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Engagement Does Not Mean Compliance


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Twenty percent of people who leave their doctors' offices with a new prescription don't fill it. Up to one-half of those who do fill their prescriptions don't take the drugs as recommended. These individuals are considered non-compliant. But does that mean they are not engaged in their health care? Engagement and compliance are not synonyms.

I am compliant if I do what my doctor tells me to do.

I am engaged, on the other hand, when I actively participate in the process of solving my health problems. This new prescription is an element in that process. If I am engaged in my care, I might want to learn about this medication. Such as: what it can and cannot do to ease my pain or slow the progress of my disease; what side effects it might produce and what I should do about them; how long it will take to work; when I should take it and how; how much it may cost; and what will happen if I don't take it. I might want to consider the barriers to taking it and weigh the risks and benefits of alternatives. Could I instead make changes in my physical activity level or diet, try a dietary supplement or watchfully wait to see if the symptoms subside?

If my clinician has done more than just hand me the prescription - if she has, for example, raised these questions and discussed these concerns with me - I probably won't have a prescription in my hand if I don't intend to fill it.

But I can be engaged in my health care even if I don't have that conversation with my provider. I can ponder each of these questions with family and friends. I can search the library and Google for answers. I can consult online with others who have taken that medication. And sure, I'll accept the prescription in case I decide to fill it. But I make no guarantee.

The rhetoric of engagement is attractive to all of us: patients, providers, hospitals, employers and health plans. That rhetoric says that we have choices about our health care, that we are empowered to participate actively in our health care. And of course, that it's time we take responsibility for our health.

Many who speak about the need for us to engage in our health care confuse compliance with engagement. They assume that the only rational choice we can make is to behave consistently with our clinicians' directives, whether that means filling a prescription, losing weight or undergoing surgery.

But this is not how many of us hear these messages. The rhetoric says we have choices? We hear "You have the power to choose which doctor to consult and which advice you will follow." It says we are empowered to find good health solutions? We hear "Your Web searches and new friends online can help you figure out what to do as well as your doctor can." The rhetoric says we are responsible for our health and health care? We hear "You are on your own." What we hear is reinforced by reality: a paucity of clinicians who encourage and welcome our participation in our care and office visits that rarely allow time for in-depth conversations.

Saying "engagement" when meaning "compliance" supports the belief that we are the only ones who must change our behavior. Doing so misrepresents the magnitude of shifts in attitude, expectations and effort that are required for all health care stakeholders to ensure that we have adequate knowledge and support to make well-informed decisions. And it fails to recognize that our behaviors are powerfully shaped by many contingencies money, culture, time, illness status, and personal preference. Being engaged in our health and care does not mean following our clinicians instructions to the letter.  Rather, it means being able to accurately weigh the benefits and risks of a new medication, of stopping smoking or getting a PSA test in the context of the many other demands and opportunities that influence our pursuit of lives that are free of suffering for ourselves and those we love.

More Blog Posts by Jessie Gruman

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Jessie C. Gruman, PhD, was founder and president of the Center for Advancing Health from 1992 until her death in July 2014. Her experiences as a patient — having been diagnosed with five life-threatening illnesses — informed her perspective as an author, advocate and lead contributor to the Prepared Patient Blog. Her book, AfterShock, helps patients and caregivers navigate their way through the health care system following a serious or life-threatening diagnosis. The free app, AfterShock: Facing a Serious Diagnosis, offers a pocket guide based on the book. | More about Jessie Gruman

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Patient Engagement   Jessie Gruman   Communicate with your Doctors   Inside Healthcare  

Comments on this post
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dirk says
July 18, 2011 at 11:05 AM

truly the closer such exchanges between providers and patients can be to a conversation, versus a lecture, the better for all involved. And as the impacts of medical tx falls mainly on the patient there should be no doubt about who has the final word/authority on what treatments will be undertaken. But as long as we largely put providers in the position of having to treat patients regardless of their level of cooperation (not compliance) there will be an unnecessary level of tension/resentment involved. On the legislative side we must err on the side of treatment for all but we also need to develop a culture/ethos of mutual engagement that recognizes/values the human investments on all sides.

Med-Blog Grand Rounds Takes a Virtual Tour « Medical Lessons says
July 19, 2011 at 6:33 AM

[...] the Wash­ington, DC-â??â??based Pre­pared Patient Forum, where Jessie Gruman clar­ifies that Engagement Does Not Mean Com­pliance. As Jessie says, â??I am com­pliant if I do what my doctor tells me to do. I am engaged, on the [...]

Carolyn Thomas says
July 20, 2011 at 9:25 AM

Excellent points, Jessie. One of my blog readers at Heart Sisters recently wrote me that her physician had prescribed a beta blocker drug to treat her 'white coat hypertension' (blood pressure numbers go up only in the doctor's office, even though her daily self-monitored BP averaged a very acceptable 110/70).

What to do? If she chose NOT to take the antihypertensive meds as ordered, she'd be considered "non-compliant" by her doc. One of "those" patients. Difficult! Yet as a longtime RN herself, she honestly saw absolutely no reason to take this drug (for the rest of her natural life, mind you) when it made no sense to her to do so.

Even the word "non-compliant" seems offensive to many patients, implying old-fashioned subjugation to another's authority - the authority of a person with the letters M.D. after their name.

The Accidental Amazon » Compliance Or Manipulation? says
July 21, 2011 at 1:05 AM

[...] by Jessie Gruman, Ph.D., president of the research institute Center for Advancing Health, called Engagement Does Not Mean Compliance. And I do beg you to recall that in health care, the bottom line is that it’s the patient who [...]