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Friday
Apr082011

Adherence Challenges For Physicians & Patients

One of the great challenges physicians face is getting patients to take their medications properly and on a regular, continuing basis.  

All too often, patients skip doses, take drug holidays, discontinue treatment early, or even fail to initiate a recommended course of treatment.  These issues are particularly problematic in the treatment of chronic diseases, leading to treatment failure and to frustration for both patients and their doctors.

Oddly, Nobel prize-winning work on microlending may provide a window on how to enhance patients’ adherence to treatment (http://www.tocatchadollar.com).  Microlending—giving poor people tiny loans to start small businesses—has been extremely effective at helping poor women achieve a greater degree of self-sufficiency.  Compliance with loan repayment has been extraordinarily high.  In theory, these programs are supposed to work because people need money in order to make money.  Perhaps far more important to the success of these programs, however, is the support system that complements the loan.

Successful microlending programs have borrowers organized into small teams that meet once a week, reporting what was purchased with the loan and what is being done to sell product in the business.  Each week, borrowers are expected to make a small re-payment toward the loan and to set aside a small amount in their savings account.  If borrowers miss meetings or are otherwise unable to meet the requirements of their borrowing contract, they suffer the social pressure of their team.

These weekly visits are powerful motivators that drive loan repayment compliance.  The visits foster the discipline and provide the social support needed for spending and selling behaviors that result in business success.  Without this discipline and support, it is unlikely that just giving the borrowers a bolus of money would result in a high level of successful business outcomes.

Too often in medical practice, prescriptions of medication are handed to patients without the support needed to get patients to use their medications regularly.  While research studies may have weekly visits to record changes in disease severity—visits that drive patients’ adherence behavior—in clinical practice, medications may be given with no follow up scheduled for months, perhaps without any planned follow up.  Expecting patients to use their medications successfully under those conditions would be like expecting borrowers to use the loan wisely without timely follow up.

Like the weekly visits in the microlending program, office visits with physicians are a powerful social motivator for patients to adhere to their doctors’ recommendations.  I’m not entirely sure why, but the phenomenon is powerful and ubiquitous, explaining why people floss their teeth right before visits to the dentist, why they practice piano just before the lessons, why medications work better in drug studies than they do in real life practice, and why so, so many patients report, “Doctor, you always catch it on a good day.”

Weekly visits to a physician may not be practical or efficient.  But one follow up visit or phone call contact shortly after initiating treatment may be enough to encourage more patients to fill and start their prescriptions.  If patients do use their medication well at first, they may develop the habit of using medication, resulting in a long-term pattern of regular use.  That would be a huge help in our management of patients with chronic illnesses.  Other approaches that solicit regular feedback from patients on the effectiveness, safety and tolerability of their treatment—particularly approaches that give patients a sense of watchful caring from their physician—would add to the support (and perhaps pressure) needed for patients to successfully adhere to the recommended treatment regimen.

About: Steve Feldman, MD, PhD, is founder of the www.DrScore.com physician rating website and author of the book Compartments. He is Professor of Dermatology at the Wake Forest University School of Medicine in Winston-Salem, North Carolina.

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