Adherence vs Compliance

Is adherence better than compliance? I recently saw a doctor tweet a list of words he hates to read in patient charts. One of those words was compliant. He indicated adherent was superior, always. I’ve been thinking about that in light of the difficulty many of us have in complying with medical advice – including specialized diets.

I know, it may seem like semantics. But maybe in this case semantics matter. And I think this doctor makes an important point.

To get the greatest benefit from medical advice, patients need to adhere to plans developed by their medical team and agreed to by them. But I’ve most often heard this described as compliance, not adherence.

Why does this distinction matter?

In the strictest definitional sense, compliance means acquiescing or yielding, especially in a weak or subservient way. I don’t want to feel weak or subservient when it comes to decisions about my health. I’m pretty sure no one does.

I strongly believe in patient-centered care. In such a system, the patient is a valued part of their medical team. I’m not sure you can feel valued as part of the team when are related to by medical professionals as though you are, or should be, weak and subservient.

And let’s be honest, many times there’s pressure from medical professionals for patients and families to behave in a subservient way. If they do not, they may receive dismissive or condescending treatment. When this happens, it seems predictable that patients will tire of such treatment and rebel.

If a doctor talks down to, bristles at questions, fails to explain, or refuses to listen to patients, that physician is not going to be as likely to get a buy-in on a prescribed health plan. If that professional perceives there is pushback and relies on a position of superiority to attempt to enforce compliance, the patient will rebel even more.

And why not?

Our lower brains may perceive this kind of pressure as danger. When that happens, the patient must try to somehow twist their being into compliance while feeling they could be in danger. And the feeling of danger is exacerbated by a constant barrage of advertising pushing medications and health screenings.

Essentially, we’re asking people to do something very difficult to do. Intellect may not intercept the lower brains signals on a conscious level leaving behavior to be guided by survival instinct or reflex. Of course this won’t be true in every case. But it may be true often enough that we could improve adherence just by changing our rhetoric.

Adhering connotes steady devotion, allegiance, and attachment. In other words, if I choose to adhere to something, I embrace it. That sounds like the relationship I want when it comes to my health. I hope to embrace a plan that I perceive as the healthiest for me in any given moment.

Adherence places the patient back in a position of power in charge of their health. It is willingly given and does not require pushing at all.

Why not change our approach to seek adherence? When we treat patients in a manner that encourages them to embrace a plan, there will be no need for pushing, cajoling, shaming, or arm twisting them into compliance.

Could such a subtle shift make a difference?

There’s no way to really know until we try it. But if one physician has recognized the benefit, I’m guessing there are others. And if we as patients push for this change, we may get more palatable healthcare.

I feel like eating plans tailored to the needs of an individual and presented respectfully will make many dietary recommendations less objectionable and easier to embrace. That will take us a long way toward adherence.

Some may determine that adherence vs compliance is a bit potayto, potahto. I disagree. I feel like a shift toward adherence is just the shift we need.

Dig Deeper

When trying to eliminate foods that irritate, sometimes we have to dig deeper. Everything affects everything – allergies, sensitivities, disease process, gut microbiome, diet. Complex systems sometimes mean complex interactions. We want it to be simple, but sometimes it’s not. In order to be a productive member of our healthcare team, we may have to dig a little deeper and meticulously record our response to foods. 

Let’s dig a little deeper into histamine intolerance. When making food choices, it could be helpful to know that the level of histamine detected in canned fish has ranged from none detected to 657.05 mg/kg as compared to fresh fish which ranges from none detected to 36.55 mg/kg. That’s a big difference. And it partially explains why you might easily tolerate canned fish in one sitting and experience significant symptoms in another.

It can also be helpful to know that the high-end range for beer is 21.60 mg/kg and for red wine, 55 mg/kg. If you can tolerate gluten, beer (other than specialty GF) may be a better choice than red wine. 

And, of course, histamine consumption is cumulative so a meal of sausage (up to 357.7 mg/kg), sauerkraut (up to 10 mg/kg), and beer could leave you feeling miserable. Or maybe you pair sausage with spinach and red wine and end up missing your daughter’’s soccer game. Most of us want to avoid feeling miserable and missing out, right?

And yet it’s difficult to get the kind of specific information we need to make good decisions. And when you can find the information, some amounts will be listed in milligrams (mg). Others are listed in micrograms (mcg). Without moving lots of decimals around, it’s difficult to determine what indicates a high level or how one level compares with another.

In spite of growth in translational research, a grand gulf remains between research findings on diet and readily accessible, easy-to-understand, standardized dissemination of information to the general public. As patients, we’re often expected to follow guidelines that are so general (avoid fermented foods if you’re histamine intolerant) they seem off-base when we have sausage without beer and sauerkraut and still suffer.

No one is happy to follow a specialized diet. When a patient agrees to do so then experiences symptoms anyway, they are less likely to continue the regimen. They may even become less likely to comply with other doctors’ orders. 

I can talk all day about the need to dig deeper and even if you’re willing to and have unlimited time, you may find that the healthcare system is not in a place to meet you in the middle. Translational research could be that place, well-care (well-child care) could be that place, holistic medicine could be that place, integrative medicine has some potential, but right now the gaps are great in all of these areas. The crux of the problem is insufficient communication and dissemination of information. Whether this is deliberate or results from low priority, it seems to be culturally pervasive. 

I know from personal experience how frustrating that feels. I still believe that digging deeper is worth it. But I understand that the time investment may not be realistic for everyone. 

The purpose of this post is to raise awareness that a prescribed dietary regimen may be appropriate. You may be complying with the guidelines you’ve been given. And you may still have symptoms due to incomplete information with which you’ve been provided and/or which is readily available for your condition.

Before you give the plan up as futile, you may want to dig deeper.