion, sadness, and anger. Are we powerless to change this interaction with patients, or are there ways to break the impasse?
Compliance is now concordance
As doctors, we tend to like those patients who do what they are told. Such patients are “complying” with our advice. But this kind of paternalistic relationship is outdated and unhelpful. The patient's view of the world - based on experience, culture, family history, and personality - may be different from ours. If we see this as an obstacle to be overcome at all costs we will alienate our patients and they will continue to make unhealthy choices. Encounters between doctors and patients entail the bringing together of often conflicting explanatory systems about illness and health, and negotiation is the key to a “successful” outcome.4 We should try to build an honest and open therapeutic alliance with our patients, sharing our own thoughts and beliefs with them, to reach …
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