American College of Physicians: Internal Medicine — Doctors for Adults ®

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Saturday, May 21, 2011

Why do patients stop taking their medications?

Lots of smart people over the years have been trying to figure out why people stop taking their medications within the first 12 months. Within the first 12-months of starting a new prescription, patient compliance rates drop to less than 50%. This rate is even lower for people with multiple chronic conditions taking one or more prescription medications.

If these medications are so important to patients, why do they just stop taking them? It defies common sense. Sure issues like medication cost, forgetfulness, lack of symptoms, and psychosocial issues like depression play a role in patient non-compliance. But there also something else going on ... or in this case not going on.

The problem is that doctors and patients simply don't talk much about new medications once prescribed. Here's what I mean. Let's say that at a routine check-up a physician tells a patient that he/she wants to put them on a medication to help them control their cholesterol. The doctor spends about 50 seconds telling the patient about the medication. The patient nods their head takes the prescription and boom, the visit is over.

Let's say the patient actually gets the prescription filled. For some people that is a leap of faith considering the likely chain of events up to that moment:
--The physician didn't really make a good case for why they needed the medication. If the doctor wanted me to take it he/she should have been emphatic about it, as in "I recommend you take this," not the simple "I want to try something", or to describe what it would do or what would happen if the patient didn't take it.
--The doctor didn't mention how the new medication would interact with the two other pills I am already taking.
--Consequentially, the patient may not believe they really need the medication.

Fast forward 12 months. The patient has been back to see the same doctor twice for problem unrelated to cholesterol. At neither of these appointments did the doctor mentioned or ask how the patient was doing with the new medication. The doctor did mention the need for a blood test to check for liver issues and that they should recheck the cholesterol levels at the next visit.

So at this point the patient concludes the following about the new medication:
--The doctor never talks about cholesterol or brings up the subject of the medication. I assume I am taking it correctly.
--If the doctor doesn't mention it (the medication) it must not be important.
--I haven't notice any difference in my health. I guess I don't need the medication.

Sure, the patient should have asked their doctor if they had any questions about the new medication. But patients seldom ask their doctor questions. Sure they could ask the pharmacist ... but the pharmacist would tell them to just ask their doctor.

It's so much easier for the patient to just not refill the prescription.

We have all heard the expression that whatever doesn't get measured doesn't get done. Well the same thing is true for when it comes to physician-patient communications. Whatever issues doctors don't talk with patients about will not get done over the long haul either. In this case patients simply stop taking prescribed medications.

As primary care slowly shifts from episodic, acute care to continuous care with the aid of electronic medical records and the focus of patient-centered care, things should get better with respect to patient compliance. It needs to. Give the current focus on episodic acute care too many chronic health issues simply are not being addressed for one visit to the next.

That's what I think. What's your opinion?

This post by Steven Wilkins, MPH, appeared at Get Better Health, a network of popular health bloggers brought together by Val Jones, MD. Better Health's mission is to support and promote health care professional bloggers, provide insightful and trustworthy health commentary, and help to inform health policy makers about the provider point of view on health care reform, science, research and patient care.

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2 Comments:

Blogger ryanjo said...

Ho-hum. Another post in a long series of self-flagellating articles by physicians, excusing patients from responsibilities for their health.

The same mid level business manager responsible for dozens of employees and millions of dollars of corporate assets decides he doesn't need his cholesterol med as his doctor hands him a prescription, because the doc doesn't beg him to fill it. A 75 year old retiree remembers to file his taxes annually and make his car loan payment, but decides he doesn't need to refill his BP meds (when called by the pharmacy), because his doctor didn't specifically mention the refill at the last visit when remarking on his good BP control. Even more common, a patient is convinced by a friend (working for a well known vitamin seller) to drop a prescription med, use a homeopathic remedy, and never lets the doctor know.

Let's stop fooling ourselves on who is playing games here. I have no problem holding patients to a level of responsibility and maturity that the rest of society expects of them.

May 21, 2011 at 9:25 AM  
Anonymous theYogadr said...

This is a sad commentary on the role of docs today. Dean Ornish, M.D.'s Spectrum program has shown us that diet and lifestyle changes REVERSE angiographic evidence of atherosclerosis, lower cholesterol 40% at one year equal to Lipitor, lower blood pressure and treat diabetes. But we're not talking about that, nor being prompted to do so by this article. Professionally, it is our responsibility to first do no harm - and all meds have side effects (ones we know about and ones we don't). It doesn't look like primary prevention with cholesterol meds helps much of anybody. How you live does. Don't take an extra five minutes to convince your patient to take their cholesterol medicine. Take the five minutes to teach them about the importance of nutrition and walking 30 minutes every day. It's want they want, if you listen to the buzz, and it's "best practice."

May 22, 2011 at 6:03 AM  

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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