Do your patients take their meds? Talk to them
Do your patients take their meds? Talk to them
Adherence, linked to doc-patient communication
When patients walk out of your office with a prescription, one-third of them will throw it away, according to a review of studies on patient adherence. Another third won’t take the medication as directed.1
While theoretically that could be a "cosmic balance" for those unnecessary prescriptions that physicians sometimes write, the patients ignoring their medicine might be the ones who really need it, notes Martha Johns, MD, MPH, a family physician and medical director of health promotion and disease prevention for Centura Health, an integrated health system in Denver.
The odds that patients will follow more complicated regimens or advice that requires behavioral change are even worse.1 But here’s the good news: Research shows that physicians can improve both adherence and outcomes by improving their communication with patients.2 (For specific techniques, see related story, p. 30.)
In fact, better communication can improve not only adherence, but diagnostic accuracy, patient satisfaction, and physician satisfaction, as well as decrease malpractice risk, says Vaughn Keller, MST, associate director of education of the Bayer Institute for Health Care Communication in West Haven, CT.
"[Communication] is something that’s absolutely central to health care," says Keller. "It can’t be assumed, and it can’t be ignored."
Do you always follow advice?
As physicians consider the extent of the adherence problem, Keller urges them to ask themselves: Have you ever skipped doses of medicine? Do you always brush after every meal, as your dentist advises? Do you exercise at least three times a week?
Many physicians themselves fail to adhere to recommended practices. And they often underestimate how many of their patients fail to adhere to their treatment plans.
Adherence isn’t related to economic status, gender, age, education level, or any other demographic characteristic, notes Johns.
"Physicians have to realize that poor adherence can occur with anyone," she says. "We shouldn’t just assume that because someone is less educated, their adherence would be worse, or that the higher-educated, higher socioeconomic status person would adhere better. We have to be thinking about this all of the time as a possible issue."
Keller relates the story of a surgeon who attended his communications workshops. This surgeon was seeing a cardiologist who had set up a regimen of medication and rest that the surgeon couldn’t possibly follow because of time constraints but the surgeon had never told that to his doctor.
"[Physicians] have the responsibility to raise the question with patients: Is there anything that will make it difficult for you to follow through with this regimen?’"
Learn patient’s perspective
Adherence is most affected by the patient’s perception of his or her illness, not by the physician’s opinion,3 says Johns. So physicians need to solicit feedback from patients, directly asking how the patient feels about the recommended treatment, she says.
"The physician needs to understand that the patient has his or her belief system about both what the problem is and how to cure the problem," says Keller. Finding out that belief system is "an absolutely necessary step," he says.
Keller advises physicians to tell patients, "I’ve arrived at one possible explanation of what the [medical] difficulty is. How does this fit in with what you’ve been thinking?’" In other words, the physician acknowledges that the patient has been thinking about his or her medical situation and may have consulted friends or family members for their opinions.
If the patient leaves the doctor’s office with the same preconceived ideas about the medical problem, and the patient’s explanation differs from what the physician said, the patient may ignore the physician’s advice, Keller says.
"Getting the belief systems aligned is absolutely critical," he says. "Once the belief systems are aligned about what the problem is, the belief systems have to be aligned about what the treatment is. If the patient doesn’t believe the treatment is efficacious, the patient isn’t going to do it."
For example, a physician prescribing a course of antibiotics may ask the patient, "Does this make sense to you?" or "How does this sound to you?" By doing that, "they test out whether the patient buys in," says Keller.
How to ask about adherence
When physicians follow up to find out if patients are fulfilling the prescribed treatment, they need to ask open-ended, gentle questions, says Johns.
"If I say, Are you taking your medicine?’ they’ll say yes," she says. "[Instead] I say, It’s very hard to take medicine regularly. It’s easy to miss doses. How often would you say you missed a dose?’ You’ll get a much more honest answer."
Johns also suggests that physicians consider non-adherence as a problem before they decide that a certain treatment or medication isn’t working. "If you have a hypertensive patient who isn’t responding to therapy, you should first assume that they aren’t taking the medication correctly," she says, rather than automatically raising the dose.
When nurses or physicians follow up with patients to find out how they are doing with their treatment regimen, helping them work out any problems that have developed such as dealing with side effects, adherence increases substantially, says Keller.
While such dialogue may require the physician to take more time with some patients, the payoff is well worth it, says Johns. "If you communicate well and make sure you’re understanding each other, then you’ll get better information about the diagnosis and you’ll have better adherence and health outcomes," she says. "This is time-saving and money-saving in the long run."
[Editor’s note: For more information about workshops offered around the country by the Bayer Institute, contact Vaughn Keller, Associate Director for Education, Bayer Institute for Health Care Communication, 400 Morgan Lane, West Haven, CT 06516. Telephone: (800) 800-5907.
For further information on the topic of patient adherence, refer to these resources:
Meichenbaum D, Turk DC. Facilitating Treatment Adherence: A Practitioner’s Guidebook. New York: Plenum Press; 1987.
DiMatteo MR, DiNicola DD. Achieving Patient Compliance. New York: Pergamon Press; 1982.]
References
1. Meichenbaum D, Turk DC. Facilitating Treatment Adherence: A Practitioner’s Guidebook. New York: Plenum Press; 1987.
2. Kaplan SH, Greenfield S, Ware JE Jr. Assessing the effects of physician-patient interactions on the outcomes of chronic disease. Med Care 1989; 27(suppl 3):S110-127.
3. Helman CG. Communication in primary care: The role of patient and practitioner explanatory models. Soc Sci Med 1985; 20:923-931.
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