As a new clinician I am still developing my confidence and so I was actually quite surprised when I started having patients report significant improvements. Eager to learn, I always ask “Why do think you are getting better?” Invariably patients answer “I’ve been doing everything you recommended.” My reaction to this statement was a revelation: I was surprised! I realized that I wasn’t really expecting people to follow through with my prescriptions. I also didn't really know what to expect even if they did comply.
 
As far as I can tell there are at least three types of patients. There are some patients who will consistently and precisely do whatever you recommend without question. Then there are other patients who will only do what they want no matter what you say to them; and finally, there are the ones in between. For the first group, the only challenge is making sound recommendations. It doesn't matter how difficult or expensive these are, if the recommendations are good, the patient will get better. As for the second group, they have their minds made up and are unlikely to be persuaded to do anything they don't already believe in. These are the patients we may not be able to help. The largest group, of course, is the one in the middle. With these patients we have the opportunity to negotiate compliance.
 
This process of negotiating compliance can have several components. First of all, we need to accurately assess the patient’s capacity so that the recommendations we make are achievable. Next, we need to spend time educating patients as to the why they should do what we are suggesting. This step is essential for motivation. So many times I see patients taking medications and they don’t know why! Next we need to get buy-in.  Patients should leave their appointment feeling confident about their treatment plan and motivated to follow through. Finally we need to troubleshoot. We need to understand the challenges patients are facing in adhering to their prescriptions and work with them to modify their plan, educate them further, or simply remind and encourage them stick with it.
 
Although my experience is still quite limited, I’ve started to see that one of the biggest predictors of improvement in my patients is not a complicated diagnosis, a comprehensive treatment plan, or a precisely selected remedy. While necessary components, these become worthless if the patient doesn't follow the recommendations. As a result of this observation I have resolved to put more emphasis on these areas when making initial recommendations and devote more time to compliance counseling during follow up visits.