Setting: Medical office setting, patient is sitting in doctor's office during follow-up appointment.
Doctor: Your blood pressure is still quite high. I'm a little puzzled by that, I would have expected it would have gone down by now since you were here a couple of months ago. You've been taking the medications I prescribed?
Patient: (sheepishly) Um, actually, no... After I got home, I decided not to fill the prescription. I was hoping that my blood pressure will come down on its own.
Doctor: (surprised) Oh, okay. Well, have you at least reduced your salt intake as we discussed?
Patient (hesitantly): Well, you know what, that's kind of complicated...
Doctor: (waits for patient to pause) All right, maybe we better take a step back. Listen, why don't we both have a seat? (gestures to patient to move from exam bed to chair) So, do you have any concerns about your health that we haven't talked about?
Patient: Well, I mean, I could lose a couple of pounds or I could exercise more maybe. I mean, who wouldn't these days, right? (becomes more serious) Um, you know, doctor, to tell you the truth, I was bit surprised when you told me that I have a problem with high blood pressure because I feel fine.
Doctor: Well, what's your understanding of high blood pressure?
Patient: Well, I mean, in my case it's just one of the numbers that's slightly off, I don't think it's that important. I don't think it's affecting my health at all.
Doctor: Well, in fact, with high blood pressure you often don't know it's a problem until it's too late. But before we get to that, why don't you tell me a little bit more about why you didn't take the medication I prescribed?
Patient: Well, you know, last year my uncle went to see his doctor, he didn't feel well and he gave him medications for his heart and some blood pressure medications. And after that he got really, really sick, and ended up in hospital for 2 weeks. Now he's on disability. My aunt had to quit her job to take care of him. And I just... you know, I'm very careful when it comes to meds. I don't want something like this to happen to me. You know, we all think that he may have been just under a lot of stress and that was it.
Doctor: So, what are your ideas for dealing with your high blood pressure?
Patient: Well, since you asked... (pulls empty bottle out of pocket) I mean, I have this herbal supplement that my aunt told me about that apparently is supposed to be really, really good for your blood pressure. You know, where I come from we're really big on natural remedies before we take medications. My grandfather for example, he was ninety-two, he never took a single prescription in his life.
Doctor: (genuinely) Huh! Well, that's interesting. You also mentioned you're having trouble with reducing the salt in your diet. Let's talk about that a little bit.
Patient: Yeah, I mean, my wife is also reminding me constantly that I'm supposed to reduce salt, and my parents are the same. Their doctor is after them to reduce salt as well.
Doctor: Who does the cooking at home?
Patient: Well, since my parents live with us, my mother does. I mean, she's a great cook, she cooks all traditional meals. And she feels it's her responsibility, so even if we have a day off, she will not let anybody near the kitchen, so she does.
Doctor: So, mealtimes are important in your family?
Patient: Well, yeah, we try at least 3 times a week, for all of us to get together, my kids, my parents, and then we have a meal, which is a nice traditional meal just like we did back at home. And, in fact, it's one of the things that reminds us of home. We like to get our kids involved to see a part of their culture, which is how that food is prepared and things like that. And another thing that doesn't help is the fact that we go to a lot of parties within our community, and people host dinners, we take turns. And you know, it's all food prepared traditionally just like back home—it's very spicy, it's very salty—so it is hard.
Doctor: It's really difficult to keep the salt out of your diet then, yeah? Okay, well, what else would you like to get out of this appointment today?
Patient: I was going to talk to you. I was hoping to get some more information from you regarding me taking these supplements before I take the medications.
Doctor: Anything else?
Patient: No, I would just like to get your opinion on that.
Doctor: Okay, well, before we get to that, I'd like to pass on some information that I think may help us make some of those decisions...
Concluding facilitation question: What could you do now to approach the patient's non-adherence?