NO IMPROVENT / SLOW IMPROVEMRNT

DR.M ABBAS SUBHANI
 MBBS DCH

Majority of the patients improve with the timely administration of appropriate treatment, but not all. Some of the patients either do not improve or improve very slowly. Knowledge on the part of the physicians about the possible reasons of poor improvement increases the chances of improvement of their patients and speeds it up.

FOLLOWING ARE THE REASONS

1-INEFFECTIVE PLAN INCLUDING IT'S IMPLEMENTATION

2-ILLNESS IS ADVANCED/ COMPLICATED/RECURRENT OR INCURABLE

3-ASSOCIATED CONDITIONS IN THE PATIENTS

4- NONCOMPLIANCE

5- FALSE STATEMENT OF THE PATIENT (DENIAL- PATIENT HAS IMPROVED OR IMPROVING BUT DOES NOT ADMIT THIS)

Correct diagnosis is must for effective treatment, otherwise inappropriate treatment is chosen. IF THE PATIENT IS NOT IMPROVING REVISE THE DIAGNOSIS. Implementation of the plan is as important as the plan itself. If the plan is not applied and explained properly either by the physician or nurse or pharmacist, patient does improve.
SPEND SOME TIME ON THE EXPLANATION OF PLAN, IT IS HIGHLY REWARDING.

Patients suffering from complicated illnesses e.g.-malaria either do not improve or improve slowly. Recurrence and/relapse also obstruct the improvement, e.g.- asthma/malaria. Resistant infection is also a cause of poor improvement (it may be due to the use of sub-therapeutic doses. RARELY THE ILLNESS MAY BE INCURABLE (THALASAEMIA PRESENTING AS ANEMIA). DO NOT FORGET THE POSSIBILITY OF IATROGENIC COMPLICATIONS

IF THE PATIENT IS NOT IMPROVING CONSIDER THE POSSIBILITY OF COMPLICATIONS/RESISTANCE/RECURRENCE/RELAPSE OR INCURABLE ILLNESS

Associated conditions in the patients e.g.-malnutrition/congenital heart diseases may lead to advancement of illness and change them into completely or partially incurable illness.
Non compliance on the part of the patient also hampers the improvement.

Very rarely the patient improves but does not admit this fact. CONSIDER THIS POSSIBILITY ONLY AFTER THOROUGH AND LOGICAL EXCLUSION OF ALL OTHER POSSIBILITIES

NONCOMPLIANCE

NOT COMPLYING WITH THE PHYSICIAN?S ADVICE IS NONCOMPLIANCE. IT MAY BE FOR FOODS/ENVIRONMENT/INVESTIGATIONS/DRUGS OR ALL OF THEM. OCCASIONALLY IT MAY BE INTENTIONAL
It is the duty of the physician to find out the existence of noncompliance and it?s reasons. After finding the reasons physicians should guide their patients to remove/ reduce the chances of noncompliance.
IF THE PATIENT IS NOT IMPROVING OR IMPROVING SLOWLY CONSIDER THE POSSIBILITY OF NONCOMPLIANCE

FOLLOWING ARE THE COMMON REASONS OF NONCOMPLIANCE

1-MISCONCEPTIONS ABOUT VARIOUS ASPECTS OF ILLNESS
(About cause, presentation, investigations and treatability of illness)
If the patients do not realize the diagnosis and nature of the illness, they either discontinue the treatment or resort to other form of treatment. Some attendants do not admit that a child can suffer from asthma. Some attendants falsely consider bronchopneumonia as common cold and their attention is focused on warming up the baby and avoidance of cold foods (their perception) rather than on the suggested treatment.
Illnesses without apparent sufferings or manifestations are common cause of noncompliance e.g.-early Rickets/asymptomatic intestinal worms
MISCONCEPTION THAT NORMAL INVESTIGATIONS RULE OUT THE ILLNESS IS A VERY COMMON CAUSE OF NONCOMPLIANCE e.g.- x-ray chest without any abnormal finding in early Tuberculosis
Some illnesses are falsely believed to be incurable e.g.-tuberculosis. SOME ILLNESSES ARE TREATABLE (TO A LARGE EXTENT) BUT THE TREATMENT IS NOT ACCEPTABLE e.g.-Repeated blood transfusions in Thalasaemia . If the illness is recurrent e.g. asthma the given treatment is considered ineffective and either discontinued or changed

2-TREATMENT RELATED
*Not understanding the need of treatment * Cost of treatment *Fear or actual development of side-effects *No/slow improvement * False feeling of complete cure *Inconvenient form and timings of the drugs
SOME OF THE ATTENDANTS DO NOT REALIZE THE NEED OF THE ADVISED DRUGS, e.g.-cough caused by sinusitis need the treatment with antibiotics, but the attendant may think only cough syrup is needed and do not give the antibiotics
SOMETIMES ATTENDANTS DISCONTINUE THE DRUG SINCE THEY CAN NOT AFFORD IT.
ATTENDANTS MAY BE MISGUIDED BY FAMILY MEMBERS OR OTHERS (side effects are magnified). Fearing this attendants discontinue the drug. If the improvement does not occur or it is slow attendants may consider the drug ineffective and do not use it.
False feeling of complete cure is a very common cause of noncompliance e.g.- not completing total duration of anti-tubercular treatment.
Inconvenient form and timing may be a cause of noncompliance e.g.-injections, 4 or 6 hourly use

3-BECAUSE OF THE SUGGESTIONS OF OTHERS
Some times family members, neighbors, pharmacist, practitioners of other system, spiritual healers, even other physicians may suggest that advised treatment is not suitable for the child and other better treatment options are available. This can lead to noncompliance
SOMETIMES MESSAGES IN THE MEDIA ARE NOT UNDERSTOOD BY THE ATTENDANTS IN THEIR TRUE SENSE THIS CAN CAUSE NONCOMPLIANCE e.g. *the message given in the media is *treatment of diarrhea is O.R.S* attendant may think that only O.R.S is required and they do not use other drugs.