There’s a particular kind of tiredness that sets in somewhere around the twentieth patient of a busy OPD. A patient comes back after three months. Blood pressure still high. HbA1c climbed again. The medicines barely touched. It’s tempting, on those days, to just think, why won’t they follow the treatment.
For a long time I called it non-compliance. Wrote it in the notes. Said it during handovers. It sounded clinical enough, neutral enough. Looking back, I don’t think I was being neutral at all.
There’s one patient who changed how I think about this.
She was in her mid-fifties, referred for hypertension that just wouldn’t settle. Three visits already, and each one looked almost the same. The notes said take your medications regularly, cut down salt, walk daily. She nodded every time. Her pressure came back high every time too.
By the fourth visit I was ready to give the same speech again. Something made me stop though. I asked her to just walk me through an ordinary day instead. When she woke up. What she ate. Who she lived with. And how, exactly, she was taking her tablets.
She said, “I was taking them doctor. Both of them. But the white one finished, and the shop gave me a different one. I thought it was the same tablet.”
She hadn’t stopped anything. She’d swapped a calcium channel blocker for an antacid because the strips looked alike and nobody at the pharmacy had bothered to check. She didn’t know the names of her own medicines. Just that she had “tablets for the pressure.”
That one conversation shifted something in me.
I started paying attention to how much of our counselling is really just us talking at people. We explain, they nod, we write patient counselled in the file. Counselled about what though. That hypertension is a chronic condition? That it affects the kidneys? Those facts are true, sure, but they’re nothing like knowing which white tablet goes before breakfast and which one can wait till after lunch. There’s a big gap between what we teach in five minutes and what someone actually needs to survive on for the next twenty years, and most of us never stop to measure it.
Then there’s cost, which we almost never ask about directly. Once I started asking, some of the answers were hard to sit with. Patients prescribed four medicines quietly buying two because that’s what they could afford that month. Some rotating which two, depending on when they got paid. A lot of people skip the “less important” one first, usually a statin or an ACE inhibitor, mostly because it’s the one they can’t feel working. It’s not carelessness. It’s someone doing the maths with too little information and too little money.
We write a prescription and call it treatment, but really the prescription is just potential. The actual treatment starts once the patient walks out of our clinic and back into their life, where the tablets have to compete with a busy household, an opinionated relative, a confusing label, something they read on WhatsApp, or just plain forgetting. That part is invisible to us. It’s also where most of the real work happens.
Diet is its own separate mess. I’ve had patients newly diagnosed with diabetes cut out rice completely because someone told them rice was dangerous, then load up on roti instead because wheat “felt safer.” Patients eating unlimited fruit because it’s natural. People fasting for festivals without touching their insulin timing, because it never crossed their mind to mention it, and it never crossed ours to ask.
I don’t think any of this comes down to people being careless or not smart enough. It’s what happens when fifteen minutes is expected to carry years of nutrition advice into someone’s actual daily life, and it just can’t.
Medical school taught me the diseases very well. My patients taught me what actually living with them looks like.
I think about the practical side of things more now too. Someone working a twelve hour shift, then going home to cook for five people, when are they meant to fit in a thirty minute walk. An elderly patient living alone who can’t always get to the pharmacy easily. A joint family where one person runs the kitchen and doesn’t rate this particular doctor’s opinion very highly. None of that is an excuse. It’s just what real life looks like outside our clinic room, and our treatment plans have to survive inside it somehow.
I haven’t landed on any tidy conclusion. Some afternoons I still get frustrated. I still catch myself halfway into the same old counselling speech before I notice. What’s different is I stop sooner now, and ask a few more questions before I start handing out answers. I’ve also started writing out what each tablet actually does, an idea a pharmacist friend gave me once. Not just the drug name.
This one stops your pressure spiking at night.
This one protects your kidneys.
This is the one you never skip, no matter what.
I’ve slowly come around to thinking the compliance problem isn’t really one problem. Some of it is translation. Some of it is money. Some of it is just what happens when a complicated, lifelong condition gets squeezed into a short, rushed appointment. And honestly, some of it is on me too, for not listening properly. That part I’m still working on.
Over her next two visits, her blood pressure came down.
We hadn’t changed a single medicine.
We’d just finally had the right conversation