It's the Behavior...

With only a slight variation from the 1981 James Carville election campaign quote, “It’s the economy, stupid!” We don't have to make a giant leap when it comes to provider’s increasing their patients chances of following their plan of care: it’s the behavior!

Change the name and call me in the morning... We love to re-label things in the hopes that finding the correct word will improve or change perceptions. Years ago, when I was a Green Beret in the 3rd Special Forces Group, the word came down from Washington bureaucrats that we could no longer use the word “guerrilla” as in guerrilla warfare. The new politically correct phrase was “Internal Defense and Development.”  Nothing else changed.  Our mission remained the same except for the fact that we were no longer “guerrilla warriors.”  Back then, when people asked what I did, I told them that I was an “IDAD warrior.”  Most agreed that being a dad was a tough job, but did it really rise to the level of going to war with my kids? Well, sometimes, YES! But that was not what I meant.

You say adherence and I say compliance… For those of you who may remember the song “Let’s call the Whole Thing Off” by Louis Armstrong and Ella Fitzgerald, substitute the words adherence and compliance for the lyrics “You like potato and I like potahtah…” and see if that little tune isn’t still ringing in your ears when you reach the end of this article. For those of you not familiar with the tune, go to this YouTube site and listen.

The term “compliance” was satisfactory for several millennia until late in the 20th Century when the label fell from grace. In the July-August 2010 issue of Geriatric Nursing, the authors stated in their title, “Medication Adherence is a partnership, medication compliance is not.”  Adhere means to stick with and Comply means to go along with. Is there really a sufficient difference in going along with the plan of care to state so emphatically that either term is not a partnership? You say adherence and I say compliance. Festhalten or Beachtung? Adhérence or conformité? Adrenza or conformitá? The World Health Organization reports that 50 percent of the world’s population is inadempienza or nichteinhalten. Has the emphasis on label change really made a difference over the years since the name change debate started? The debate was to ensure that providers were more "patient centered" and adherence was more reflective of inclusion. If you really want to be patient centered you need to understand the science of behavior and spend less time parsing the definitions of words.

Neither compliance nor adherence are behaviors…  They are labels!  The great compliance/adherence debate, thankfully has begun to subside. It only took a decade or two, killed thousands of trees for publishing hundreds of articles and really made no difference in the total numbers of people following their plan of care. In the centuries following Hippocrates through the 20th Century,  50% of the people went along with their plan of care and 50% did not.  A decade and a half into the 21st Century, 50% of the people follow their plan of care and 50% do not. Changing names has not changed behavior. Changing consequences and reinforcing desired behavior will change behavior. Like any other habit, it takes time and a lot of reinforcing. A prescription and the directions to “See me in a couple of months” has a 50/50 chance for success. Batting .500 in baseball will make you a hero and very wealthy. Batting .500 in medicine will cause significant heartburn.

If your pet rock has behaviors… send a video to YouTube.   Most of the research indicates that the primary reason people are not following their plan of care is related to behavior. Taking a pill by mouth is a behavior. Not taking the pill is not a behavior. Dr. Ogden Lindsley came up with the “Dead man” test to show what a behavior isn’t.  In his behavior based world, if a dead person could do it perfectly, it was not a behavior. When I was a nursing student, many years ago, my primary clinical instructor directed me to observe Mrs. Smith and then write an appropriate nursing note. Following my observation, I wrote of the 86 year old patient, “Mrs. Smith is resting quietly and is in no apparent distress.” My clinical instructor, Mrs. Burroughs, was a 60+ year old nurse with many decades as a practicing nurse. She reviewed my note and said, “Very nice, Mr. Wright” and off she went to the next student. I believe the first question

Dr. Lindsley might have asked after reviewing my note, however, “Was she dead?” Dead people, after all, can rest quietly in bed and be in no apparent distress. Because we deal with life and death on a daily basis, let’s change “dead man” to “Pet Rock.” If your pet rock can do something perfectly, then it is not a behavior. Pet rocks can rest quietly in bed and be in no distress. Rocks can be non-adherent and non-compliant and it really doesn’t hurt their feelings if you use compliant or adherent. Describe the behaviors that demonstrate compliance. More importantly, describe the behaviors that everyone you work with can agree. Pet rocks will not take medications as prescribed. Pet rocks can forget. If you don’t believe that, go find one and ask if it took its medication. If the rock answers you, it’s a verbal behavior and like the burning bush of Biblical days, it is a sign. Pay attention. Compliance and adherence are labels and not behaviors. Go back to your pet rock and direct it to not move or lay still. The rock can do it perfectly and without hesitation. It is therefore not a behavior and the rock doesn’t care whether it complied or adhered.

Not doing is not a behavior…Behavior is what a man does. It is not what he thinks, feels, or believes.” (Emily Dickinson) “I forgot!” It’s the most popular get out of jail free card for patients who do not follow their plan of care. Forgetting represents about 25% of the reasons given by people when they don’t take their medications. From the patient’s perspective, “I forgot” really means something else is going on and I don’t want to share that information with you. It may also mean that, as their provider, your reaction to their behavior may not be as punishing if they tell you they simply forgot.

Astra-Zeneca and Frost and Sullivan also showed inconvenience, expense, side effects, accepting [the illness], and distrust as “behaviors,” for causes that patients use for not following the plan of care. These behaviors are actually consequences -- not behaviors!  We can, however, develop plans to change the consequences and reinforce the actual behaviors that we need our patients to develop into habits.

Choice was the only item in their list of eight that is actually a behavior and choice is affected by the consequences listed above. Behavior is always about consequences. “Illness” was the eighth “behavior” shown in this study. Illness is an antecedent to behaviors related to self-care or seeking care. Without illness, there would be no need for a provider to prescribe a plan of care. Antecedents get the patient to act at least once. Consequences, such as those listed above, will with high levels of confidence, stop desired behavior.

If you want to increase patient’s following your plan of care… Spend more time learning about behavior. Taking pills has a lot of consequences that we need to explore with our patients. Some consequences are negative and the patient is aware of them. The therapeutic effects of prescribed medications may be good for the patient. Unfortunately, they are not perceived by the patient and the consequence is noncompliance. People go with what they perceive as good and stop things that are perceived bad (cost, side effects, imposing schedules, etc.). Increasing desired patient behaviors requires an applied behavioral approach and is not a single visit epiphany. New habits take time and reinforcement. New labels take only a minute.

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