AlignMap

Again With The Names?

Yep, and here’s why – I read a lot of the contemporary lay and professional literature dealing with what is commonly known as   patient compliance or treatment adherence or something similar – i.e., the variation between a prescribed treatment regimen and a patient’s implementation of that treatment regimen.

Based on that reading, my unproven but sincerely and confidently held contention¹ is that the most frequently and most vehemently addressed issue in that corpus of material is the re-naming of the phenomenon (i.e., compliance, adherence, concordance, … ) itself.

There’s more. I suspect that much of the sturm und drang associated with this effort has less to do with advancing adherence to treatment than with labeling who is right and who is wrong.

A significant number of folks consider the name, compliance, to be not only a suboptimal term but an abomination² in general and a roadblock specifically to progress in the field to be formerly known – if the re-namers are indeed successful – as compliance.³

Further, they are also certain that the correct, not-a-roadblock label is adherence

… except in the U.K., where the preferred appellation appears to be concordance

… except for those who lump adherence and concordance together with compliance as equally nefarious elements of the same Satanic vocabulary used to sustain the pjower of the healthcare  establishment and suppress the rights and independence of patients.⁴

There’s Still More – Naming Becomes Name Calling

Some re-naming diatribes clearly posit compliance Vs adherence⁵ as a litmus test. As far as I can determine, compliance is associated with a paternalistic, condescending, and uncaring style of medicine while adherence is an indicator of medicine practiced such that the patient is co-equal with clinicians, the inevitable consequences of which include mutual respect and caring between the patient and clinicians, enhanced treatment outcomes, and quite possibly humankind’s last best chance for peace on Earth, good will to men.⁶

The compliance Vs adherence battle has another unusual quality; adherence adherents and other anti-compliance groups are vocal and thus easily identified, but I have yet to track down the leaders of the compliance crusade. These days, the most adamant pro-compliance stance may, in fact, be something along the lines of my own laissez-faire recommendation found elsewhere on this web site:

Lacking compelling advantages favoring the use of any of the suggested terms and given the institutionalized encoding of “patient compliance” and “patient noncompliance” into the National Library of Medicine database’s official Medical Subject Headings, it makes sense — until something better comes along — to continue using this familiar phrase to designate the extent to which individuals follow an agreed upon treatment plan, and, unless specified otherwise, assume that adherence, compliance, and concordance refer to the same phenomenon.

It’s not going to replace The Ride of the Valkyries in those battle scenes, is it?

An (Apparently) Little-known Fact

Reading this re-naming material gives one the idea that, sometime in the 1970s, the Grand Vizier of Medical Literature decided it was time to name this process by which patients follow, don’t follow, or partially follow treatment recommended to them. He (in the 1970s all Grand Viziers of Medical Literature were white men; at least 67%, in fact, were dead white men) looked about and malignantly/inexplicably (choose one) selected, from the hundreds of thousands of words in the English language,⁷ the despicable compliance even though the far better adherence was right there, probably giving off a wholesome inner glow, available under “A,” near the front of the dictionary. Thus was healthcare progress stymied  for half a century.

What was he thinking?

As it turns out, reality is less dramatic but far more significant than my How The Grand Vizier of Medical Literature Named Compliance tale.

Compliance and noncompliance were first used in the healthcare literature in the 1950s but were popularized in the 1970s when Sackett and Haynes wrote and edited books, symposia, and articles about these phenomena.

The term compliance was, in fact, consciously chosen as a nonjudgmental alternative to earlier descriptions, such as “untrustworthy,” “uncooperative,” “unreliable,” or, my personal favorite, “faithless.” Compliance and noncompliance were specified as declarations of fact rather than indications of blame.⁸

Put another way, compliance was the 1970s version of adherence.

Well, I bet we get it right this time, by golly.

My Dirty Little Secret

I don’t much care which term – compliance, adherence, concordance, persistence, or any combination or permutation of these words or any other existent or yet to be coined word – is used to indicate the variation between a prescribed treatment regimen and a patient’s implementation of that treatment regimen. As long as everyone knows what that term is and what it means, and I can use it as an effective search term in the medical databases and Google, it’s OK with me.

The New Compliance

So, here’s my offer. You guys for whom this re-naming is a big deal – and you know who you are – get together and decide on a name for the new compliance. Heck, new compliance has a nice ring to it. Use it if you like  – gratis. Anyway, debate, vote, fight a duel, use a Ouija Board, draw straws, whatever. Once you have reached a decision, convinced the administrators of databases and search engines to enter a few fudge factors into their codes to make the new term work for old data, and spread the word among clinicians, researchers, patients, and, of course, all other stakeholders (don’t forget to translate the new term into every language used by organized healthcare), just e-mail me and I’ll adapt.

And yet, some folks think I’m argumentative.

1. If “unproven … contention” causes you to effect that  well-practiced sneer of contempt that you tragically believe passes for a bemused, classy, sardonic viewpoint and automatically dismiss whatever notion follows, just pony up the bucks and a couple of grad students to process the literature and I’ll produce the statistical proof. Otherwise, you’ll have to take my word for it.↩
2. I kid you not. “Abomination” is by no means the worst accusation hurled at compliance. One comment on a post, for example, condemned both adherence and compliance as “some of the worst terms in the health care industry!”↩
3. My apologies to the artist previously – and now once again – known as Prince↩
4. To complicate matters, certain subgroups, prominently but not exclusively in the pharmaceutical industry, have begun to stridently insist on the distinction between compliance, adherence, and persistence. Roughly, compliance is the extent to which a recommended treatment is followed within a designated timeframe while persistence addresses how long a patient follows the treatment plan. In oversimplified form, compliance + persistence = adherence. The good news is that I haven’t found any complaints that persistence furthers the Dr. Darth Vader agenda – yet. ↩
5. There are also cases in which compliance, adherence, and even concordance are all targeted as the vocabulary of a conspiracy against the rights and dignity of individual patients. For now, I will focus on the compliance Vs adherence model for the sake of simplicity.↩
6. For the record, I experienced the same kind of  pseudo-epiphany when I first became interested in patient compliance. It went a little something like this

   Doctors are just too paternalistic, too narcissistic, and too out of touch with their patients. As a result, they just tell patients to take X pills Y times a day, without explaining why the medicine is necessary, what the side-effects are, etc. If only all doctors were empathic, perceptive, and sensitive  – well, like me, for example – we could whip this noncompliance thing in a couple of weeks. Why hasn’t anyone else figured this out? It’s so simple. …

   It seems  I fancied myself the Luke Skywalker of adherence in this particular battle of the forces of good against the evil empire.

   Then I saw the sequel to the first epiphany. It turns out that the arrogant doctor thesis may explain some cases of noncompliance but by no means does it account for even a majority of patients who who don’t adequately follow their treatment plans to an adequate degree. So much for the Force being with me.↩

7. The second edition of the Oxford English Dictionary, for example, includes over 600,000 definitions according to Wikipedia.↩
8. See, among others, Haynes RB, Taylor DW, Sackett DL, eds. Compliance in Health Care. Baltimore, MD: The Johns Hopkins University Press; 1979 and Sackett DL, Haynes RB, eds. Compliance With Therapeutic Regimens. Baltimore, MD: The Johns Hopkins University Press; 1976.↩