Why our patients are not compliant?

I had the pleasure of working in the GIM Rapid Referral Clinic yesterday. What I found unique and exciting about this clinic is that you can never predict what type of medical concerns are sitting in your exam room. Yesterday was a great example.

I saw Mr. J, a young gentleman following up with the GIM clinic for a follow-up appointment from a 24-hour ambulatory BP monitor. Mr. J’s ambulatory BP averaged an elevated mean, meeting a diagnosis of hypertension. However, he wanted to repeat the test because he claimed to be going through significant stress and felt that the values were not a fair representation of his usual blood pressure. He stated he had been non-compliant with an antihypertensive drug prescribed to him during the previous appointment for this reason.

After the repeat test also revealed an elevated mean, I broke the news to Mr. J that the results cemented a diagnosis of hypertension. I predicted frustration and disbelief. To my surprise, I was met with calm and acceptance throughout the discussion. He was also very receptive to my suggestions of increasing his weekly exercise and eating healthier meals. I proceeded to discuss pharmacological treatments and asked whether he had been taking his medications. He replied that he had been taking them regularly but recently ran out of them. I offered to increase his dose and caught a glimpse of hesitation flicker across his face. Probing further, he admitted he had completely non-adherent because he didn’t like how the medications made him feel. Initially, he wasn’t willing to elaborate. I repeatedly asked him what symptoms he was experiencing and after finally let out a long sigh, he said that he was primarily concerned about the drug cost.

Mr. J told me that he didn’t have any drug coverage and paid about $90 every few months for his BP medication. He was worried that increasing the dose would add to what he was paying already. After comparing different medication prices, I switched him to another drug that was a fraction of the cost of his current pills. Both the patient and my preceptor were satisfied with my recommendation and Mr. J agreed to follow up with us in 3 weeks to reassess his blood pressure.

All it took for me to help Mr. J was a quick search of an online drug formulary and a call to a local pharmacy. This case taught me that treating our patients often requires us to understand them holistically. Physicians can order a plethora of investigations and prescribe a multitude of medications but if we don’t have a solid grasp of a patient’s social determinants of health, we will never be able to deliver patient-centered care.
- AX