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133 The Problem of Patient “Noncompliance” 7 The Problem of Patient “Noncompliance”: Paternalism, Expertise, and the Ethos of the Physician Billions of health-care dollars are spent each year because patients do not follow the instructions and advice of their doctors. One authority estimates the cost of medication noncompliance alone, in the United States alone, at $100 billion per annum (Gerbino). Medical and social-science literature counts patients’ rebellions and misdemeanors: • In a study of patients’ recall of interviews with rheumatologists within two weeks of visit, 11 percent had forgotten almost everything , including the names of prescribed drugs, tests ordered, and the diagnosis; 33 percent recalled most of the information given; 56 percent recalled some of the information and forgot some (Donovan). • In a study of seropositive patients at twelve English hiv units, where adequate adherence was defined as taking more than 95 percent of prescribed doses of antiretroviral therapy, 27 percent of patients were found to be inadequately adherent (Brook et al.). • Only 61.7 percent of travelers to East Africa (97.1 percent of whom were aware of the risk of infection) used regular chemoprophylaxis and two or more antimosquito measures to protect themselves from malaria (Lobel et al.). 134 The Problem of Patient “Noncompliance” A literature search turns up thousands of books and articles on noncomplying patients. Jenny Donovan counts eight thousand English-language articles listed on medline to 1990 and six thousand more to mid-1994. “Patient compliance” is a subject heading for over sixteen thousand medline-indexed articles published between 1994 and 2005. Most of these are measurement studies. This chapter argues that measurement studies in general reinstantiate the terms of the problem that they are measuring. It further argues that recent moves in the medical literature to reconfigure the “compliance” question as a “concordance” question, a question of doctor and patient collaboration and agreement, do not so much improve adherence rates to doctor-recommended treatments as they confound issues of who is qualified to give advice and what are the warrants for taking it. The chapter outlines a rhetorical approach to questions of patient adherence to physicians ’ advice, noting that patients do in most cases make decisions about their own care, and it is best if they are persuaded to make good ones. First, a word on terms. Noncompliance came into use in the 1960s, with the work of sociologist Milton Davis (see Davis and Eichhorn). Professional interest in noncompliance was established in the 1970s with publications by David L. Sackett and R. Brian Haynes following a 1974 symposium at McMaster University in Hamilton, Ontario. Sackett and Haynes used the term to include all studies of patient cooperation performed since the 1940s. The term adherence gained popularity in the professional literature after Sackett and Haynes; compared to compliance, it “reduc[ed] attribution of greater power to the doctor in the doctor-patient relationship” (see Vermeire et al. 333; Greene). More recently, the term concordance has been suggested by the Pharmaceutical Society of Great Britain to denote agreement between patients and physicians (see Marinker, From Compliance). Patients do not always fill their prescriptions for medication; if they fill prescriptions, they do not always take the medications; if they take the medications, they do not always take them correctly. Donald Meichenbaum and Dennis C. Turk reported in 1987 that with an estimated 750 million new prescriptions written in the United States and England each year, over 520 million cases of partial or total nonadherence are expected . Every year, 230–250 million prescribed medications are not taken at all; as many are taken only partially as prescribed (26).1 Moreover, doctors tell their patients to quit smoking, and they do not. They tell them to do daily repetitions of a therapeutic exercise or avoid eating fatty foods or change the dressing on a wound or return to the office for a follow-up 135 The Problem of Patient “Noncompliance” appointment—and they do not. Sometimes, noncomplying patients improve anyway, because they had some condition that would get better eventually on its own, but sometimes they do not improve. When nonimproving patients return to their physicians, if they do, they may be candidates for tests for a new diagnosis, on the mistaken idea that illness did not abate with treatment for the original one. Physicians, according to D. Dante DiNicola and M. Robin DiMatteo, assume that patients have complied with their instructions; even if they are aware of the extent of occurrence of noncompliance generally, physicians tend to...


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