In total, five virtual post-session facilitated group reflections were held. Forty-two internal medicine categorical interns and second- and third-year residents (39% of the program) and 8 fellows (15% of all fellows) participated in the SP encounters. Participants represented 56% of categorical interns (20/36), 36% of second-year residents (13/36), and 25% of third-year residents (9/36). The fellows represented 6 internal medicine subspecialities: cardiology, gastroenterology, endocrinology, geriatrics, infectious diseases, and rheumatology. 46 (92%) trainees consented to have their debrief participation recorded.
Negative connotation and dehumanization
Within debrief sessions, the phrase “non-compliant patient” was frequently described as carrying a negative connotation and was connected to patient dehumanization. For example, one trainee said, “overall, when you read this non-compliance thing and how the guy skipped an appointment and is looking for the work letter, you can't help but go into the encounter thinking it will be a more resistant or a jerk back to you...” A trainee commented, “It doesn't sound nice to say this, but at the same time if you feel that your patient doesn't care (because of the non-compliance) it makes you feel like, “should I care if they don't care?” Not that that's the case but it really makes you think about that. Why am I doing what I'm doing if the patient doesn't even want to get what they need?” Another stated, "When I see the word non-compliant in the chart, it automatically changes my prognosis that I have set for the patient is what I would say… and maybe on a subconscious level, I won't be trying as hard for this particular patient."
A few trainees humanized and connected to patients by considering their feelings about being labeled. One trainee commented about how they would feel if they had been labeled “non-compliant” in their chart and suggested asking patients for their feelings:
I think it's probably going to be interesting to see what happens when patients see that in their medical chart when they are able to review their notes soon. I think if I was a patient and “read non-compliant” in my chart, I would probably be offended. I mean, I definitely would be. I think there are probably better terms that we could use. We spend a lot of time drilling in what type of heart failure we have when we put that in a chart. We want to be as specific as possible. I don't know, it's just my personal opinion. Perhaps we should consider a different terminology. We can poll patients and see how they feel about the term.
Another reflected on how it might feel to be labeled and what the term tells the patient about their role in the doctor-patient relationship:
...if I was a patient and someone said that I was non-compliant. I mean, if you think about it, to have to comply with somebody is like you're being dictated to do something. So from the patient's perspective, it shouldn't be a dictation from the doctor. You must do this. I think it should be a conversation. So, I think that would kind of give them the impression that I don't see myself as someone that's working with them for their health, more so as someone that's dictating what they're going to do…
Impact on the doctor-patient relationship
Trainees described the dynamics of the relationship between themselves and the patient labeled as “non-compliant” in three ways which align with a previously published schema (Table 1).21 The activity-passivity model was described very rarely in the debrief sessions. When it was described, the comment was to dehumanize a patient in a theoretical case of activity-passivity:
I do not think it was the case with this patient, but I think often it happens more when it is a translator patient. When you try to explain what you want to prescribe or the changes you want to make, I feel like sometimes the patients just tend to nod and say okay, but you have no idea if they are ever going to follow those recommendations. Sometimes you think you are just maybe talking to a wall because certain cultures do not want to disagree with what the doctor...
More commonly, trainees took the stance of “guidance-cooperation.” These trainees described the patient in dehumanizing and/or humanizing terms with similar frequency (Table 1), sometimes speaking about the SP case and other times reflecting on their experiences overall. One trainee spoke in generalities about a guidance-cooperation stance that humanized patients, “I think if patients are motivated, you have to figure out or come to a plan with them and realize that it’s not that they don’t want to be treated, it’s maybe they don’t know how to approach it. Then you can deal with the situation.” Another trainee spoke in generalities about a guidance-cooperation stance that dehumanized patients, “…There are some patients that will be non-compliant no matter what you do for them. But you should always start with the assumption that there is a possibility of “converting” this patient to become compliant again…”
Those who adopted the mutual participation relationship model did not use dehumanizing terms and often investigated the underlying social determinants of health18 (Table 1). For example:
You're trying to optimize their health and there are multiple factors holding them back from being able to do that. So for (SP name) it could have been anything from his culture to lack of literacy or education or social support… He mentioned to me, he wasn't taking one of his blood pressure medicines because it was interfering with him at work. It was making him use the restroom way too frequently for his comfort. So we always want to be able to develop a plan that works for us but also one that works for the patient.
De/humanization and the doctor-patient relationship
Medical trainees noted how the term “non-compliant patient” can serve as a biasing function that risks patient dehumanization and impacts the doctor-patient relationship, as noted in the following four examples: 1) “I think it creates a barrier for a good doctor-patient relationship. It's very easy to just read non-compliant and say, ‘Oh, you know this is going to be a difficult encounter. I'm going to have a hard time with him,’ so you'll just be predisposed to that from the start;” 2) “I just feel that non-compliance is such a negative word. I don't think that it should be used as much as we use it because it creates a very negative impression about a patient. It blames the patient… I think non-compliant is a very strong word to be used and I guess we should use it more carefully when describing anybody;” 3) “I think we're also very vulnerable to being biased. You know when someone says this is a non-compliant patient coming here again with another COPD exacerbation, I think it is human to say: What am I going to do differently? I think that does play a big role in how you approach a patient. I think if someone just comes and tells you this is a non-compliant patient, you no longer see what he's up to;” 4) “Big pet peeve because negative connotation comes to it, and oftentimes we just say it's just a difficult patient rather than trying to consider what the reason is. Oftentimes, we just say take this medication and we don't consider how it might impact someone's personal life. I think that's the underlying issue. So, labeling patients can become problematic, and we pass it along from provider to provider. We're in a rush walking into a room, and we say: it's another non-compliant patient.”
Perception changes
Many trainees recognized the potential negative consequences of using the term after
participating in the SP encounter, despite previously using the term as a “flag” to “dig” into a patient’s history:
I have used that frequently and I've heard other people use it as well. To me it kind of
stands out as a red flag. Sometimes you do have patients that are frustrating and don't seem to care much about their health, but oftentimes I use it as a red flag to alert myself that the patient may have barriers to health care, and it helps me dig deeper. When I was speaking with the patient, I used the word and discussed compliance with him. So I could see kind of how it could come off negatively to a patient or someone, and that maybe avoiding that term and finding a different word for it would be a bit more appropriate.
Some trainees noted a change in their impression of the SP encounter, indicating an initial negative emotion that transitioned to a more positive one after collaborating with the SP:
I felt pretty good after figuring out the side effects and we came up with a better plan for how we're going to re-adjust. At the end, we had much better rapport. We also talked about having his son at the next appointment and he was appreciative of some of those things. At the end, I left the conversation at a much better level than when I came in. In the beginning, I was borderline judging a little bit and thinking he was going to be non-compliant, but in the end I felt a lot better about it.
Other trainees described the impact of the SP encounter on their future clinical behavior as noted in the following example:
The term non-compliant has a bad connotation to it and I felt that that did play a part in my encounter with him. The feedback that I got, I realized that instead of delving more into what exactly was the reason behind his non-compliance, I spent a few extra minutes going over the risks and consequences of him being non-compliant, which I think happens more often in real patient settings than actually getting into the reason behind the noncompliance. I think that is definitely something that I'll keep in mind going forward.
Impact on marginalized communities
A few trainees described how marginalized communities might be more susceptible to the negative connotation associated with the term “non-compliant patient.” For example:
A lot of times, we assume that especially for patients who are immigrants or those with language barriers. We kind of jump into conclusions very prematurely. And then if you just listen to them patiently and then you can get to the bottom of “why was he worried about losing his job?” or “why has he not been taking the medicine properly?”…As an immigrant (myself), I think I also must have been guilty of jumping to a conclusion very prematurely. And we should avoid that bias at all costs.
In the following cases, trainees seemed to actively “dig” into the patient’s history and possible underlying causes for not following a physician’s recommendation, despite using the label:
The word non-compliant doesn't always have to be a bad term. When you use it to say, all right, they are non-compliant, let's figure out why. And I think making sure that we use that term to say we have to dig deeper and use the resources that we have… Some of my patients in clinic have had problems where they don't know English, they don't know which medications to take, what the bottles look like, and what they're supposed to take and when. And when I've gotten them the dispill packs, I've seen significant success. This doesn't work for every patient, it doesn't fix every patient's problem, but trying to figure out why is really important.