There are some health professionals who think anyone who went off ADD meds after age 18 is non-compliant. Even if the medical professionals involved in that person’s life would not recommend or, more importantly, prescribe the medication anymore.

EXACTLY. Fears about mortality, and subsequent Fundamental Errors of Attribution.

Diseases are complex issues with often complex, multifaceted causes. It would be so nice and simple if we could just attribute them to immorality and stupidity — our brains would like that so much better, because then we wouldn’t have to grapple with ambiguous, confusing reality. And we could dispense with the inconvenience of compassion altogether.

Unfortunately, reality is a supremely noncompliant patient who doesn’t bow easily to our intellectual or moral preferences.

I just wanted to chime in about a friend in Medical School who is deeply concerned about her peers ability to practice medicine ethically and effectively because of their seemingly deep-seated antagonism toward pretty much any non-perfect patient. The fatties, the smokers, the people who may have merely experimented with drugs at one point, the sexually active, the queer, etc. We often discuss the specific comments/assumptions of her peers and how they pretty much come down to fears about mortality and how we often think “X only happens to ABC people, not me–I’m a good person, I exercise, I’m not a glutton, etc.” She said that the first class in which many of her peers had to recognize that not all illness was a result of individual sin was a genetics class in which several of her peers were REALLY SURPRISED THAT “NOT ALL DISEASES ARE THE PATIENTS FAULT?” Its been kind of scary to learn about her jock-like, asshat med school peers. At least she’s their to influence them–to say, “hey, that’s out of line” when one of them goes on a tirade ab0ut how stupid and ignorant and non-compliant X patients are. These biases they carry around are really impacting their capacity to provide medical care. It’s about the myths we tell ourselves to get to sleep at night, that we and our loved ones are safe from disease because we’re “good” or the Christian Fundie who protests the abortion clinic but sneaks into that same clinic the day her church isn’t protesting because her abortion is deserved, but every other woman’s is a result of being a hussy. Yes, there are frustrating individuals one meets in the course of the professional life–my sister’s a social worker, my mother a teacher, I’m in non-profit; we all have encountered people whose lives would be easier if they X, Y, Z, but where they are today is a matter of a complex interaction of experiences, family life, genetics, location, education, etc. that I can’t fully understand.

Truly one of the great aphorisms of all time.

“First do no harm” is a motto we should all adopt, regardless of our jobs. I like it almost as much as “be excellent to each other”.

Interesting topic.

It is also true that some treatments are totally necessary in order to save a person’s life.

Not all treatments with which people find hard to comply are BAD, per se. They may be effective treatments that are implemented poorly or incompletely with regard to the patient’s actual life circumstances — like telling a very thirsty and uncomfortable renal patient to simply STOP DRINKING when they’re thirsty, without offering any other ways to keep them comfortable, such as treatments for dry mouth. (However, in the case of dieting, I do believe it is a bad treatment, in that it is risky and mostly ineffective.)

These two statements (that we shouldn’t blame patients for noncompliance with treatment, but that many treatments are helpful and necessary) are not irreconcilable — I guess what I’m trying to say is, if a patient is having trouble complying with something that is necessary for survival, then the onus is on the healthcare practitioner to find out WHY, and to help alter the patient’s circumstances in order to make it possible for them to comply. Not to blame the patient for being bad, bad dog and wash one’s hands of them.

Does that make sense?

“In my mind, the onus is on US (as healthcare practitioners) to offer good treatments. If a patient is incapable of complying with that treatment, then, in my opinion, the problem more often lies with the treatment than with the person.”

And later you said:

“Well, unfortunately, in the case of kidney disease, it’s true that the fluid restrictions are there for a reason. And not just to reduce the frequency of dialysis needed, but to help ensure proper electrolyte balance, as well, I believe. The latter consideration can be fatal if not heeded.”

So it seems that you’re saying that we can’t blame the patient for non-compliance, that it’s the fault of the treatments. Then you say that sometimes these treatments are necessary and ignoring them can be fatal.

I do understand what you’re saying about a patient’s life circumstances making it hard for him to take proper care of himself. But how can you say that a treatment is bad, so lets not blame the patient for non-compliance? As I’m sure you know, medical science isn’t perfect. We do the best with what we’ve got, and if there’s a proven, effective treatment that many patients DO manage to stick with, how can you blame the treatment?

I’m not trying to be rude or obstinate; I hope you can see why I’m having a problem reconciling your 2 statements. Thanks.

Doctors are always handing out, recommending, and administering weight loss diets that either don’t work or don’t work permanently, and that sometimes do harm. For example, low calorie diets can cause kidney stones and (of course) all the symptoms of starvation. When they hand us these diets, they say things like “if you don’t lose 50 pounds, you’ll have diabetes within five years.” The first time this happens, the patient may go on the diet, lose 50 pounds, gain it back again, and not get diabetes. After a few times, no significant weight loss occurs. Still no health problems. Finally, 5, 10, or 15 years later, the patient says “screw it” and doesn’t try the diet. Once again, no diabetes, no weight loss, and the patient has learned that the doctor is full of shit. If the patient is forgiving, then he or she may still trust the doctor on non-dietary matters, but there’s no doubt that the doctor has lost some credibility.

Because of this, a large percentage of people have probably come to view the dietary advice they’re given by doctors as bullshit, or at best, optional.

I didn’t think about this until now, but the medical provider probably considers being fat alone as non compliant.

I do realize that the US healthcare system (I’m assuming the MetaFilter commenter is American) is set up in such a way as to penalize doctors and healthcare workers for spending a lot of time with patients, but “helping” implies some degree of collaboration and being supportive. Ordering people around and then writing them off for not doing exactly what you say is working from the ego, not the heart.

Some of what you said seems to be just a slightly different perspective but parallel to what I was trying to say, I think. I’m not so sure that you are advocating a perspective that is incompatible with what I was saying…just an ideal versus what I perceive is the reality of what people in healthcare deal with. Correct me if I’m wrong.

While what you’re outlining would be ideal, I think the reality is what you already acknowledged. The pressures of limited resources. Doctors…medical staff…are people, and people probably don’t see their lives dedicated to just being defined by that career choice, and if they don’t think that what they do will make a difference how do you compel doctors and staff to put 100% into every patient that walks through the door? The effect is what we see. Staff prioritizing their efforts on patients that give the impression that they will follow through with the instruction while writing off the ones they think are going to just waltz off and do what they want to do.

It’s just not practical for them to do the extra paperwork and effort of following up with everything else they have to do if they are pretty sure the patient is just going to nod and walk away while continuing to ignore them.

It would be wonderful if we could have the system you outlined. I just think that medical staff feel they have enough paperwork and workload that it’s not practical to do that and most hospitals are understaffed for what you’re describing.

I also don’t know how many people would have the energy or devotion to the field to give the kind of compassion for everyone that comes in through the doors. The doctor that originally referred me to the bariatric office…I think I blogged about how I went into his office, sat down, he rattled off the checklist of comorbids I was experiencing, then immediately said I’d need surgery before shuffling me out of his office (I think it took about six minutes from going in to leaving)…was recently told that I had gone through with the surgery by a relative of mine that was having a followup with that doctor. He seemed surprised that I had followed his instructions all those months ago! I felt as if I was another patient herded in to see him and probably just another anonymous face that he’d tell what his advice was before leaving and not coming back to see him again; I can understand that if that’s what a doctor constantly encounters every day from the majority of his patients that he wouldn’t bother getting invested in working with the patient.

Of course I don’t work in the medical field and you do, so you’d know whether my speculation is more reality or fantasy!

“at what point am I non-compliant?”

If I seek a second opinion am I non-compliant with the first doctor?
If I research my treatment options and decline a specific treatment because of the risks am I non-compliant? (even if there are other treatment options available?)

At what point is the line drawn where I become an obedient and deserving patient vs a willful jerk who has a death wish to satisfy my own comfort?

And I hope this doesn’t come off as snarky – because I feel this is an important issue. I have had experience with doctors who were incompetent and had I blindly followed the treatment they had given I would be dead. I had a doctor who prescribed a Spironalactine to treat PCOS and within 2 hours of taking my first pill I had excruciating pain in my left elbow accompanied by a red rash that was spreading rapidly. When I called my doctor they said it was “mild” and would “go away”. After the pain worsened I went to the ER where I was immediately treated for an allergic reaction. The ER doctor said my kidneys were shutting down and had I continued the medication I could have died.

So – even tho the doctor “thought they had the answers” to how my life would be better, was I non-compliant? Ya darn well betcha I was!