A dangerous misunderstanding

WHY do some patients fail to follow medical advice? The answer could be a simple communication failure.

WHY is it that some patients seem to struggle to follow medical advice or fail to take prescriptions as ordered? The cause of patient non-compliance is the subject of much debate in the UK and beyond. The World Health Organisation estimated in 2003 that only about half of patients with chronic diseases living in developed countries followed treatment recommendations.

Some doctors may suspect non-compliant patients are acting irrationally or being wilfully disobedient but it is likely there are other factors at work. One element to consider is a simple communication failure – where doctors issue unclear or ambiguous instructions that risk being misunderstood or misinterpreted.

Professor Theo Raynor and his colleagues at Leeds-based Luto Research have recently looked at this issue in relation to the wording of medicine labels. When drug information leaflets are misplaced, Professor Raynor says, the label on a particular medicine “plays a very important part in guiding people’s behaviour.”

His team’s research found that the word “drowsiness”, for example, was not always readily understood and should be replaced with the phrase: “This medicine makes you sleepy.” He found similar results for the instruction “Avoid alcoholic drink” – where some people thought it only meant they should limit their alcohol intake – and suggested it be replaced with: “Do not drink alcohol while taking this medicine.”

In light of this research, the British National Formulary announced last month that it is recommending medicine labels should be improved “to ensure the wording is better understood by patients.” Terminology should be simpler and more precise, the study found, and changes are likely to come into force within six months.

A cause for complaint

These recommendations can be applied to more than just medicine labels. It is crucial that doctors are clear and precise when issuing any written or verbal patient instructions – particularly when consulting over the phone. MDDUS is aware of a number of cases where unclear or ambiguous patient instructions have led to negative outcomes and given rise to a patient complaint.

One significant risk area relates to advice about medication. Particular care should be taken when advising patients on how and when to take their medication and doctors should be as precise as they can about timings and quantities. Instead of instructing a patient to take pills “at meal times”, consider narrowing this down to a more specific time frame, ie: “Take one tablet within two hours of eating a meal”. Check the patient has understood by summarising your instructions at the end of the consultation. Some patients who fail to take their medicine may simply not understand how or when to take it or, indeed, why they should take it.

Another risk area involves advising patients when to return for further treatment. One case handled by MDDUS involved a patient with gastrointestinal problems who was told by his GP to “come back if the symptoms get worse”. His symptoms persisted over several days but, because they had not worsened, he didn’t return to his GP. This resulted in a prolonged illness and the patient went on to lodge a complaint of negligence against the GP. In this case, the doctor should have told the patient to come back within a given time frame if the symptoms continue or worsen. It helps to be as precise as possible. This is particularly important in cases that can change or progress rapidly, such as febrile illness in children. In these cases, it may be helpful to advise the patient seek further treatment within a given number of hours/days if their fever doesn’t fall below a certain level.

Phone consulting

The need for clarity is heightened when doctors are consulting patients by phone. In the absence of a physical examination, doctors must make sure the patient is clear about what they should do if things do not improve or deteriorate. Ask more questions than normal, speak slowly and clearly and consider asking the patient to write down the details of any agreed management plan.

When giving patients advice or instructions, doctors must always make comprehensive notes reflecting what is discussed and the specific advice given. In the event of a patient complaint, medical notes may prove an important piece of evidence in the doctor’s defence.

In patients with a record of non-compliance, be sure systems are in place to follow-up on their treatment to minimise the chance of missed appointments, test results and so on. Consider taking extra time to discuss treatment to root out possible reasons for non-compliance. As before, note any discussions in the patient’s record.

ACTION Give clear, precise patient instructions and ensure the patient has understood, and take comprehensive notes of what is discussed/advised. Be aware that non-compliant patients may simply require instructions that are easier to understand.