Medical Student Reflection II: Change in Volume per Unit Change in Pressure (dV/dP)

by Academy of Clinical Excellence on March 5, 2012

I have never had a patient who was completely non-compliant. As a rule, the bones are non-compliant, but the muscles and subcutaneous tissues are almost always compliant...I have had a number of patients who chose not to follow my advice. It is quite likely that the problem was with me, not with the patient. I had failed to spend enough time to persuade the patient of the presumed wisdom of my advice or perhaps I had not got to know the patient well enough to understand why the advice would not be attractive. That failure on my part does not justify appropriating a word from the physical sciences to hide behind while blaming the patient.
– Dr. Joseph Sapira, Sapira's Art & Science of Bedside Diagnosis
Semantics is a tricky thing. When we think about the meanings of the words we say, the result is often eye-opening. Of course, the truly difficult thing is finding the time—as medical students, we are quickly caught up in acquiring new phrases while climbing the steepest part of the learning curve that has more to do with physical exam skills, diagnostic testing, and evidence-based medicine than grammar, phrasing, or double-meanings. Learning to speak the sometimes archaic language of the body and its diseases is one of the skills that sets medical professionals apart from the lay public, but this heedlessly indoctrinated vocabulary can be harmful to our patients and ourselves.
Take, for example, the concept of compliance. Originally a term from physics for describing how a specific substance relates volume and pressure, compliance is now used to assess whether or not the patient is following doctor's orders. Although putting the patient in the backseat with the doctor refusing to let go of the wheel is unsettling, the danger truly comes when someone is labeled “non-compliant.” That patient is now often viewed as subversive, stubborn, or unwilling to listen—an embodiment of a waste of time and resources.
I started thinking about the how much I dislike the term compliance in regards to patients on rounds last week. When the resident presented the new patient, there was “a question of compliance.” She had brought her bulging bag of full pill bottles, but her diagnosis was directly related to not taking her medicines yet again. Leading the already frustrated team into the room, the doctor leading rounds said, “We are not getting at the heart of the problem. Let's talk to her.” She began a gentle discussion with the patient, not about the need for her to take all these pills, but about how hard it is to be a single mom. How much she receives a month and where the money goes. What her kids like to do. Who puts out her medicines and how many times a week she forgets. How her appointments are all over town. Why she says she doesn't trust her doctors. How she thinks her disease is affecting her body and one thing she would fix. Some of her answers surprised us but more importantly, gave us insight into who she was. We understood a little bit how the pressures of being a single mom have squeezed out her ability to care for herself with a chronic disease in a difficult health care system. We left, initial plan in place, labels forgotten.--Helen Prevas, MS IV

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