November 11, 2009
Language Tips: Compliance, adherence, or concordance & more on furthermore and moreover
Tip 1: Compliance, adherence, & concordance
A reader writes:
How about adherence vs. compliance (especially in medical care)…another thorny and oft misused pair!
Oh, what an interesting topic! Particularly, when we think about how these words are used in the negative, as in non-adherence and noncompliance as in the noncompliant patient versus the non-adherent patient.
But first, I’m going to interrupt this discussion to vent a little about one of my pet peeves. No, I’m not going to talk about principal versus principle investigator although that is my primary pet peeve. This is something different.
When I went to school, I was taught that when defining a word, we should never use the word we are defining as part of its definition. This makes a lot of sense, right? After all, if we don’t know the meaning of the word to begin with, how are we going to understand it when the same word is in the definition? Common sense, right? Well, dictionaries do it all the time, and it drives me crazy. For example, I wanted to be careful when explaining what ‘adherence’ means so I looked it up online, and just about every definition I found contained ‘the quality or act of adhering.’ This is kind of thing that makes me nuts. If I didn’t know what ‘adherence’ meant in the first place, how would that definition help me? There are lots of words out there. It seems to me that it wouldn’t be too hard to find a word other than adhering to be part of the definition. For example, ‘obedience’ or ‘act of accordance’ or ‘act of faithfulness’ or even ‘act of compliance’ or something of the sort. Anything but ‘adhering.’ That seems the lazy way out! That’s all I have to say on the subject. For now.
Okay, I feel much better now. So, we were talking about adherence and compliance in the context of medical care.
Mosby’s Medical Dictionary (2009) provides this definition for adherence:
The process in which a person follows rules, guidelines, or standards, especially as a patient follows a prescription and recommendations for a regimen of care
And this definition for compliance:
Fulfillment by a patient of a caregiver’s prescribed course of treatment
The American Heritage Medical Dictionary makes this distinction:
Adherence is the extent to which the patient continues the agreed-upon mode of treatment under limited supervision when faced with conflicting demands, as distinguished from compliance or maintenance.
Compliance is the degree of constancy and accuracy with which a patient follows a prescribed regimen, as distinguished from adherence or maintenance.
Since the American Heritage Medical Dictionary definitions allude to ‘maintenance,’ here is that definition:
Maintenance is the extent to which a patient continues good health practices without professional supervision, as distinguished from adherence or compliance.
Enough about maintenance.
As I see it, according to these definitions, the distinction between adherence and compliance is the action of the patient. Compliance implies passive obedience, and adherence implies active decision-making.
After spending a few minutes staring at the definitions and trying to tease out the differences, I asked a physician colleague what the words meant to him as a doctor. And he told me,
There’s no difference; they mean the same. Adherence is just more politically correct.
Okay. Let’s get to the real issue; the trouble with these words comes when we are talking about patients, and we refer to them as non-compliant or non-adherent, that is they are not following their prescribed treatment regimen.
Noncompliant has a strong negative and paternalistic connotation-the bad patient is not following the physician’s orders.
Non-adherent is not so strongly negative-the patient has made a conscious decision not to follow the prescribed regimen.
Some make the argument that adherence implies shared decision making between the patient and the physician.
From an article in Diabetes Care,1999:
The purpose of this study is to evaluate existing research in the area of patient “compliance,” to endorse reconceptualizing “compliance” in terms of “adherence,” and to discuss the benefits of such a change for medical practitioners. This study critically reviews existing medical, nursing, and social scientific research in the area of patient “compliance.” We assert that the literature reviewed is flawed in its focus on patient behavior as the source of “noncompliance,” and neglects the roles that practitioners, the American medical system, and patient-practitioner interaction play in medical definitions of “compliance.” The term “compliance” suggests a restricted medical-centered model of behavior, while the alternative “adherence” implies that patients have more autonomy in defining and following their medical treatments. We suggest that while the change in terminology is minor, it reflects an important paradigmatic shift for thinking about the delivery of health care.
Lutfey, K.E. and Wishner, W.J. (1999) Beyond ‘compliance’ is ‘adherence’. Improving the prospect of diabetes care. Diabetes Care 22: 635_639.
Interestingly, the term ‘compliance’ was coined for this usage in the 70s, and at that time, was viewed as nonjudgmental and preferred over other previous terms describing patients who veer from the regimens, such as ‘recalcitrant’ or ‘uncooperative’ or ‘unreliable.’
And it does seem better than those terms and others I found such as ‘untrustworthy ‘and ‘faithless.’ Yikes, that’s a little harsh.
It may be that after some time passes, a term assumes negative connotations and needs to be replaced.
In fact, the use of adherence is now being questioned, and it is suggested that concordance be used in its place. Proponents of concordance suggest that while adherence connotes some decision making on the part of the patient, it is still largely passive, while concordance suggests total patient involvement with the treatment decision making and plans.
The advocacy for concordance began in the UK, and is described in an editorial of the British Journal of Clinical Pharmacology, 2007:
Concordance is not synonymous with either compliance or adherence. Concordance does not refer to a patient’s medicine-taking behaviour, but rather the nature of the interaction between clinician and patient. It is based on the notion that consultations between clinicians and patients are a negotiation between equals. How individual patients value the risks and benefits of a particular medicine may differ from the value assigned by their clinicians. In adopting a concordant approach clinicians should respect the rights of patients to decide whether or not to take prescribed medicines. The aim of concordance is the establishment of a therapeutic alliance between the clinician and patient. Concordance is synonymous with patient-centred care. Nonconcordance may occur if a therapeutic partnership is not established and therefore may denote failure of the interaction.
Bell JS, Airaksinen MS, Lyles A, Chen TF, Aslani P. Concordance is not synonymous with compliance or adherence. Br J Clin Pharmacol. 2007 November; 64(5): 710-711.
I’m not sure this approach is realistic, but there it is.
So where does this leave us? First, I have to marvel at the subtleties and complexities of the English language and its continuing evolution. And I applaud the continuing movement toward a vocabulary that demonstrates respect for patients and their participation in their own health care.
Should we endorse a distinction in the meaning between compliant and adherent? I think we should. But far more important than the vocabulary is whether the values represented are actually carried out in medical care. If patient autonomy and participation are not really respected and welcome, then, well, we’re just talking a good game.
Tip 2: More on furthermore and moreover
I thought that we should probably lighten up a little for this next tip, and I ran across this email in my files. A reader writes:
I have always been a fan of ‘furthermore’ and rarely used ‘moreover’ until I was told recently that it is improper to use ‘furthermore’ before using ‘moreover.’
CORRECT: This project will do this. Moreover, it will accomplish that. Furthermore, it will prove the other.
INCORRECT: This project will do this and accomplish that. Furthermore, it will prove the other.
I had never heard of this rule, perhaps because it isn’t really a rule.
Wow! I won’t go far as to say that this is the goofiest rule I’ve ever heard, but it’s pretty darn goofy. The writer had it right when she remarked that it isn’t really a rule. It isn’t a rule. There are not different degrees of ‘more’ between furthermore and moreover; it’s just more. They both mean in addition, and one does not precede the other.