More of a misnomer than a fact

I’ve been a healthcare provider for over 23 years. As a physical therapist, I get to spend more time with my patients than most medical professionals, and I’ve learned a few things about the description of “non-compliant patient.”

I’ve spent the majority of my career practicing in a hospital-based setting. This is one place where this term is thrown around quite a bit. But this is also where the safety net lies for the critically ill. When we round on patients, we often hear this phrase tossed out as a reason for the medical disaster that caused one’s admission. 

A younger version of me bought into this phenomenon, asking questions like, why wouldn’t someone just take the medicine they are prescribed? Why won’t they listen to their doctors? Why would they eat junk food and eat most meals at fast food restaurants, contributing to various chronic diseases? I really didn’t get it. 

Certainly, patient education is an important component in managing this common problem, but there are other factors frequently beyond the control of these patients that come into play.  

When my eyes were opened

My first round of practicing in the home health setting was truly revealing, and I expanded on this enlightenment when I returned to this setting years later. 

What you see as a home health practitioner can be both frightening and sad, provoking anger with our society. It also leaves you at a loss for how to best help your patients. How can we call ourselves civilized when we don’t take care of our most marginalized?

I saw patients in some of the poorest parts of Richmond. Some of my patients were on food stamps, Medicaid, and in HUD housing. I had patients who rationed insulin and blood pressure medications. On many visits, I would observe wrappers from fast food meals, empty refrigerators, and mold on the walls, not to mention critters not meant to cohabitate with humans. 

How can anyone with a limited income, living amid a food desert, and in terrible housing be “compliant” with recommendations from their doctors? You simply can’t. You’re merely trying to survive.

Add to these problems often associated with aging like limited mobility and dementia, and you have a recipe for disaster. 

I encountered one elderly patient who had mobility issues herself but was the primary caregiver for her husband, who had his own mobility issues on top of dementia. She also had diabetes. She couldn’t even successfully load her syringe for her insulin, and often neglected to eat or care for herself because of her husband’s needs. I ended up getting the nurse on my team involved to facilitate a change in her insulin regimen, switching to pre-loaded pens. That was a small help. 

But I also had another patient who had no business living on his own. He was also dependent on insulin, and he couldn’t even walk the 15 feet from his couch to his refrigerator to access his medication. Every time he went to the ER, they immediately sent him home, as he was a frequent flyer, even despite my intervention with our agency’s liaisons in the hospital. It was frustrating. He desperately needed help that was beyond my scope of practice. 

In these conditions, problems manifest themselves as all of these deficiencies compound upon each other. As a healthcare provider, I was at a loss about how to fix it. I’m the type of practitioner who looks at their patients holistically. 

I’m not just there to throw a band-aid on one problem. I want to address all of the contributing factors to health issues and prevent future ones from developing. 

Is preventive care the answer?

Preventive care is not a novel idea, but as a healthcare system, the United States fails at this. Yes, with the Affordable Care Act, mandating that this type of care be covered under insurance is a step in the right direction. 

But the ACA has also been an excuse for insurance companies to increase premiums exponentially. And with high deductible plans the norm, many average Americans take a wait-and-see approach to any problems that do occur, even among the insured, potentially making a small problem something much worse by the time it gets addressed. How sad that the financial burden of medical care keeps us from seeking help. 

Cheap calories equals full bellies

No one will dispute the fact that diet contributes to your health. You could even go a step further and say it’s your health’s foundation. But when your nearest grocery store is a Walmart several miles away, and your only transportation is the bus, how do you buy healthy food? 

Food deserts are more common in America than you might think, and are a real barrier to living a healthy life. And even if you make it to the store, subsidized food sources like snack foods are much cheaper than whole foods. And if you can’t make it to the store, the neighborhood fast food joint with a dollar menu will suffice. 

Poor diets, although filling, can lead to a multitude of issues. Obesity, diabetes, high blood pressure, and high cholesterol can all be symptoms of less-than-ideal food choices. But if you look at the circumstances, these aren’t entirely choices. They are strategies for survival forced by the system in which we live.

The traps of being poor

As a physical therapist, I often encourage my patients to get more active. The simplest form of exercise is simply taking to the streets to go for a walk. But if you look outside the door of many of the homes of my patients, their streets aren’t safe at all. Some neighborhoods don’t even have sidewalks. 

Other safety issues besides traffic can also be barriers to exercising outdoors. Some of the neighborhoods I visited as a home health provider were notorious for drug trading and random gunfire. It was always unsettling to see a place on the news close to where my travels had taken me that day. 

I had one patient describe the time that she and her husband endured a night of terror where 38 bullets were fired into their house as they lay under their bed, holding tight to each other. How can you ask someone who lives in a neighborhood like this to risk their life just to go for a walk? 

Someone with average means may argue that they should join a gym. Sure. Take that extra money you need for medications and food and spend it on a gym membership. That doesn’t make sense. In Richmond, we do have some programs that teach group exercise classes for free in underserved communities. That is helpful, but it’s only once a week. But that also takes transportation to get there. 

When you have limited means, you may be forced to make difficult choices between paying rent, buying food, or paying for lifesaving medications that you need to survive. It also affects what medications your doctors prescribe. 

Say you have atrial fibrillation and need to be on blood thinners to prevent a stroke. Instead of a new generation, safer drug like Eliquis, which costs upwards of $400 per month, you may stay on traditional coumadin, which requires frequent blood tests to maintain safe therapeutic levels. And then the transportation issue comes into play again, unless you are lucky enough to have home health services that can run these labs for you. It’s a real rabbit hole.

Once poor, always poor, and it’s your fault

Our society is only as strong as its most marginalized members. One of the problems, however, is that in America, we blame the poor for being poor, like it’s a sin. It’s one of the many downfalls of capitalism and even a common theme taught by evangelical churches. 

Do a quick Google search on “poor being a sin.” I’ll wait. Some of the results might make you feel ill. Our society takes no responsibility for creating the circumstances that keep people economically disadvantaged. We blame it on the poor. But there’s a whole industry focused on preying on the marginalized, from our prison system to payday loans. 

Can we make it better? 

To make these problems better, to ensure that patients can be compliant with recommendations for safer housing, better diets, exercising more, and taking their medications as prescribed, we need systemic changes. 

Eliminating food deserts, creating safe and affordable housing, making our neighborhoods safer and more inclusive for outdoor recreation, and regulating the cost of medications would be a great start. The problem is, there are too many obstacles in the way. Corporations and localities that will profit from the sick and poor are one problem, but I also don’t think that lawmakers want to hear what it’s really like in the trenches. 

I was only a tourist in the world of the marginalized, but I take the lessons I learned and observations I experienced with me back to my hospital practice setting. I can now be that voice in rounds who can educate my colleagues on how challenging things can be for those “non-compliant” patients, and I can serve these patients with a greater lens of compassion. 

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Have you heard of this term? What’s your impression of the “non-compliant patient.” I’d love to hear your perspective. 

As always, I hope you all are safe and healthy.