Compliance versus success

During a recent Quality Initiative meeting at our medical center, concern was voiced that non-compliant patients make it hard for our individual providers and the institution as a whole to achieve our QI goals.

This is undeniably true: those patients who take their medication and exercise will generally have better controlled blood pressures, diabetes and lipids than those who do not.  However, I found the concept and conversation more than a little troubling. “What happened,” I asked “to the patient-centered piece of our mission statement?” The expressions on the faces around the table said more clearly than any words: Hunh?

I pointed out that we had been talking exclusively about OUR needs, namely, to show improvement in metrics like the A1c (which reflects average blood sugars over the previous 3 months). I suggested that we might see better results if we included patients as partners in our quality work, helping us from day one with goal setting and project planning, not just as bit players to be manipulated to improve our scores. Perhaps the mediocre improvement we were seeing was because the patients didn’t share our perspective? Or perhaps they did, but there were other things going on in their lives about which we knew nothing? 

The objections were sadly predictable: it would be too cumbersome to include patients, the data is too sensitive, we’re stuck with the targets anyway, scientific and evidence-based targets take precedence over subjective patient preferences.

Predictable - but irrelevant. If the issue is compliance (a paternalistic term I find objectionable and incompatible with my approach to clinical medicine), it would pay to bear in mind a basic behavioral concept: people are most ‘compliant’ with plans they are invested in because the plans are aligned with their personal goals and because they participated in the formulation of the plans. Until we are engaged in a collaborative quality improvement effort with our patients, it will always be a case of our attempting to coerce them into helping us achieve our goals. And we will fail.