I don’t pretend to be an expert on patient compliance, and have found most of the studies I’ve read on how often and how well patients follow their doctor’s orders to be confusing and inconclusive. I’m sure others do, too. It’s a tough subject. In a world where many people — including me — believe the system tends to over-treat people to begin with, some non-compliance is probably not a bad thing. In addition, defining non-compliance — versus poor communication, wrong clinician/wrong situation or four or five other issues that might impede care delivery and/or recovery — is no easy task.

But as I recover from my idiotic vacation accident, in which I tore ligaments in my right foot, bruised bones in my ankle and damaged a boatload of cartilage, I’ve learned a few personal things about referrals and compliance that I thought were worth sharing. Let’s start with finding the right specialist. Before I hurt my foot/ankle, I’d visited a physical therapist a few times who specializes in back pain. She was very good at helping me with mine. So when my doctor said, “Okay, it’s time for some PT to get some movement back in your ankle and take down that swelling,” I went to see her a couple of times for this new problem as well. And while it was helpful, she said she thought I’d be better off going to a different physical therapist. She said he was closer to my house — but I think she knew more than she was letting on.

In any case, she was absolutely right. The new guy and his practice were all about sports injury rehab — and while this was not that (I’m too old for that!), my injury sure looked like many of the other injuries and maladies he and his team were treating in their practice. There is no doubt in my mind that my original therapist’s suggestion that I go see someone else took weeks — maybe months — off my recuperative time frame. It could be I landed there at the right time, or it could be the closeness to my house made scheduling visits easier, or it could be I just happened to be more committed to getting back to normal by the time I showed up there — but I don’t think so. I think this PT was simply better suited to solve my problem.

I’m pretty sure I never would have figured this out on my own, and I’m quite sure my orthopedist couldn’t have figured this out, either. This little bit of serendipity came about because someone I already had a relationship with did the right thing and referred me away from her practice — where she thought my current problem was a “bad fit” — and sent me to a practice that she thought would be the “right fit.” How much of compliance in health care is really about getting sent to the right person for the right reason and getting the right fit?

Then there are the traditional compliance/non-compliance issues. When I was still in a boot cast and keeping my weight entirely off my foot, I was supposed to keep my foot elevated whenever I could, and take the boot off three times a day and do a variety of stretching exercises. I was pretty good about doing both, but I could see how not doing this — not staying off it, not keeping it elevated, and not doing my stretching exercises three times a day — would dramatically prolong my recovery period. I was motivated — I hated being on crutches — and I’m sure most people in my situation would be. But still, if you don’t do what you’re supposed to do when you’re supposed to do it, it adds time and expense to your treatment, and diminishes clinical progress and performance. And there’s not a whole lot a clinician can do about that.

And now that I go to PT, which doesn’t happen every day, I have a series of exercises I’m supposed to do when I’m not there to keep me moving forward. Again, I think I’m pretty compliant. I do the exercises at least once a day, and usually twice. But I don’t do them three times every day, which is what was recommended to me by the fellow I’ve been visiting for PT two or three times a week. He’s doing everything he can to get me back to normal when I’m with him, but I’m not doing everything I’m supposed to do when I’m on my own. Maybe that’s impeding my recovery, or maybe not. So far, I seem to be ahead of the recovery schedule people originally had in mind for me.

My points here are pretty simple. First, patients don’t always know who the best person would be to help them get better, and given the enormous fragmentation and distribution that exists within the care delivery system, clinicians don’t always know, either. Add to that the fact that patients have a major role to play in their own recovery — and that they may or may not live up to their own responsibilities in every case — and I can see why some clinicians worry about being held accountable for their patients’ behavior.

A small sample size of one, to be sure. But I’m guessing the two issues I’ve encountered would sound pretty familiar to many caregivers and patients dealing with injury, illness and disease.

Posted by: Charlie Baker in Care Management