Table 2. Measures of Physician-Patient Relationship Quality and Adherence .. Rethinking nonadherence: historical perspectives on triple-drug therapy for HIV disease. Ann Intern Med. Laws MB, Wilson IB, Bowser DM, Kerr SE. Taking. Medical liability case study: case study and risk management recommendations related to dismissing a patient for non-compliance. Patient non-adherence is a well-documented medical phenomenon. It has been refusal. It is a clearly established point of medical ethics and law that a com- . ethical duties in the physician-patient relationship (Jacobson, ; Brown.
Anybody who does serious work is busy and also has spent gobs of money on education and equipment. A fourth named cost as part of the barrier to disclosure: These included asking about cost, asking about compliance, and anticipating and troubleshooting problems ahead of time. Strategies for improving the patient side of communication also abounded, mainly encouraging patient assertiveness: The second was a shift in the patient role toward self-reliance and self-protection. In strategic action, speakers are less interested in mutual understanding and more focused on achieving individual goals.
Strategic action succeeds to the extent that the actors achieve their individual goals, whereas communicative action succeeds insofar as the actors freely agree that their goal or goals is reasonable and merits cooperative behavior.
Communicative action is thus an inherently consensual form of social coordination that describes the core ideal of concordance. For example, some might argue that drug companies are not as interested in reaching a shared understanding with potential customers as they are in persuading them to take pills.
Habermas thus imports speech act theory into an analysis of institutional power relationships by recognizing the essential role of trust in the production of perlocutionary force and the interpretation of speech acts. The forum commenters in the current analysis frequently described physicians as at least in some cases untrustworthy because they appeared to be engaged in strategic action on behalf of drug companies and the health care institution, rather than being engaged in communicative action in pursuit of understanding and consensus with their patients.
The well-publicized scandals about drug companies withholding unfavorable findings from publication, 32 paying for ghostwritten articles, 33 and the influence of drug manufacturers on physicians 34 make such distrust seem understandable.
Implicit in many of the posts is an important redefinition of the traditional physician—patient relationship. Some patients feel the onus is on them to double-check doctor recommendations, perform their own research, or decide how to make their care congruent with other demands of life including financial pressures. Furthermore, it appears that these older models of how the physician and patient should interact are sometimes being replaced without explicit discussion and recognition that this is happening.
Previous research has noted how the professional status of doctors is reinforced by patient deference and by avoiding open disagreement and conflict. Indeed, if there is a preoccupation with holding up a norm of politeness and deference while covertly mistrusting the system and the doctor, then communicative action is impossible.
Only strategic action can get the parties through the visit comfortably. Patients who challenge the status of their doctor in their own minds may be avoiding conflict on two levels: Doctors would not only have to solicit patient input but also prove that they can accept this level of patient criticism amicably.
Furthermore, Stevenson and Scambler 30 suggest the emphasis on patient-centered care may in itself create a barrier to open communication: The movement towards mutuality and reciprocity … means open strategic action has become less acceptable.
It may have been replaced by concealed strategic action. Concealed strategic action incorporates not only conscious deception or manipulation but also unconscious deception or systematically distorted communications.
We know that discussing nonadherence can be a delicate matter. In research specific to human immunodeficiency virus care, physicians have been described as lecturing or scolding patients about adherence, 38 and some patients have reported concealing their nonadherent behavior at future visits or even, in some cases, discontinuing clinic attendance or stopping medication taking altogether as a result.
Whereas the focus of this article is physician—patient communication about medication adherence, not about the outcomes or consequences of medication-taking decisions, we would be remiss not to comment on the medical risks for patients and the legal risks for physicians that dysfunctional communication can engender. It is hard enough to provide high-quality, safe pharmacologic care to patients, particularly those using multiple medications, when communication is good.
One limitation of this study is the found nature of the data set. We could not interrogate participating voices to clarify the meaning of their posts, or follow up with them to elaborate on their thinking. A second limitation is that we do not have demographic data about the people who commented, only general information about New York Times readers.
Finally, it is possible that the people who were motivated to comment felt provoked by some aspect of the article or other comments, creating a selection bias toward people who have negative feelings toward doctors or medicine.
Non-adherence to medication and doctor-patient relationship: Evidence from a European survey.
As we were interested in identifying barriers to concordance, this bias was found informative, but these views should not be interpreted as being generalizable.
A review article concluded that despite increasing access to the Internet and other societal changes, patients still prefer to discuss medications with their usual doctor and that they value their relationship with their doctors. Practitioners may benefit from encouraging their patients to express dissent and even mistrust about medications and medical practice. It may be necessary to invite shared decision-making overtly and to encourage disclosure of opinions that may be perceived as taboo or threatening.
Concordance about prescription medications is a worthy goal, but one that may be more difficult to realize than many, including patients and physicians, expect. Treatment adherence in chronic disease.
J Gen Intern Med. Physician-patient communication about prescription medication nonadherence: Medication adherence behavior and priorities among older adults with CKD: Am J Kidney Dis. Kremer H, Ironson G. To tell or not to tell: Enabling patients and physicians to pursue multiple goals in health care encounters: The impact of health information on the Internet on health care and the physician-patient relationship: J Med Internet Res.
Misunderstandings in prescribing decisions in general practice: The Silent World of Doctor and Patient. The Free Press; Makoul G, Clayman ML. An integrative model of shared decision making in medical encounters. Decision aids for patients facing health treatment or screening decisions: Marinker M, Shaw J. Not to be taken as directed. Cushing A, Metcalfe R. Ther Clin Risk Manag. The role of the Internet on patient knowledge management, education, and decision-making.
Telemed J E Health. The New York Times Company. New York Times; Interviews and Internet forums: Three approaches to qualitative content analysis.
Antidepressant drug effects and depression severity: Stevenson F, Scambler G. The relationship between medicine and the public: The physician cannot walk away.
Non-adherence to medication and doctor-patient relationship: Evidence from a European survey.
The physician must follow specific procedural steps to ensure that the relationship is ended in the appropriate legal and ethical way. Termination of the physician —patient relationship is a two step process. First, identify the behaviors or patterns of behavior that trigger termination. Then provide the appropriate notice of termination to the patient. The first step is to determine what behavior or pattern of behaviors, actions or omissions by the patient can trigger termination.
Terminating the Physician-Patient Relationship
It may be a pattern of negative behavior such as missed appointments without excuse, non-compliance with treatment, failing to honor their financial commitments, drug seeking behaviors or an irreconcilable difference in treatment philosophy that triggers the termination. The underlying element in each of these triggers is a breach of trust in the relationship.
The steps taken by the physician to address the negative behavior, such as telephone calls, letters and or conversations with the patient should also be well documented. Notice of Termination Proper termination of the physician—patient relationship requires proper notice to the patient.
A Case Against the “Noncompliant” Patient | Bill of Health
The following steps need to be done: Notify the patient in writing that the care will be terminated. It should be a certified letter, return receipt requested.
A copy of the letter should also be sent via regular mail. In some cases, you may want to contact the patient directly to notify them of the termination.Challenges to physician-patient communication about medication use - Video Abstract: 25971
In those cases, you must document the conversation and written notice must still be sent to the patient as follow up.