Monday, February 12, 2007

Adherence versus Compliance

Just the other day, a conversation was born amongst colleagues regarding two words/concepts that are used almost interchangeably in healthcare. Adherence and compliance, those somewhat subjective measures of how well a patient follows medical instructions, appear in medical charts, professional journals, PowerPoint presentations, scholarly articles, and all manner of medical ephemera on a regular basis. These concepts are even the subject of professional workshops and conferences. Our conversation centered around the difference between the two, and what it means when we use one versus the other, both, or neither.

First, we should begin with definitions. "Compliance" is defined by as "conformity; cooperation or obedience; accordance; the act of conforming, acquiescing or yielding; a tendency to yield readily to others, especially in a weak and subservient way." Hmmm (hand scratching chin pensively).

As for "adherence", our friendly neighborhood Internet dictionary defines this term as "the act of adhering; adhesion; the quality of adhering; steady devotion, support, allegiance or attachment." Also quite interesting.

What immediately grabs my attention is the notion that "compliance" is defined as a type of obedience, especially a subservient breed of obedience. Perhaps this is also why I seem to notice the term "non-compliant patient" used so often in medical charts. In this culture where doctors are somewhat deified and in which medicine can often take on a paternalistic pallor, definitions of a patient's relative obedience to medical advice would be the language expected of medical personnel when documenting patient behavior.

When we providers see ourselves as offering the patient the best, most inarguable advice, we must implicitly expect a certain obedience or acquiescence to our prescribed treatments. We all have known patients who seem so eager to please us, so passive and opinionless, that we wonder how much of their ingratiating attitude is simply displaced desire to please a demanding parent. While we do at times feel like substitute parental figures---even for elderly patients---these are not healthy roles for provider and patient to assume. Wanting a patient to "comply" with one's advice does indeed seem that one wishes to "bend" the other's will towards one's own. How healthy can this be for either party on a psychic level?

Conversely, the definitions of adherence bring to mind notions of support, devotion, and attachment, with "allegiance" bringing to mind a sense of something shared cooperatively by both parties rather than forced upon one by the other. Using this term in relation to a patient does certainly seem to carry a very different tone which lacks a certain paternalism that "compliance" seems to engender. Partnership and bilateral decision-making come to mind, rather than unilateral command and obedience.

I am remembering as I write this post that the visit note forms which our agency uses has a small section entitled "Medication Adherence" in which we document our assessment of the patient's medication-related habits. Was it a deliberate choice to use "adherence" rather than "compliance"? I'll have to ask my boss.

In the course of my blogging, I seem to write a great deal about patients who are not exactly following the medical script. I note that I recently posted a missive entitled "Non-Compliance, Apples and Surrender". Did I think about my choice of words or did compliance roll right off my tongue, or rather, keyboard? I must say that when it came to the patient in question, I naturally chose non-compliance. Perhaps it is when patients seem to be making choices which we know will certainly cause them harm that we see them in this way.

For many providers, I think there is a certain proprietary quality to some provider-patient relationships. Within our practice (and many others, I'm sure) there is constantly comments like, "She's my patient" or "He's not mine, he's hers." Ownership can be a positive aspect, meaning that the nurse or provider is taking responsibility for the individual's care. Similarly, our patients will say, "That's my nurse" or "She's my doctor". These are all socially acceptable and understood notions of belonging, of connection. We simply must be cautious in their contextual use.

Coming to the close of this particular missive, my jury is still out whether I feel it is "wrong" to use the term "non-compliant". It is certainly food for thought, and very worth pondering vis-a-vis my own practice and documentation. As I learned in nursing school, medical and nursing notes are legal documents, and labels which we apply to patients can haunt them for the rest of their lives, often coloring how a new provider will feel about a patient before even making their acquaintance. Not only do we carry the responsibility to do no harm in relation to our care, we should also be careful to do no harm with our words.

I may need to revisit this question as time goes on, and welcome any comments on the topic. This particular blog entry is very much a process of thinking out loud, and I welcome any reader to do the same. (But will you comply?)

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