Non-Compliant? Are You Sure?

John Fuller Beckwith5/14/2025

One of the trends in treating patients that really irks me is the quickness with which providers or clinics will label a patient, ‘non-compliant.’ Is that fair? Is it even accurate? Does the clinician even know? In most cases the reason a patient is labeled, ‘non-compliant,’ is because the clinician set some task or instruction for the patient and the patient did not do what was instructed. But the clinician did not take into full account the patient’s extenuating circumstances that may make compliance harmful or too much of a burden to be accomplished.

The circumstance that reveals this injustice to me has to do with compression garments for obvious edema, in my experience specifically with wound care and with lymphedema. When lymphedema is first recognized and then addressed at the primary care level, many patients go through a sort of misguided treatment algorithm that starts with prescription of diuretics and then often goes directly to compression garments. Most patients with lymphedema find that diuretics make them pee a lot but then also the diuretics don’t really resolve the ‘swelling.’ The limb does not really reduce in size. Wrong diagnosis (as an uninformed doctor once told me when we were discussing lymphedema, “its just edema, John”), wrong intervention. But the patient, who stopped taking the diuretics, is often labeled in the medical record as, ‘non-compliant.’ Then there are compression stockings. Patients with lymphedema often get the diagnosis of, ‘peripheral edema,’ and intuitively the providers get them compression. But not effective compression, rather just a generic knee-high stocking. In almost all cases the stocking does not fit well and as a circular knit elastic construction it will typically bind painfully at key anatomical points. Yes, it's the wrong stocking, but more to the point compression stockings are not a reducing intervention, they are meant to contain edema. So, again, wrong diagnosis, wrong solution. And again, in the medical record the patient is labeled, ‘non-compliant.’

In these circumstances is the patient actually, genuinely, non-compliant? In both of the examples above the provider is shifting responsibility for a poor outcome onto the patient. In a way, the provider is saying, “it's not my fault this health issue was not resolved. I provided the standard of care. The patient is at fault for their bad outcome.” It is actually a form of, ‘patient-shaming.’

Of course, patients can actually be non-compliant or non-adherent. I will use myself as an example. I’m in my 60s, a physical therapist for 30 years, and developed a painful apparent plantar fasciitis. Though I have exclusively treated lymphedema for the past 25 years, I tried to treat it myself. I am a PT after all. The plantar fasciitis doesn’t get better, so I see my PCP, who is kind and a good doctor. She gives me a prescription for PT. But do I go? No, I have my own clinic, I work too much, I can’t make the time, I think any PT will not tell me anything I don’t already know. The plantar fasciitis persists. No surprise, but in this case I am clearly non-compliant. So, yes, judge me without reservations. But I would argue this is not all patients, and not the case with most lymphedema patients.

In lymphedema treatment, we are first compelled to treat each patient effectively and comprehensively in order to, as much as possible, reduce the volume of lymphedema. Then they are to get compression garments. In order to do our part in helping patients to be successful in managing their compression garments we have a few obligations that are our responsibility and not the patients': we must recommend appropriate garments, meaning the right compression level, a good material, and most importantly, a good fit. Then we are obligated to provide the proper education so they can learn how best to don and doff the garments, how to properly wear them throughout the day. Some folks need more education than others, but again, that is just human nature. In my experience, the majority of lymphedema patients, given a good fit and the proper set of garments in their toolbox, will be successful. Which is to say compliant. So, really, are they non-compliant or have we just not provided what is needed for them to be successful?