Strategies to assist patient compliance with lifestyle changes

Introduction
Many of the serious, debilitating and even deadly diseases confronted by doctors are significantly contributed to by the patient's lifestyle. Lifestyle modification is often the most effective treatment available and is frequently the most cost-effective.¹

Patient compliance with our earnestly repeated entreaties to 'lose weight', `stop smoking', `exercise', etc. is the exception rather than the rule. Time and energy expended in counselling for lifestyle change often seem wasted in the face of the implacable resistance to change the majority of patients seem to display.²

Most doctors will remember patients who have made unexpected and often sudden lifestyle changes. Such changes may seem to be unrelated to our medical input, merely a chastening reminder of our limitations. At other times, we can identify an event which seems to have catalysed the process of change, something that causes a re-evaluation of the patient's priorities, values or beliefs. The challenge for us as medical communicators is to create such events in our consultations. This challenge can only be met from an understanding that such moments are primarily emotional, not rational.

Reason and emotion
A decision to make a change in lifestyle is not made primarily on the basis of reason or logic. If such factors were as important as we like to believe, then sensible changes would follow appropriate information - smokers would read the warnings on the packets and simply quit.

It is emotion that predicates change. When reason alone dictates, denial and rationalisation soon follow. The paradox rests in the observation that our rational mind seems to persist in the irrational belief that reason is the most influential of our faculties in spite of overwhelming rational evidence to the contrary. Try falling in or out of love on purpose.

Rapport
Influential communicators are those who engage the emotional faculties of their listeners. They have high levels of rapport. They speak to the deeper forces that notionally reside in the limbic system, rather than the rational neo-cortex.

Curiously, one of the most effective communication tools in this respect is listening. The doctor who listens well, reflecting the content and the emotion of the communication from the patient, is inevitably more influential.

Reflective listening
Reflecting content and emotion allows the patient to know that they have been heard and understood. Generally, patients are not ready to listen until they know with certainty that they have been listened to. The expert communicator is one who is able to respectfully match the style of the patient's communication whilst reflecting content and emotion. Using the patient's own words often accomplishes this both simply and powerfully.

It is not necessary to agree with the patient; simply to listen and respond without immediate disagreement is sufficient. Articulation of other evidence and contrary beliefs is most effectively postponed until the patient is ready to listen.

Specific strategies

Sharing concerns
In the context of the medical consultation, doctors often give advice in the form of instructions, e.g. `You should stop smoking'. Unfortunately, the result of such instruction is usually unrewarding, strengthening oppositional thinking. This is because, when seeking to evaluate the proposition in an attempt to answer the inevitable 'Why?', the patient will review, refresh and strengthen all the reasons for the contrary action. The doctor will either hear the familiar litany of justifications or gain apparent acquiescence at the time, only to discover a problem of non-compliance later.

A more effective, indirect method of saying the same thing is for the doctor to share genuine concerns with the patient, e.g. 'I am really concerned about your smoking'. Patients must then evaluate this proposition to answer the same 'Why?' question. In doing so, they inevitably review, refresh and strengthen all the reasons for the doctor's concern. More specific messages can be used whilst repeating the original concern, e.g. 'I'm really concerned about the effect your smoking is having on your blood pressure'.

The drug doctor
Dr Michael Balint coined the term 'the drug doctor' in 1957.³ With it, he sought to illustrate the potency of a doctor's involvement with a patient and the power of mutual expectation of a particular therapeutic result.

In clinical trials, we encounter this problem as the placebo effect and have devised the randomised double-blind controlled trial to circumvent it. Control patients commonly have significant responses to placebo, often as much as a half of the treatment effect.

The inverse of this problem is a therapeutic virtue. When a doctor expects both compliance and a response, and carries the patient along with that belief, each is more likely to occur.

Lifestyle prescription
As doctors, we are well educated and experienced in writing prescriptions. We have clear and specific ideas of the therapeutic result we seek to create and of the means we have chosen. The patient leaves our office with precise and concise written directions for the pharmacist. Our clear and specific intention is then communicated to the patient through labelling, consumer medicines information and the pharmacist's advice.

How many of us are similarly well educated and clear in our 'lifestyle prescriptions'? Often we talk in vague generalities about exercise, weight modification or stopping smoking, but our recommendations lack clarity and specificity. We leave the patient as unclear as we are and meaningful change is unlikely to follow.

Lifestyle prescription pointers:

– be specific and detailed in your recommendations

– break down big tasks into smaller, more easily achievable pieces

– deliberately personalise lifestyle prescriptions for the individual

– write lifestyle prescriptions down in the patient's presence

– use simple `bullet point' lists

– use handouts only as an adjunct to a personalised lifestyle prescription

– be educated about all the possible choices and options open to the patient

– be authoritative rather than authoritarian

– include plans for follow-up, monitoring (including self-monitoring) and reinforcement

Follow-up
Follow-up is an essential part of any prescription for a chronic condition. It certainly needs to be part of a lifestyle prescription, but may be seen as intrusive and be resented by patients who like to be in control of their lives themselves. The challenge for the doctor in dealing with these patients is to achieve compliance with both the follow-up program and the medical regimen.

Alternatively, follow-up may be received as a welcome validation of the doctor's genuine interest and concern, particularly by patients who prefer to let the doctor be in control. Such patients are often compliant, particularly with the follow-up process, but achieving compliance with the medical regimen may present greater challenges for the doctor.

In each case, the degree of success largely depends on the doctor's behaviours, attitudes and beliefs.

The partnership principle
The doctor who uses the partnership principle will greatly improve compliance with follow-up. Using the partnership principle, the doctor forms an alliance with the patient against the condition. Therapeutic successes strengthen the alliance and failures refocus attention on the condition and not the individual. Failure thus becomes a stimulus for further change, rather than an opportunity for blame, justification and denial.

However, mere compliance with follow-up does not necessarily predispose to successful change. Many patients will assiduously attend follow-up visits because this is much easier than making the lifestyle change itself! In this circumstance, practitioners can use the partnership principle to advantage by addressing the apparent compliance at one level (the level of follow-up) with the lack of results at the other. The patient can be invited to recognise that results are not being achieved and therefore the partnership needs to seek a more successful method or cease the existing approach.

The partnership principle particularly assists with patients who want the doctor to make medical decisions for them. Experienced practitioners will recognise this seductive trap as leading to dependence and the expectation that not only will they then take all the decisions, but they will also take total responsibility for the outcomes!

The essence of gaining compliance with lifestyle prescriptions is for patients to take responsibility for their own health. By asking the doctor to make all the decisions, the patient is withdrawing from equal participation in the partnership and from any responsibility for the results. Faced with this withdrawal, the doctor can most usefully withdraw to the same degree by gently but firmly refusing to make decisions for the patient. This emphasises the patient's ownership of the health problem and the attendant responsibility to themselves to be actively involved in its solution.

Choices
Patients are more likely to comply with lifestyle prescriptions when they are actively involved in them. One of the easiest ways to ensure such involvement is to offer choices. Very few medical encounters offer no choice of possible therapies. Even in these few, there is invariably the choice of doing nothing, which the patient is always at liberty to choose.

Offering the choice of doing nothing is a powerful stimulus for patient involvement: `Of course, we could always do nothing about your blood pressure, but you will need to accept the increased risks of heart attack and stroke as you get older.'

From this perspective, non-compliance is simply the patient covertly exercising the right not to accept a particular choice of treatment and to take the choice of doing nothing. Rather than blame the patient, or the doctor, we can thus more productively acknowledge the choice actually being made and review the current range of choices.

Choices, responsibility and the partnership principle
Offering choices allows the delineation of responsibilities in the medical encounter to be clearer and more precise. Making choices inevitably implies taking responsibility. The doctor takes responsibility for informing and educating the patient about the benefits and consequences of each choice. The patient takes responsibility for the selection and for compliance with that choice. This approach fits well with the partnership principle.

Successes become successes of the partnership alliance against the illness. Failures and adverse reactions become an opportunity for the mutual re-appraisal of the choices available. Such a re-evaluation of choices might easily extend to diagnosis, offering opportunities to share diagnostic dilemmas and uncertainties and their attendant choices with the patient.

When the doctor applies the partnership principle and offers choices, the differential responsibilities inherent in the process become clarified. The patient is responsible for making choices; the doctor is responsible for the accuracy and clarity of information presented to allow the choice to be made. The patient is responsible for carrying through the necessary actions (including attending for follow-up); the doctor for monitoring, appropriate feedback and the delineation of further choices.

When lifestyle prescriptions are approached in this way, the likelihood of the patient sabotaging progress is minimised. Even if it does occur, the doctor also benefits from the partnership principle, in that the persistent sabotage of appropriate medical management can be viewed as the patient exercising a choice outside the partnership-agreed options. The partnership principle allows a solution to this dilemma by focusing on the sabotage as a legitimate problem for prior resolution by the partnership. Here again, the patient is free to exercise the right to choose no action just as the doctor is then free to choose to discontinue treating the patient.

Doctors' lifestyles
As doctors, we are not good at acknowledging our own needs for lifestyle change or acting rationally upon them. Relatively few doctors follow all or even any of the lifestyle prescriptions we blithely expect our patients to comply with simply because we tell them. The deep incongruity of our stated position with our own actions inevitably appears in our own non-verbal communication. Patients are consciously and unconsciously influenced by such incongruity and much of the power of our words can be lost.

Doctors who live out their lifestyle prescriptions in their own lives will live healthier and longer, influencing their patients accordingly. They will have healthier practices as a result of their healthier practises.

Conclusion
Patients' low rate of compliance with lifestyle change recommendations⁴ can certainly be improved with a good communication technique. However, it seems to be difficult for doctors to recommend healthy lifestyle changes consistently and persistently. Perhaps due to the poor success rate, we feel our efforts are not well enough rewarded, although the evidence suggests substantial health benefits for our patient populations when we do make the effort.^1,4,5

Certainly, to persist with lifestyle change recommendations when the overwhelming majority of our recommendations are rejected or ignored requires a strong rational sense of its undoubted value and purpose. It is easy to allow our own emotions to subvert reason. This is particularly so when our own core belief systems are fragile, as our profession's own attention to lifestyle matters suggests.