Last week I began my 8-week long pediatric externship, beginning first with pediatric infectious disease (PID) for 2 weeks. I've had the pleasure of working with Dr. H and his resident all of last week.
Today he left me with some parting words:
We in the health field need to be cognizant of the struggles patients endure. No one is perfect, and no one should ever be expected to maintain near-perfect drug adherence. We in the health field should not assume an accusatory and antagonistic tone with patients. Let's not assume the all-too-easy tone of voice, "I see you didn't take your meds."
There are a plethora of reasons why patients are unable to adhere to drug regimens. It's not simply that they don't want to; as Dr. H states the obvious, "No one wants to die." So what gives? If you have to take 3 HIV meds twice a day approximately 12 hours apart, and you knew that if you didn't, you're risking your life, why wouldn't one adhere to that strictly? One's life certainly does depend on it.
Consider this: Mondays through Thursdays are pretty standard for most working people. Thus medications are easier to time to daily schedules. But Fridays through the weekend are a different story. If one were to go out somewhere and forgot his/her meds, one would have to return home to take the meds. It's very difficult to revolve one's life around one's medication schedule.
Furthermore, patients may simply not be ready to take their meds and/or don't know why they're taking them. Both are critical issues that must be addressed over a long period of time. At diagnosis, patients may be so overwhelmed by the disease and the implications on being on medication indefinitely that their minds are in a state of shock and disbelief. Imagine you were just diagnosed with HIV, and the person giving you the diagnosis then launches into this long talk about the different meds you have to take, when to take them, how many times a day, the importance of taking it, the disease progression, etc - all in the span of an hour or so. And then for it all to sink in that this will be for the rest of your life. Yeah . . .
There is a model of health behavior called the "transtheoretical model." It begins with "precontemplation" and progresses to "contemplation," to "preparation," to "action," and then finally to "maintenance." With precontemplation, the patient isn't even thinking of medication. Then in contemplation, the patient begins to consider the possibility of medication. With preparation, the patient readies him/herself to take medication. Action is where the patient is actively trying to remember and take the medication; and with maintenance, adherence becomes more or less routine.
It's a long process that requires a lot of counseling from the health provider. It may take months to years to progress from precontemplation to action. I believe I read somewhere that many patients don't even make it to maintenance, because it's so difficult.
So we should ask, "Why can't this patient take his/her meds?" instead of "Why won't this patient take his/her meds?" A patient may be in the precontemplation phase, a patient may be unable to afford his/her meds, a patient may not understand why he/she is taking the meds, a patient may react to an adverse side-effect, and there may be psychosocial factors at play. It is our job, our duty, to help patients work through such issues so "can't" changes to "can."
As with all things, easier said than done.
Today he left me with some parting words:
When a doctor or a student says, "The patient won't take his/her meds," change "won't" into "can't" in your mind. Think, "The patient can't take his/her meds."Dr. H was of course referring to drug adherence or compliance. In general drug adherence is surprisingly low, though there is also a lot of variability. There have been studies looking at how often and how timely prescriptions are filled, and studies looking at the difference between drug adherence for "acute" illnesses (e.g. infections) and for "chronic" illnesses (e.g. hypertension, diabetes, HIV). And there have been studies looking at dosing. Unsurprisingly, taking few medications and taking them only once daily is associated with better adherence. Increase the number of medications and/or increase the dosing to twice daily or even thrice daily, and adherence drops like a rock.
We in the health field need to be cognizant of the struggles patients endure. No one is perfect, and no one should ever be expected to maintain near-perfect drug adherence. We in the health field should not assume an accusatory and antagonistic tone with patients. Let's not assume the all-too-easy tone of voice, "I see you didn't take your meds."
There are a plethora of reasons why patients are unable to adhere to drug regimens. It's not simply that they don't want to; as Dr. H states the obvious, "No one wants to die." So what gives? If you have to take 3 HIV meds twice a day approximately 12 hours apart, and you knew that if you didn't, you're risking your life, why wouldn't one adhere to that strictly? One's life certainly does depend on it.
Consider this: Mondays through Thursdays are pretty standard for most working people. Thus medications are easier to time to daily schedules. But Fridays through the weekend are a different story. If one were to go out somewhere and forgot his/her meds, one would have to return home to take the meds. It's very difficult to revolve one's life around one's medication schedule.
Furthermore, patients may simply not be ready to take their meds and/or don't know why they're taking them. Both are critical issues that must be addressed over a long period of time. At diagnosis, patients may be so overwhelmed by the disease and the implications on being on medication indefinitely that their minds are in a state of shock and disbelief. Imagine you were just diagnosed with HIV, and the person giving you the diagnosis then launches into this long talk about the different meds you have to take, when to take them, how many times a day, the importance of taking it, the disease progression, etc - all in the span of an hour or so. And then for it all to sink in that this will be for the rest of your life. Yeah . . .
There is a model of health behavior called the "transtheoretical model." It begins with "precontemplation" and progresses to "contemplation," to "preparation," to "action," and then finally to "maintenance." With precontemplation, the patient isn't even thinking of medication. Then in contemplation, the patient begins to consider the possibility of medication. With preparation, the patient readies him/herself to take medication. Action is where the patient is actively trying to remember and take the medication; and with maintenance, adherence becomes more or less routine.
It's a long process that requires a lot of counseling from the health provider. It may take months to years to progress from precontemplation to action. I believe I read somewhere that many patients don't even make it to maintenance, because it's so difficult.
So we should ask, "Why can't this patient take his/her meds?" instead of "Why won't this patient take his/her meds?" A patient may be in the precontemplation phase, a patient may be unable to afford his/her meds, a patient may not understand why he/she is taking the meds, a patient may react to an adverse side-effect, and there may be psychosocial factors at play. It is our job, our duty, to help patients work through such issues so "can't" changes to "can."
As with all things, easier said than done.
I agree with this post completely, and it's a lesson most pharmacists learn early in their career. In one of my very first projects in pharmacy school, we were split into three groups. One group had to take their "drug" (tic-tacs) once daily, the second group had to take theirs twice daily, and the third had to take it three times daily. I was unfortunate enough to be in the third group, and I can tell you it was really hard. If I forgot even for a few hours, it threw my whole schedule off. Or if I stayed up late on a weekend night and slept in the next morning, that also threw my schedule off. I failed miserably. At the end of the week, I had about 5 or 6 tic-tacs left!
Imagine having to take a drug four times a day (and yes, there are drugs where that's necessary). You would only be able to get 6 hours of sleep per night...indefinitely!
There are other factors that affect compliance besides timing and being overwhelmed though. Side effects is a big one, especially when the side effect is nausea or vomiting and you don't know whether you should repeat the dose you just threw up. Taste is a big one in kids- sometimes you have a 2-year old who spits out their antibiotic even when it's mixed with applesauce or chocolate syrup. Also, some pills are just really big and hard to swallow, and some drugs have to be injected, which takes training to do properly at home.
Accessibility is another important one. I've seen it happen where a patient is running out of money, or doesn't have insurance, and takes their maintenance meds every other day, or every third day, trying to make it last longer. Or sometimes low-income patients on special programs get bogged down in all the paperwork they have to deal with to get their drugs. Pharmacies see it all.
I could go on, but the point is: taking drugs is not an easy task. It means a lifestyle change in many cases and good problem-solving skills in almost all.