ICU and You · Aphorism Series · Number 39
“With teenagers, never say they are non-compliant.”
An aphorism is a compressed argument, not a rule. It earns its shape by leaving things out, which is exactly what makes it memorable and what makes it arguable. Every one in this series is contestable, and chosen because it is.
Each is a mantra, a paradigm, a truism or occasionally a plain myth — something repeated in our units often enough that nobody examines it any more. The piece sets out the case for it, the case against it, and the case for something in between, and then asks which you hold.
There is no right answer waiting at the bottom. The point is to find out what you actually believe and why, because the beliefs that run your practice at three in the morning are mostly ones you have never said out loud.
It is one of the few words in medicine that is a verdict wearing the clothes of an observation. It appears in the handover, it appears in the discharge summary, and once it is in the record it travels with the patient for years. Nobody writing it thinks they are passing judgement. Everybody reading it receives one.
And it attaches to adolescents more than to any other group. Not because they are worse at taking medicines than the rest of us — adults are unremarkable at it too — but because adolescence is the period when responsibility for the medicine transfers from a parent to a person whose judgement is still arriving, and the consequences of the handover show up in intensive care.
The consequences are real and they are documented. In established type 1 diabetes, insulin omission is the cause of most episodes of ketoacidosis, and a small minority of patients generate a large share of all admissions. In transplantation, graft loss peaks between about seventeen and twenty-four years, with no recipient group exempt from it. These are not soft findings.
But look at what the registries actually record. In that literature non-adherence is an attributed cause, not a measured one — somebody wrote it in a box. The number counts how often a clinician reached for the explanation, which is not the same as how often the explanation was right.
That is the first problem. The second is what the word does to the person saying it. “Non-compliant” is a complete sentence. It closes the file. It converts a modifiable situation into a fixed characteristic, moves the problem from the clinician's side of the bed to the patient's, and ends the inquiry at the exact point where the useful questions begin: what does the regimen actually cost them? Who is paying for it? Where do they take it, and who watches them do it? What happened in the week it stopped?
A seventeen-year-old who stops tacrolimus because taking it in front of friends means explaining the transplant has not failed at compliance. They have made a completely intelligible choice with a catastrophic price, and every part of that sentence points at something you could work on. “Non-compliant” points at nothing.
There is also a plain question of accuracy. Compliance describes obedience to an instruction, and it was largely retired for that reason in favour of adherence, and then concordance — words that at least imply two parties. Adolescence is the age at which a patient stops being someone to be obeyed into health. Using the older word in exactly the age group where it is least true is a small failure of attention that tells the reader something about the writer.
What did you find out once you stopped calling it non-compliance?
Most of us have had the case where the label was already in the notes, and where asking one ordinary question — about money, about school, about who else is in the house, about what the medicine actually does to them — produced an answer that made the whole thing obvious.
Tell me yours, and tell me your verdict. And if you think the word is fine and the objection is fashionable, say so — that case deserves making and I would rather print it than not.
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