A long-time patient comes to the office for a routine physical examination accompanied by his wife. He has a history of hypertension, obesity, and osteoarthritis. At the last visit, the physician recommended an exercise and weight loss regimen to improve his condition. The patient subsequently cancelled his next 2 appointments, explaining that things came up at the last minute. At today's visit, the patient reports low energy and pain in his knees, back, and hands. His wife is worried that he is not doing well. Blood pressure is 150/90 mm Hg, pulse is 84/min, and respirations are 18/min. Examination shows a 3.18-kg (7-lb) weight gain and decreased range of motion. During the visit, the patient shows a detailed understanding of his illnesses and readily acknowledges the importance of medication, diet, and exercise. However, he admits that he has a hard time dieting, has not exercised because it hurts his knees, and sometimes forgets to take his antihypertensive medications. Which of the following is the best initial response to address this patient's nonadherence to treatment?

Question

A long-time patient comes to the office for a routine physical examination accompanied by his wife.  He has a history of hypertension, obesity, and osteoarthritis.  At the last visit, the physician recommended an exercise and weight loss regimen to improve his condition.  The patient subsequently cancelled his next 2 appointments, explaining that things came up at the last minute.  At today's visit, the patient reports low energy and pain in his knees, back, and hands.  His wife is worried that he is not doing well.  Blood pressure is 150/90 mm Hg, pulse is 84/min, and respirations are 18/min.  Examination shows a 3.18-kg (7-lb) weight gain and decreased range of motion.  During the visit, the patient shows a detailed understanding of his illnesses and readily acknowledges the importance of medication, diet, and exercise.  However, he admits that he has a hard time dieting, has not exercised because it hurts his knees, and sometimes forgets to take his antihypertensive medications.  Which of the following is the best initial response to address this patient's nonadherence to treatment?

Quizplus · Accepted Answer

Nonadherence is a common cause of poor medical outcomes. This patient is having difficulty adhering to his medication regimen and recommendations for diet and exercise. Reasons for poor adherence are often complex and include inadequate understanding of the illness, complicated regimens, medication cost, side effects, illness perceptions, treatment beliefs, and psychological factors (eg, depression, anxiety, hopelessness, cognitive impairment, denial). This patient appears to have an adequate understanding of his illness and treatment, but other causes are not clear. His repeated cancellations may reflect his desire to avoid his medical issues and/or his fear of the physician's disapproval. The best initial approach is to empathize with the patient's difficulty and engage him in an open-ended discussion. The physician should strive to create an environment in which the patient feels comfortable discussing personal issues and difficulties that may be interfering with adherence. Communications that are empathic, patient-centered, and nonjudgmental will have the best chance of building rapport and engaging this patient in collaborative treatment planning. (Choices A, E, and F) Although further efforts to educate the patient about his condition and treatment or reinforcing the importance of daily medication adherence may be helpful, the first step is to build a treatment alliance so the patient does not feel judged. (Choices B and C) Although these statements convey concern, they may be perceived as critical or condescending. Educational objective: Physicians should explore nonadherence in an empathic and nonjudgmental manner and try to understand behavior from the patient's perspective. This will help build rapport and facilitate development of a united plan. References: Physician communication and patient adherence to treatment: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/19584762) Strategies to improve adherence with medications in chronic, 'silent' diseases representing high cardiovascular risk. (http://www.ncbi.nlm.nih.gov/pubmed/20528525)

A Long-Time Patient Comes to the Office for a Routine