Through the Looking Glass of Noncompliance

Ashwini Kamath Mulki, MD

Fam Med. 2018;50(4):306-307.

DOI: 10.22454/FamMed.2018.420257

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The corner of my eye spots the chocolate frosted donut in our break room. Chocolate, my favorite! Just what I need after a busy patient session. I grab my quick meal and look at my watch, 12:50 pm. Munching sweetness and balancing my backpack on one shoulder, I lightly wave goodbye to my colleague as I leave the health center. My cell phone rings, a reminder: prepare learning lab for next week. Later, I think, as I jump into the car and hit the pedal hard. I’m trying to beat the clock now! The speedometer reads 10 mph above the speed limit when the sign of my obstetrician’s office suddenly appears and welcomes me. I’m here! Ten minutes late but basically on time, I reassure myself.

In a matter of minutes, I am called and follow the nurse to a patient room. She tells me to relax while recording my vital signs and shortly thereafter reads 148 lbs on the scale. That’s a lot for someone 5’2”, I think self-consciously. Trying to calm my racing heart, I take deep breaths and stare at the ceiling with beautiful butterfly prints. My legs dangle off the exam table as my hands clench the glucometer announcing past weeks’ readings: 120, 140, 160, 200. Oops, I missed my insulin dose, again.

“Knock, knock,” out go my thoughts and in walks the doctor with his clean white coat, kind smile, and gentle handshake. “How are you? Let’s see how the baby is doing,” he says in a friendly manner as he sets the measuring tape on my belly and then the doppler to hear her heartbeat. He turns to log in to the computer and I see my vital signs, pregnancy ultrasound report, and blood sugar logs. “The sugars are a little high... is everything ok?” the doctor inquires.

“I’m good,” I nod as I feel my daughter kick, “Really mom?”

The next day my nurse tells me, “Your patient is here for a routine diabetes follow up.” A short, dark -haired woman is seated comfortably on the corner of a wide chair; her smile familiar. “How are you Irene?” She cheerfully replies, “I’m good doc, how have you been, how is your baby?”

“We’ve been good, thank you Irene! I see you are here for your diabetes follow-up, is there anything else you’d like to talk about today?”

Her shoulders shrug. I pull up the screen in front of me, “A1C 12.” I click on the past three results to compare, and Irene’s eyes are glued to the screen with me: “A1C 13, A1C 11.5, A1C 12.”

“So, tell me what’s going well and what we can do better?” I say. She pauses. I wait for her usual response about more exercise, better control of sugary foods, and increasing the insulin dose. But Irene’s calm smile breaks into tears.

“Doc, I’m going to be honest with you today. I have not been taking my insulin for years. Not like I am supposed to. My husband is very sick and has a lot of doctor appointments. He doesn’t speak English and wants me to drive and be with him everywhere. He yells at me; sometimes he hits me. I don’t like it. But there is no one for him or for me. I feel bad…” Her voice fades. I feel numb. The lab results, the diagnostic algorithm, my medical skills; it all disappears. We hold hands. Tears roll down my eyes. I feel my daughter kick, “… So this is life?”

As a patient, doctor, teacher, and wife, it is hard to keep up with my own treatment plan. Medically, I am aware of how my blood sugars should be managed. Realistically, I can’t always keep up. Compared to a lot of my patients, I have privileges due to my education, medical training, and socioeconomic status, and yet I struggle with managing my own health care. I juggle multiple chores, deadlines, and try to suppress my shame at not practicing what I preach. In short, I am a noncompliant patient, and I know it. Being on both sides of the looking glass was a powerful reminder for me, the physician, to be nonjudgmental. When I saw Irene the next day, I was more vulnerable and emotionally open due to my own experience.

Now, when I hear medical students and residents mention noncompliance, I wonder about the unintended consequences of imposing this label on patients. While caring for patients like Irene, I often use the Clinical Hand1 as an educational aid. This tool serves as a curricular map specifying what content and skills are important for relationship-centered care. It reminds me of the conceptual, behavioral, spiritual, and functional aspects of patients’ lives that contribute to health. Often, like many clinicians, I used to focus solely on the medical aspects of a patient’s treatment plan. Listening to Irene with empathy, I realized that I need to also consider socioeconomic determinants of health. To be able to do this, it was crucial for me to form a relationship with Irene, which demanded openness on my part and hers. While compliance with a treatment plan was a part of restoring and maintaining health, her noncompliance was an indicator of the external (nonmedical) challenges that she faced, and not only an indication of her ability to follow through with diet, exercise, and medication. Avoiding labeling Irene noncompliant helped me get a better picture of her situation and ultimately helped with shared decision-making.

As a family medicine attending for the past 5 years, I still struggle to fully understand medicine. Not the numbers. Not the disease or the algorithm to manage it. I struggle to understand the lives. How do I untangle the mystery of each patient’s life? How do I help patients recognize health and meet their health needs, rather than focusing primarily on the treatment plan and their (in)ability to comply with it? To learn, to teach, I continue with patience, one patient at a time.


Acknowledgment: I thank Nicole Defenbaugh, PhD for her exceptional insight and guidance in helping shape this piece.


  1. Miller WL. The clinical hand: A curricular map for relationship-centered care. FamMed. 2004;36(5):330-335.

Lead Author

Ashwini Kamath Mulki, MD

Affiliations: Lehigh Valley Family Health Center, Allentown, PA

Corresponding Author

Ashwini Kamath Mulki, MD

Correspondence: Lehigh Valley Family Health Center, 1730 Chew Street, Allentown, PA 18104. 610-969-3589. Fax: 610-969-3605.


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