Personal paper: writing prescriptions is easy

Introduction

To write prescriptions is easy, but to come to an understanding of people is hard.

Franz Kafka, A Country Doctor

Only about 50% of patients with chronic diseases take their medicines in therapeutically effective doses.1 Although the cost of non-compliance in illness and premature death is staggering, the issue has been neglected in the debates on healthcare resources and rationing. This week a working party of the Royal Pharmaceutical Society of Great Britain publishes its report on medicine taking.2 It was set up to consider the scale and consequences of non-compliance and to make recommendations. Many of our group, which was made up of doctors, pharmacists, nurses, and social scientists, admitted early on that we rarely took medicines as prescribed. Some confessed to abandoning courses of antibiotics after the first day or two. After we reviewed published work it became apparent that non-compliance might be no more deviant behaviour than compliance, and that this often had serious consequences.

Patients frequently fail to adhere to their antihypertensive drug regimens, for example, which profoundly undermines the attempts to prevent strokes and reduce the risk of coronary heart disease.3 One study suggested that failure to take immunosuppressive drugs was the commonest cause of kidney transplant failure.4

Although efforts have been made to improve patients' compliance, there is little evidence of sustained success.5 There seem to be two reasons for this. Firstly, resistance to taking medicine seems to be quite profound and pervades different cultures and categories of disease. It is instinctual and complex. Secondly, there is something morally and psychologically flawed in the very concept of compliance.

Compliance may be described as follows. The patient presents with a medical problem for which there is a potentially helpful treatment. What the doctor brings to the consultation—scientific evidence and technical skill—is classed as the solution. What the patient brings–“health beliefs” based on experience, culture, personality, family tradition, and so on—is seen by the doctor as the impediment to the solution. The doctor's task is to overcome the impediment.

A more robust model is needed

It was only when the working party met representatives of patients' organisations, many of whom were themselves patients, that a different and more robust model of the relationships between doctors and patients was suggested. This can be described as follows. The clinical encounter is concerned with two sets of contrasted but equally cogent health beliefs—those of the patient and those of the doctor. The patient's task is to tell the doctor his or her health beliefs and the doctor's task is to enable this to happen. The doctor must also convey his or her (professionally informed) health beliefs to the patient. The intention is to form a therapeutic alliance—to help the patient make as informed a choice as possible about the diagnosis and treatment. Although this alliance is reciprocal, the most important determinations are made by the patient.

We called this model “concordance.” It recognises that just as all prescribing is an experiment carried out by the doctor so all medicine taking is an experiment carried out by the patient.6 But concordance does not imply any abandonment of the evidence from science. Rather, we wanted to convey mutual respect for the differing perspectives of both doctor and patient without predicating that the differences between them should be resolved on the grounds of “superior” medical evidence.

Compliance is out of date

There is a historical perspective to this. Compliance may have been appropriate within a welfare state rooted in the values and thinking of society in the 1930s, when services were driven by benign paternalism and the practice of medicine was based on patients trusting their doctors. In the l990s these values and assumptions are changing. The media, consumer groups, policy makers, and patients challenge them and look for relationships between doctors and patients that are based more on openness and respect.

These earlier values are not rejected but overlaid with more modern concerns for transparency of information and accountability. The price of compliance was dependency—it belongs to an older world. The price of concordance will be greater responsibility—in the doctor's case for the quality of the evidence, diagnosis, treatment, and explanation; in the patient's case for the consequences of his or her choices.

The achievement of concordance will require a major effort in research, professional re-training, and public awareness. It will also require the scarcest of commodities—more time in the consultation. The likely cost is high. But not as high as continuing to pay the exorbitant, though largely hidden, price of failing to make optimum use of powerful and potentially effective treatments.