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April 2005


“But Doctor ...” An Invitation to Listen?
By Richard P. Mills, MD, MPH

Ophthalmologists communicate with patients all day long. Mostly, patients reward our communications with, “Thank you, doctor.” Or “Thanks for spending time with me.” Once in a while, a patient will utter the word “but.” It’s usually phrased diminutively, almost apologetically, in the context of a give-and-take about therapy. Most of the time, the objection seems trivial, the sort of thing that any informed individual would not dwell upon. It is easy to pick up the challenge and counter the objection that follows the innocent “but.”

After years of doing so, I’ve learned not to do so. Nowadays, for me, the word “but” is like a giant stop sign, quite different from the socially argumentative conjunction listed in the dictionary. Why? The word “but” from a patient is not an invitation to argument, it is a statement that the patient does not intend to comply with the treatment plan. It is not a position subject to modification based on reasoned argument. In fact, reasoned argument is a waste of time.

Nowhere is this more evident than in the treatment of ophthalmology’s chronic disease glaucoma. It’s what I spend my professional life treating, and I am continually reminded about the big disconnect between what I think patients are doing and what they actually do. The fact of the matter is that I am mostly clueless about how well my patient is complying with the treatment plan. There is plenty of literature to suggest that most physicians vastly overestimate the degree to which patients adhere to their prescribed treatment.

Joyce Cramer, BS, at Yale, has spent her career studying patient compliance. She writes, “The typical assessment of medication compliance is similar to the assessment of an iceberg from the ship captain’s window. . . . On average, patients treated for a variety of medical disorders take approximately 75 percent of doses as prescribed, irrespective of the potential for negative consequences.”1

Neuropsychological correlates show that compliance is not correlated with intelligence, memory, personality disorder, age or educational level. As might be expected, the number of doses correlates strongly with noncompliance, but surprisingly the number of medications does not, since patients tend to take all their pills together. (It might be different with eye drops that should be spaced at least five minutes apart, so there’s time to forget to instill the second or third drop in the sequence.) A study of elderly patients newly treated for hypertension revealed that they filled prescriptions adequate to cover 49 percent of days during the first year.2 So, compliance involves not just regularity of dosing, but persistence with the treatment over time.

When I was growing up, my dentist told me that my teeth would fall out if I didn’t floss after every meal. My reaction for 30 years was to floss regularly for the 24 hours prior to each dental appointment. After my gums predictably deteriorated, I ran across a periodontist who listened to my “but doctor” and said that some dentists thought once a day was probably good enough, and it was certainly better than what I had been doing. I felt liberated, and I began complying. I could do once a day. And I still have my teeth.

1 Heart 2002;88:203–206.
2 Monane, M. et al. Am J Public Health 1996; 86:1805–1808.