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OB/GYN Editorial JUNE 2005
Why WonÕt Patients Do What TheyÕre Told?
Stephen A. Brunton, MD
Armed with the best medical knowledge, clinicians proceed to educate patients about their medical conditions and advise them about appropriate lifestyle modifications and pharmacotherapy. However, something often seems to happen between the clinicianÕs pronouncement and the patientÕs performance of the desired behavior.
This communication and resultant patient action has been
variously termed compliance, adherence, and now (more politically correct) concordance. The concept of concordance implies more patient empowerment and sharing in decision-making, as opposed to the Òtop-downÓ process suggested by the traditional terms. While this distinction may seem trivial to some, it reflects the reality of decision-making in the clinical encounter.
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WHAT IS WRONG
There are many forms of nonconcordance, including:
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Not using medicine at all or stopping prematurely
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Omitting doses, overdosing, or underdosing
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Taking medications with prohibited foods/medications
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Taking medication at incorrect times or intervals
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Taking outdated medications
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Not attending scheduled physician appointments.
Identifying and addressing the reasons that cause patients to stop therapy can help to improve outcomes. Some common reasons for this are:
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No perceived need (ÒIÕm not sick.Ó)
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Perception that the physician
did not think continuation was important
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Adverse events or drug intolerance
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Negative media reports about therapy
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Therapy too complex or inconvenient
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Drug was not working
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Completed prescription
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Therapy too prolonged
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Changed physicians
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Therapy is too expensive
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Dissatisfaction with care.
It is important to recognize how common this problem really is. Most patients with chronic conditions will discontinue therapy within 3 months, despite the possibility of significant adverse outcomes in the future from their disease. Addressing patients in a nonconfrontational manner can often elicit more candid communications. This can be accomplished with several techniques. One is Òpermission-giving,Ó using statements such as ÒMany of my patients have trouble taking their medicine every day. How about you?Ó Another option is to ask patients how often they forgot to take their medications in the last week. An admission that this occurs about once per week can translate into a compliance rate of about 50%, whereas a response of two to three times per week
suggests that the medicine is
most likely taken less than 10% of the time.
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WHAT TO DO
There are a variety of practical strategies that can be implemented to promote compliance with therapy. Examples include simplifying regimens, using reminders (eg,
putting the medication near the toothbrush), and discussing adherence/concordance at each visit.
Perhaps it is more important to recognize that while clinicians believe that they are giving clear instructions, patients often misunderstand. This may be the result of feeling overwhelmed or intimidated by the health care environment. Additionally, there may be a problem with literacy in general, or health literacy in particular. The National Adult Literacy Survey found that 66% of US adults over age 60 years have inadequate or marginal literacy skills; 50% of welfare recipients read below the fifth grade level; and 50% of Hispanics and 40% of blacks have reading problems.1 Inadequate
literacy was found to be an independent risk factor for hospitalization among a study of 3,260 elderly managed care patients.1 Health literacy problems were independently associated with worse glycemic control among 408 English- and Spanish-speaking patients, and 75% of patients with long-term illnesses had limited literacy.1
Recognizing that these issues exist highlights the importance of verifying a patientÕs comprehension of instructions. Requesting patients to repeat instructions as they understand them can be an invaluable tool. This can reveal
a wealth of information about
the clinicianÕs communication strengths and weaknesses, as well as providing opportunities to correct misinformation. With so many variables involved in the implementation of a health care plan, perhaps itÕs a wonder that any patient complies with therapy!
Stephen A. Brunton, MD
Editorial Advisor
Board Member
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References
- Kirsch IS, Jungeblut A, Jenkins L, Kolstad A. Adult Literacy in America: a first look at the findings of the National Adult Literacy Survey. National Center for Education Statistics Web site. Available at: http://nces.ed.gov/pubs93/93275.pdf. Accessed April 4, 2005.
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