A Vision For Tomorrow: Patient-Clinician Alignment
The Practical Necessity Of Alignment
Consider these premises and the logical conclusion that proceeds from them:
Premise #1: Over the last decade, the most commonly proffered and earnestly promoted comprehensive strategy for improved patient compliance has been to educate, encourage, and empower patients to actively and independently participate in the planning of their own treatment. Typically the ideal role described for the patient implicitly positions him or her as the clinician’s co-equal and, not infrequently, that dyad’s primary decision maker vis-à-vis treatment planning.
Premise #2: The gold standard criterion for successful compliance enhancement has always been and continues to be the patient’s close adherence to treatment plan prescribed by the clinician.
Conclusion: To reconcile these premises, one must conclude that the fundamental paradigm of successful contemporary patient compliance strategy is empowering the patient to recognize that his own, independently arrived at treatment preferences are, in fact, identical to the physician’s recommendations, thus ensuring that the patient will implement that treatment plan carefully, persistently, and wisely.
By acrobatically juggling contradictions, this amalgam of ideas (admittedly presented here in grossly oversimplified fashion with just a soupcon of cynicism) efficiently rejects medical paternalism by shifting ostensible power to the patient, yet simultaneously retains the authority and scientific credibility of the clinician’s treatment decisions.
And, in some cases, the patient-clinician interaction may play out in exactly this manner. Yet, given that some patients’ preferences inevitably clash with the clinician’s decisions, one cannot help but wonder, “What happens when the forward-thinking, empathic clinician and the empowered, autonomous patient disagree?” Who casts the deciding vote? Does the clinician capitulate to the patient’s treatment preferences if they differ from his own? If not, does coercing the patient into accepting the clinician’s treatment plan doom compliance?
Concordance
Pertinent to this issue is the notion of concordance, a sophisticated, thoughtful attempt to overcome the limitations of orthodox conceptualizations of patient compliance by shifting the focus from patient behavior (i.e., whether or not the patient followed the prescribed treatment plan) to the discourse between the patient and the clinician about the treatment plan. Concordance also explicitly affirms the authority of both patient and healthcare professional such that the contributions of each are recognized as different (i.e., personal experience Vs scientific knowledge) but valued equally. These tenets can be discerned in the formal definition of concordance, “The agreement between the patient and the health care professional, reached after negotiation, that respects the beliefs and wishes of the patient in determining whether, when and how their medicine is taken … and the primacy of the patient’s decision [is recognised].”
Discussions of concordance have addressed, in an admirably straightforward fashion, the predicament that arises when the patient’s preferences and the doctor’s recommendations are incongruent. Typically, such conflicts are ascribed to variances in the inherent values sustained by the healthcare professional and those affirmed by the patient. For the physician, ameliorating or curing medical disorders remains paramount. For the patient, on the other hand, life’s myriad complexities and competing priorities often complicate a response to treatment recommendations.
Consequently, an individual may, for example, be convinced by his physician of the physiological damage done by excessive alcohol intake, yet continue to drink (in noncompliance with the physician’s orders) if alcohol sufficiently relieves otherwise unbearable stresses. Race and colleagues, in a monograph dealing with the importance of communications in the treatment of HIV, describe a subtle variation of this motif that carries the potential for more catastrophic results. They point out that physicians prescribing a regimen of aggressive antiretroviral agents must demand high rates of compliance and persistence to best serve society (by maintaining viral suppression and reducing the risk of forming resistant strains) while individual HIV patients may well decide, rationally and understandably, that maintaining an acceptable quality of requires intermittent, temporary discontinuations of the treatment to attenuate unbearable side-effects.
Because concordance affords a more realistic context in which to wrestle with such conundrums, it marks a significant advance over the fantasy that the patient is a super-rational individual who, if properly educated, will invariably and precisely follow prescribed treatment instructions. Yet, concordance, like other models of compliance, implicitly relies on the fallacy that rational processes can always be discerned in patients’ decisions and behavior and that rational responses can be marshaled by healthcare professionals to counteract these forces. Clinical experience, however, suggests otherwise. Every clinician can call to mind patients who adhered or failed to adhere to a treatment plan for reasons that seemed bizarre or whimsical or, indeed, irrational. Moreover, when a patient’s decision conflicts with a clinician’s recommendations, concordance offers few guidelines more specific than being sensitive to and aware of the patient’s needs.
Alignment
The spotlight concordance places on patient-clinician conflicts illuminates the key problem with patient empowerment as it is fits into contemporary healthcare. It is not enough to empower individuals; the target must be effective empowerment, a goal that requires alignment as a precursor. (A further discussion of patient empowerment and its relationship to alignment and accountability is found in the section, The Patient As Decision Maker.) Unless the patient and clinician first share mutual aspirations and grasp the complementary nature of their roles, patient empowerment is counterproductive if not dangerous. Senge, writing from a Systems Thinking perspective about developing Learning Teams, is blunt, “Empowering the individual when there is a relatively lower level of alignment worsens the chaos ….”
Taken as a whole, the healthcare literature promotes patient empowerment while also portraying compliance enhancement as a contest between the patient, who struggles against the recommendations of the clinician, and the healthcare professional, who, in turn, defends and counterpunches. Such incongruities evoke an interesting set of questions which are the flipside of the premises and conclusion which opened this section: If a clinician’s goal is overcoming a patient’s resistance to treatment, how will this effort be abetted by empowering this patient, who is positioned as the clinician’s opponent in this contest of wills? Is patient empowerment a sporting leveling of the playing field? Or is the purpose of empowerment to provide a weapon the patient can use to defend himself against his physician? The implications of these queries, I submit, are a compelling argument for the necessity of replacing the view that dealing with noncompliance is a battle between clinician and patient with a model that focuses on the struggle to achieve alignment among the individual being treated, the healthcare professional, and the other stakeholders, an idea further explored in the section, A Vision For Tomorrow, Part 2: Systemic Alignment.
How-To
As one might suspect from the title “A Vision For Tomorrow,” a strategy that envisions a grand alliance of patients, clinicians, healthcare organizations, government, and others is not one likely to be available off the shelf today or even tomorrow – or maybe even the day after that. More acutely, however, there is practical value to be garnered by integrating this insight and the gleanings from the years of compliance research into a step-by-step approach to planning treatment, exchanging communications about treatment with the patient, and monitoring adherence in such a way that misunderstandings and unnecessary conflicts are avoided, priorities for the use of resources to enhance compliance can be determined, the patient’s contribution genuinely acknowledged and acted on, and the clinician’s and the patient’s integrity maintained. An introduction to this process is available in the section, Fixes For Today: Tactics, Tools, & Tips.
