Why It’s So Hard to Follow Medical Instructions

Why It’s So Hard to Follow Medical Instructions

A friend recently contacted me for some guidance in encouraging her relative to wear continuous positive airway pressure (CPAP) to treat his sleep apnea. Having worked in the sleep world for 20 years now, I am very familiar with this struggle. In a 2008 study, Wolklove et al found that 31{0577333bb3a455604d8cc2e627147e6f09bad6acf3cd9976a213fc3d66388fd6} of study participants never even filled their prescription for the device! An additional 15{0577333bb3a455604d8cc2e627147e6f09bad6acf3cd9976a213fc3d66388fd6} stopped using the device after initially filling the prescription, which means that almost half of their study population was not treating their sleep apnea.

Risks of untreated sleep apnea include high blood pressure, heart disease, diabetes, metabolic dysfunction, daytime sleepiness, and even death- yep, Carrie Fisher’s death has been attributed to untreated sleep apnea in addition to her various substances. We often think of sleep apnea as being caused by weight gain, but it actually can be responsible for the metabolic issues that create weight gain; one of the brain’s go-to responses for lack of sleep is to increase cravings and consumption of carbohydrates. Being treated for sleep apnea can help you breathe better, avoid risks of cardiovascular disease, and possibly even lose weight, yet almost half of all people who need it won’t use it.

Being treated for sleep apnea can help you breathe better, avoid risks of cardiovascular disease, and possibly even lose weight, yet almost half of all people who need it won’t use itThis may seem like a problem specific to one medical treatment (who wants to wear an annoying mask anyway?), but the truth is that adherence to treatment tends to be a widespread challenge, whether we are talking about medical interventions, lifestyle changes, or psychological therapies. According to a World Health Organization report in 2003, only 50{0577333bb3a455604d8cc2e627147e6f09bad6acf3cd9976a213fc3d66388fd6} of people in developed countries use the medication in the manner in which it was prescribed and we would see a significant decrease in chronic disease if we could only increase treatment adherence. Consider how many people join the gym in January, only to stop going a few weeks or months later. So, what makes this so hard?

1. Personal Factors:

Literacy to treatments remains an ongoing issue throughout developed countries, which is not helped by our tendency to prefer sound bites in science data. For instance, how many times have you heard that red wine is good for you versus how many times you hear it is bad for you? Health literacy is an issue, but so is efficacy for health interventions. Do you believe the treatment will work for you and do you believe that you can follow the recommended treatment?

When I am working with someone on sleep intervention, I can usually tell when I might have lost someone’s willingness to follow instructions by the way that their eye contact starts to drop off. I try to take this cue to back out of instructor mode and back into collaboration. How many times have you heard a clinician’s instructions and thought to yourself, “I am never going to do that”? Do you speak up and let them know?

2. Clinician Factors:

Adherence is highly influenced by the mode in which the instructions for the treatment are delivered. In the past, I had a physician who was frustrated by the fact that their patient seemed more willing to follow instructions after I had reviewed the treatment plan with them. The difference between our message delivery was really related to time- I had more time with the patient so could get into more depth about their reasons for following treatment.

Why It’s So Hard to Follow Medical Instructions3. Healthcare System Factors:

As the healthcare debate rages through the US, access to care remains an issue. Many clinicians (myself included) have moved out of participation with insurers due to ongoing drops in reimbursement and increases in requirements to be a part of the network. A large portion of our annual healthcare costs are related to the paperwork that revolves around health care, and these escalating costs force people into decisions between medication or food. Insomnia treatment has psychological intervention as its gold standard, but there are very few trained clinicians and access to care is an ongoing challenge along with the expectation of paying out-of-pocket.

4. Societal Factors:

If you have ever tried to follow a healthier eating plan, you are painfully aware of the options for food choices and the wide range of opinions that exist. Even for people who are good at digesting clinical information, the studies and results have a wide degree of variance. Once established, people can also be very firm in their beliefs.

Research on food choices and eating patterns is extremely complicated because many studies rely on diary report of past behaviors rather than experimental intervention. It’s kind of like when my physician asks me how many glasses of wine per week I consume- chances are that the number I report will sound healthier than reality, even if I am not intentionally trying to modify my answer. The social circles in which you travel actually have some direct implications on your health behaviors, whether it is food, alcohol, exercise, sleep or even medication adherence.

patients aren't following medical instructionsSo, the next time that you are wrestling with a family member who won’t follow through with doctor’s orders (or even yourself), try to do some exploration about what barriers get in the way. Identifying specific barriers can help move the needle forward in overall health.

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Dr. Kristin Daley
Dr. Kristin Daley received her doctorate in clinical health psychology from UNCC. In addition to her doctoral training, she is one of approximately 200 psychologists who completed their certification in behavioral sleep medicine. She is passionate about assisting people in moving into healthy places in life, and spends her free time with her husband and three children.


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