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Saturday, April 27, 2013

A contrarian view of medication compliance

I saw a patient back yesterday who has suffered from a long standing and uncomfortable but not life threatening condition. It was very gratifying in that she was markedly better. However, the road to arriving at this more desirable place was a rather circuitous one. I had been treating her for more than one year before I became aware that she was less than fully compliant with my recommended treatments.

This was to me a a rather surprising discovery which I was fortunate to have the tools on hand to define. I was able to see when she had filled her prescriptions and to measure drug levels. It was all the more surprising since what I was treating was primarily symptoms driven. I tend to believe that this is a circumstance where compliance tends to be very high. When one is constantly reminded of the reason for treatment, one tends to remember it is important to comply with treatment.

I know this first hand. I am very bad with medications. I was started on a lipid lowering agent a number of years ago and I know that I was very bad about taking it every day. However, more recently I have developed a bit of prostatism and an oral agent to treat  has been instituted. If I don't take this, I get a relatively quick reminder that I failed to be compliant. I think my compliance with all my daily medications has improved.

However, what about my patient who mysteriously failed to take her medication directed toward her very uncomfortable state? Why in the world was she less than faithful about taking her medication? As it turned out, the treatment for her condition was very slow in onset, requiring weeks of consistent compliance to reap the benefits of treatment. While I was confident that treatment would work (based upon my previous experience), she remained skeptical, and the skepticism only deepened after no dramatic effects were seen after a few weeks. She failed to voice that skepticism, at least immediately, and the conversation only got around to this after I become aware of her poor compliance with treatment. She did not feel comfortable with voicing her skepticism but also did not desire to look for help elsewhere.

The lesson I cam away with from this encounter was not that my patient was stupid or unreliable. It was that people are complex. Our brief encounters with them rarely allow us to begin to understand their motivations and fears. The lack of understanding cuts both ways. We are essentially strangers to our patients. They do not know who we are, what motivates us, and why we make the recommendations that we do. There has to be a huge element of trust for them to adopt our recommendations and it begs the question; Why should the individual in front of us at any given moment trust us? What have we done to gain their trust?

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