The Patient Compliance Co-op Fantasy
Why Now?
From time to time, I invite Heck Of A Guy blog readers to take a click-trip to my biz-blog, AlignMap.com when I think a post there may interest those beyond the clinicians, those working in pharma or healthcare funding, pharmacists, and other adherence-obsessed geeks who comprise the AlignMap blog’s target audience.
I’ve hesitated (as should be obvious to anyone who notices the Miracle On 34th Street reference) to make that recommendation in this case, primarily because grasping the specific post of interest requires reading a couple of other posts as background – unless one already has knowledge of the administration of pharmaceutical company sponsored medication compliance programs – and that seemed an onerous assignment.
I have no explanation why I succumbed to such a paternalistic, condescending notion.
Heck, I’ve published complex, incredibly long posts on dispensing ketchup (5 pages of print plus illustrations and diagrams), tactics to use should one be interrogated on a TV crime show (7 pages plus illustrations), and the Spooklight phenomenon near my home town (2 posts totaling 6 pages plus many photos), in the full expectation that folks would plough through my dense syntax and obscure vocabulary choices.
In any case, I’ve now come to my senses and will return to treating readers like the adults they are.
The Invitation
Pharmaceutical companies have long sponsored medication compliance programs that are often run by their marketing departments and typically cover only specific medications, all manufactured by the sponsoring company. There is nothing unethical or evil about that; it just hasn’t worked. All of these posts address this phenomenon, and the third post, Miracle On 34th Street — The Patient Compliance Version,1 also offers an alternative vision.
Given the number of patients and the amount of money involved as well as the unrealized potential of medication compliance, these are important issues that merit attention.
The posts are best read in this order:
1. Making Pharma-supported Compliance Programs Independent Of Marketing
2. Pharma-Supported Compliance Programs: Today’s Problems & Tomorrow’s Solutions
3. Miracle On 34th Street — The Patient Compliance Version
Footnotes
- As indicated by the title, it was necessary to invoke Santa Claus and miracles to even broach the possibility of convincing the pharmaceutical industry, insurance companies, and government to play nice ~back~
Raising my hand politely for attention. ::Ahem:: Nothing personal, but patients don’t comply because we don’t trust that you Doctor types actually know what you are doing. That might be because we don’t really know you.
We do KNOW that pharmaceutical companies have marketing departments.
Prescriptions are inconvenient, expensive and secretly we suspect that either we don’t really need them or that they don’t really do anything. That and the fact that they come with slick designer pamphlets doesn’t help. Scrawl the medication specifics (and list of potential death causing side effects) on a piece of torn off brown paper bag — in pencil and have the receptionist hand it to the patients, we actually get to know her while we are waiting on you.
Comment by Mary — January 3, 2007 @ 9:19 pm
Mary, you’re not only polite but also correct – improving patient-clinician relationships in a given practice, while subject to the vagaries of defining what qualifies as an “improved patient-clinician relationship, does appear to increase treatment adherence collectively among the individuals treated by that practice. The problem is that this incremental rise in compliance results from a subgroup of patients, who represent a significant fraction of but not all or even a majority of patients. Research indicates (but falls short of proof) that the population of adult, non-psychotic, intellectually intact patients can be grouped into several segments based on their interactions with clinicians and the effect of those interactions on compliance. There are a number of such segmentation schemes; the examples that follow are congruent with my observations from my own psychiatric practice.
One such segment are those who react to a trustworthy clinician’s explanations of a medication’s uses, side-effects, and alternatives with a rational rejection of the recommended treatment or with a rational agreement to follow the prescribed treatment which they effectively implement. Other subgroups, however, include
Those who grow glassy-eyed after the first words of the side-effect spiel, wait patiently for the completion of the physician’s explanation, and then ask, “So, it’s one pill in the morning and one at bedtime, right?” (I cannot count the number of times this happened in my practice.)
Those who view the clinician as a hired hand whose job description is following the patient’s instructions. (I had an Ex who chose her physicians based on the litmus test of who would or wouldn’t follow her orders, a strategy which led, for example, to her demanding – and undergoing – a surgical procedure when standard practice would have been medical treatment, casually dismissing her surgeon’s own concerns.)
Those who are enamored of their clinicians, are enchanted by his or her every word, and prefer following an authoritatively issued treatment plan to listening to pros and cons that introduce the notions that (1) no treatment carries a guarantee of success or even safety and (2) their clinician seems to be admitting that he or she could be wrong.
Those who don’t trust anyone, especially doctors, and are therefore psychologically incapable of considering the benefits and risks of a treatment plan, regardless of how eruditely and empathetically presented.
The research does show that there is no silver bullet for noncompliance. The most effective compliance enhancements are individualized and complex. That’s no excuse for not knowing ones patients or not presenting adequate information to allow a patient to make a reasonable choice about a specific treatment. It does mean that those tactics are not sufficient for all patients.
Now that it seems that I take more medications than I prescribe, I am way sympathetic with the concerns about expense. My only response is that, assuming one agrees to the use of a medication, taking that medication as scheduled is more efficient, effective, and economical than missing doses, unilaterally changing dosages, etc.
And, it only took me a few weeks in private practice to institute a policy of always hiring receptionists who were nicer than me (not that this was a high hurdle for most candidates)
Comment by DrHGuy — January 4, 2007 @ 7:26 am