In recent years, there has been a gradual movement away from the word noncompliant in favor of the word nonadherent to describe patients who do not listen to medical advice or follow clinicians’ recommendations. Even with this shift, there is still lack of common understanding amongst physician assistants (PAs), nurse practitioners (NPs), and other providers about what these terms mean and how their use reflects our view of the patient-provider relationship.
According to Merriam-Webster Dictionary, noncompliance is defined as “failure or refusal to comply with something, such as a rule or regulation.” Nonadherence is simply defined as “a lack of adherence” or the act, action, or quality of not adhering.
Although both terms remain in common use, there is a trend in recent years to eliminate noncompliance in favor of nonadherence. Proponents say that noncompliance smacks of physician authoritarianism and is a poor fit with the shared decision-making model. Nonadherence, they argue, is broad enough to encompass all the relevant behaviors without judging the patient.1
There are 2 distinct issues when we consider which term to use to describe patient behavior. The first is understanding the difference in the meaning related to the sometimes authoritarian role of the provider, and the second is how we view events when our patients don’t follow through on our advisement or instructions, either intentionally or unintentionally.
The issue of terms describing authoritarian vs non-authoritarian patient-provider partnerships is sticky and can be difficult because of the different personalities and ways of thinking embraced by the extremely diverse world of providers.
Some providers are trained to see the patient-provider relationship as essentially parental, where the provider makes a decision, describes what is needed, and sends the patient away. This type of behavior can be nurtured by those of us who generally view the world through authoritarian glasses and tend to deal with all relationships in this manner. Such behavioral tendencies are likely to be difficult to alter in the examination room.
However, when I speak to providers, either those I work with or in the community, I more frequently hear the word nonadherent when a provider is describing a situation where a patient did not complete the instructions given by the provider. From my perspective, this is a refreshing change, and indeed reflects a general move toward embracing shared decision-making and the need for a partnership between patients and providers.
The other issue in this discussion relates to how we view our role in enhancing patients’ health literacy. Historically, the medical world has held itself in very high esteem and often felt they were gifting patients with their brilliant insights.
Having been in the patient role since birth, I’ve had countless experiences in which I have been given medical instructions almost as though they were an order. For me, this usually prompts withdrawal and shutting down, just wanting to get the appointment over with, hoping that I understand what I’m supposed to do — fearing that I really don’t — but not wanting to go through a further conversation with the provider.
The idea of health literacy (having knowledge and competence) is complicated, and may not be a result of an ignorant patient unable and unwilling to do what they are told. Over the years, there has been some refreshing new examination of this problem, specifically how medical providers contribute to and can improve health literacy information gaps.
In the last decade, a “universal precautions” approach to health literacy has arisen, promoting the need for all medical providers to assume that there is something about what is said to the patient that is being misunderstood, and using techniques to identify knowledge gaps and to clarify and establish a shared understanding before concluding the patient encounter.
The Agency for Healthcare Research and Quality (AHRQ) created a wonderful AHRQ Health Literacy Universal Precautions Toolkit, which provides simple and extremely useful tools for providers to use in promoting better understanding between providers and patients.2
The AHRQ states that the purpose of the toolkit is “simplifying communication with and confirming comprehension for all patients, so that the risk of miscommunication is minimized, making the office environment and healthcare system easier to navigate,” and “supporting patients’ efforts to improve their health.”2
Analyzing how we think about nonadherence vs noncompliance offers great value for enhancing the provider-relationship, enhancing shared decision-making with patients, and assuring that the provider and patient are speaking the same language when we discuss diagnostic and treatment options with our patients.
- Sweeney JF. Battling nonadherence: what actually works? Medscape. Updated May 7, 2019. Accessed February 18, 2021. https://www.medscape.com/viewarticle/912452_4#:~:text=Understanding%20the%20distinction%20and%20labeling,fails%20to%20follow%20a%20plan.
- AHRQ Health Literacy Universal Precautions Toolkit. Agency for Healthcare Research and Quality. Updated September 2020. Accessed February 18, 2021. https://www.ahrq.gov/health-literacy/improve/precautions/index.html