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Where Is The Quintessential American Compliance Setting?
Hint: It’s Not The Doctor’s Office

According to Robert Cialdini, writing in Influence: The Psychology of Persuasion, the quintessential American compliance setting is the Tupperware Party.¹ We’ll get to the “why” behind that claim and what the medical community might learn from get-togethers in suburban living rooms dedicated to retailing plastic food containers  in a moment; first we need to look at …

Psychology Of Persuasion, Decision-making, Influence, Motivation, Consumer Choices, … And Behavioral Economics

A widely varied group, including philosophers, economists, academicians, salesmen, psychologists, sociologists, retailers, manufacturers, marketing and advertising professionals, and others, has, for the past several years, invested much time and effort into understanding the psychological machinations which determine how an individual reaches a decision to take one or another action, such as determining the brand of blue jeans to buy, whether or not to buckle ones seat belt, which political candidate to support, who to marry, when to trade in the family car for a newer model, whether to attend religious services and, if so, which religious services,  … .

Of paramount significance in these efforts is the  focus on how these decisions are  actually – not theoretically – made.

The primary victim of this obsessively pragmatic process has been the paradigm of the Rational Man – the notion that individuals make decisions by calculating the advantages, disadvantages, costs, uses, risks, and similar factors pertaining to possible courses of actions and then choosing the option that best facilitates that individual reaching specific, predetermined goals at the least cost. ²

Decades of experiments, studies, observations, and sales data convincingly demonstrate that, instead, we routinely make decisions based on unfounded beliefs, unconscious  associations, buyer-seller dynamics, and illogical reasoning. In short, in the matter of decision-making, our confidence far exceeds our capacities.³

Back To The Tupperware Party

The Rational Man would, for example, presumably go about meeting his food storage needs by considering the price, warranties, size, sturdiness, experiences of others, and so on for implements available in the marketplace, comparing the findings with his personal preferences and then only then purchasing the items that best match his requirements.

In reality, as shown in a 1990 study by Jonathan Frenzen and Harry Davis, published in the Journal of Consumer Research, Tupperware parties were successful in merchandising the product because those attending liked the hostess, not the Tupperware. Fondness for the hostess was twice as important as whether they liked, wanted, or needed the product.

The Reciprocity Effect

Reciprocity, one element of “liking” someone selling an item or an idea, serves as a useful example of the principles underlying everyday decision-making.

The Reciprocity Effect describes the sense of indebtedness felt when someone does something for us or gives us something and our need to reciprocate in order to relieve that sense of obligation.

In a classic, much quoted experiment by Regan,⁴ subjects are instructed to rate, along with another person (the other person is actually a confederate of the researcher), the quality of a work of art. During a rest period, the confederate leaves the room. When he returns, he is carrying a Coke for himself and one for the subject. There was also a control condition in which the confederate leaves the room and comes back with no Coke for himself or the subject. So subjects in the experimental group receive an unsolicited act of kindness while those in the control group do not.

At the end of the ostensible art-rating experiment, the confederate informally tells the subject that he’s selling raffle tickets and is eligible to win a prize if sells the most tickets. He then asks the subject to help by buying some tickets. Subjects who receive the gift of a Coke buy far more tickets subjects who receive no such gift. Subjects receiving the 10 cent Coke (it’s 1974) buy at least two more raffle tickets at 25 cents each. In fact, the positive effect of the gift (buying more lottery tickets) maintains even if the confederate makes it clear that the Cokes are supplied by the research project so that there is no cost to the giver of the gift.⁵

Quoting Cialdini,

If what you give to somebody is meaningful, tailored and unexpected, that’s really the best you can do. All the evidence shows you will be repaid.

Which is why it is important that games were played and prizes awarded at Tupperware parties, why surveys come with a dollar attached, why the Disabled American Veterans organization sends personalized address labels. with its form letter asking for support (the DAV credits the inclusion of the labels with increasing their response rate from 18 percent to 35 percent), and why an especially smart business partner gave me an extensive collection of music he (correctly) guessed I would enjoy before we even began discussing working together.

The Ethics Of Persuasion In Clinical Care

The use of tactics associated with the principles of persuasion does carry with it significant ethical and moral implications that are beyond the scope of this single posting. While I will elaborate on this in a later entry, suffice it for now to note (1) the concepts of behavioral economics, not unlike the technologies of medicine, are intrinsically amoral; it is how they are put into use that is an ethical concern, and (2) casual observation at any clinic demonstrates that patients making decisions about treatment, one of the first steps in determining adherence, do not behave congruently with the Rational Man theory and are, intentionally or unintentionally, subjected to as many influences as the guest at the Tupperware party; the difference is that those influences were effectively applied to reach a goal at the Tupperware party.

Patient Compliance And Tupperware Parties

Non-rational motivations are, incidentally, equally important in the purchase of a car, the choice of pharmacies, and the election of a Senator as they are in buying Tupperware. While I lack the specific data to prove it, I am willing to wager a significant sum (say, all the money I can lay my hands on) that the same is true in the case of patient compliance.

At the least, clinicians should be aware of and be able to address those influencing forces in the context of patient compliance. I also believe a compelling argument can be made (and I will be making that argument in another post) that clinicians not only have the ethical authority to use certain tactics of persuasion in the service of enhancing the chances that a treatment regimen will be successfully implemented but that they have a responsibility to do so.

I’ve long railed against the concept of the Rational Man as it applies to theories of patient compliance. (See, for example, Patient Behavior, Current Patient Compliance Models, Neuroeconomics, The Rational Man, & Noncompliance, and Decision-Making Processes Of Prostate Cancer Patients)) Ongoing readers could well accuse me of beating a dead horse were it not for evidence found everyday in the literature, conversations, studies, and clinical practice that this particular horse is alive and well.

The concept of the Rational Man continues to dominate – and misdirect – thinking in the field of patient compliance.

And that’s a damned shame – because we should know better by now.

1. It may be helpful to keep in mind that Influence: The Psychology of Persuasion was first published in 1984.↩
2. Rational Man and Economic Man are terms used in economics, law, and other settings to stipulate a hypothetical individual that uniformly and inevitably acts logically to achieve the highest possible well-being for himself using whatever pertinent information is available. More formally, The Washington University Economic Geography Glossary defines Economic Man as the “Highly abstract model of human economic behavior based on simplifying but extreme assumptions of perfect information and perfect ability to use such information in a rational way (i.e. to achieve optimal ends)” ↩
3. For details, descriptions, and data pertaining to behavioral economics, one can turn to a number of recent books written for the lay public. My personal favorite is “Predictably Irrational: The Hidden Forces That Shape Our Decisions” by Dan Ariely. HarperCollins. 2008↩
4. Regan, R.T., 1971, “Effects of a favor and liking on compliance,” Journal of Experimental Social Psychology, 7, 627-639.↩
5. Peter A. Ubel, Free Market Madness: Why Human Nature is at Odds with Economics–and Why it Matters↩

Keep a watch also on the faults of the patients, which often make them lie about the taking of things prescribed.
- Hippocrates¹

Launching A Guerrilla Attack On Patient Compliance – The Battle Of Patients With Pants On Fire

The publication of  Lots Of Patients Fib, Sometimes By Accident, a  nicely done article by Karen Ravn in the June 8, 2009 LA Times about patients who  lie to their physicians  provides a circumscribed clinical scenario that  demonstrates  both the problems with the current patient compliance paradigm and the rationale for the kinds of changes necessary to transform it into a useful concept.

An excerpt from the Lots Of Patients Fib, Sometimes By Accident follows:

It’s well-known that patients don’t always do a perfect job of following — or “adhering to” — the treatment plans their doctors lay out for them. A paper published in 2004 in the journal Medical Care analyzed more than 500 studies on that matter and found that, on average, about 75% of patients met the adherence standards researchers had set.

But these figures may overestimate adherence because some patients are probably fudging. “Patients who say they always take their meds may not be,” says Dr. Steven Hahn, professor of clinical medicine at Albert Einstein College and an internist at Jacobi Medical Center in New York City.

“Patients who say they don’t always take them are likely to be missing significant amounts.”

One indication of how much people fib is how things change when they know they’re being watched.

In a 2001 study in the Journal of Hypertension, scientists followed 41 patients who had been unsuccessful in lowering their blood pressure with three prescribed drugs. Patients continued taking the same three drugs during the study, but they now knew they were being monitored electronically: The drugs came in special packages that recorded the date and time whenever they were opened.

After two months of being monitored, about one-third of the patients had lowered their blood pressure to the normal range. Chances were good, the researchers concluded, that those patients had not been taking the drugs properly before.

A number of other studies have found that patients in clinical trials sometimes “dump” their medication — i.e., simply dispose of it — so it will look as if they’ve been using it as prescribed even though they haven’t.

Also, in the above-mentioned 2000 study published in Chest, 236 patients used inhalers to take medication intended to help them breathe. The inhalers were fitted with electronic monitors that could record the date and time whenever patients used them. Not all of the patients knew about the monitoring feature.

During one year of the study, 30 of the 101 patients who did not know they were being monitored — about 30% — dumped at least once. (Dumping was defined as activating the inhaler more than 100 times within a three-hour period.)

Of the 135 patients who did know they were being monitored, only one dumped.

Most of the dumping incidents occurred just before a clinic visit, and researchers concluded that patients dumped in order to give the impression that they had used their inhalers more often than they had.

No experienced clinicians, I suspect, will be surprised by this information. And, I’ve found few non-clinicians, who, on reflection, fail to recognize that misleading a doctor about treatment adherence, whether by omission or commission, is common.

The potential consequences, however, may be less apparent.

I examined the difficulties created by patients misleading their doctors about their compliance with the prescribed treatment in an earlier post, Treatment Adherent Refusal Of Prescribed Medications.  There I pointed out the risk that the patient would undergo unnecessarily aggressive treatment:

Clinicians cannot efficaciously deal with treatment failure caused by noncompliance if they do not know that the patient did not follow the treatment plan. At best, physicians will be less efficient in providing appropriate care; at worst, they may modify the treatment with disastrous results.

Moreover, the dangers to the patient’s health and the financial cost to the patient and society can increase exponentially. Consider this example from Noncompliance Costs of a nonadherent patient who hides the noncompliance from his doctor:

A Case Of Routine & Tragic Patient Noncompliance

A patient with an respiratory infection does not complete the full course of the antibiotic prescribed by his physician. When symptoms persist, the patient returns to his doctor but fails to report the noncompliance. The physician consequently believes that the original medication was somehow inadequate (e.g., the pathogen was resistant to the medication or not covered within the therapeutic range of the medication) and prescribes a different agent, one that is more costly and more prone to side-effects.

Already in this scenario, noncompliance has resulted in

• At least one unnecessary clinic visit
• Two medications in a situation in which one might have sufficed
• A potentially erroneous shift in ongoing treatment
• An increased risk of adverse medication effects, both because the second drug causes more side-effects than the first and because the patient is exposed to two medications instead of one
• A deviation, based on misinformation, from the initial treatment plan which, by design, should provide the optimal combination of safety, affordability, and effectiveness for that patient. At best, the new treatment plan will be similar to but somehow less advantageous than the original therapy. At worst, the noncompliance-caused treatment failure will cause the clinician to mistakenly alter the diagnosis and treatment such that the actual problem is not addressed.

This example is, admittedly, oversimplified. Some disorders improve despite noncompliance with treatment. Some clinicians might have suspected noncompliance when the patient did not improve. Some patients do confess their failure to follow the treatment plan. Nonetheless, a plethora of evidence demonstrates that noncompliance clearly increases the risk of treatment failure, that clinicians rarely recognize or even suspect noncompliance, and that patients even more rarely reveal nonadherence to treatment. This example is, in fact, statistically condensed but conceptually accurate, and countless analogous cases occur every day throughout the healthcare system. …²

Because of the complexity and interdependent nature of the contemporary healthcare system, the impact of patient noncompliance is rarely limited to wasting one medical treatment that would have been successful if implemented. Instead, any treatment failure caused by noncompliance is subject to an array of multipliers, some obvious and some invisible, that can easily increase the potential fiscal, physiological, and social cost exponentially and connections, both direct and indirect, that distribute a similar range of losses to others. Moreover, the extraordinarily high value western culture places on both the individual and health heightens the stakes and further drives the process.

Not only is this a common problem and one with serious consequences but it is also one nurtured by the contemporary patient compliance model.

Patient Compliance Is A Self Defeating  Strategy

In Treatment Adherent Refusal Of Prescribed Medications, I also pointed out that the conflict between patient and clinician that is part and parcel of our perspective on patient compliance motivates the patient to lie to the doctor:

The currently prevalent models of noncompliance management have a final common pathway: their objective, their only measure of success, is the patient following the medication regimen as prescribed – whether this goal is attained by coercion, persuasion, incentives, moral appeals to responsibility or concern for ones family, patient education, or other methods. Even so-called “patient empowerment” can be accurately translated in this context as “the patient is empowered to choose to take the medication as prescribed.” Consequently, patients who do not take their medications as prescribed are powerfully but covertly encouraged to actively or passively mislead clinicians about the noncompliance, perpetuating this vicious cycle.

This realization led to what I then modestly called …

The Incredibly Revolutionary Idea

1. We quit pretending that noncompliance will disappear if patients are properly educated, persuaded, empowered, informed, motivated, coerced, bribed, threatened, influenced, or reminded. We acknowledge the obvious – that except in a few cases,³ the patient makes the final choice about following a prescribed treatment.

2. Rather than continue the unrequited efforts to eradicate noncompliance, we try, as a first step in breaking the vicious cycle, fixing that part of the healthcare system that multiplies the damage caused by noncompliance: the miscommunication between clinician and patient about noncompliance.

I went on to suggest how the reader might address this issue directly with his or her clinician, but precise tactics are, in this case, less important than the big picture, i.e., the afore mentioned Incredibly Revolutionary Idea.

Storming The Bastille

The New Order Of Things – Replacing Patient Compliance

While only one aspect of the healthcare process, the problem of patients lying about adherence does spotlight the need for and the type of change in patient compliance I am promoting.

Continuing to emphasize the requirement of adhering to a prescribed treatment regimen also continues the conflict between patient and clinician, which, in turn, encourages the patient to lie to the doctor about following treatment. Because every doctor has had the experience of patients lying to him or her, the mistrust has become pervasive. Wary doctors may well mistrust all patients since discerning who is and isn’t telling the truth is difficult and often impossible.   Consequently the entire system has become corrupted.

My contentions are (1) the goal is not good compliance by a specific patient but instead optimal treatment for each patient and (2) optimal treatment is most efficaciously pursued by aligning the doctor, the patient, and other stakeholders to maximize mutual trust, a strategy which takes priority over the percentage of prescribed pills taken by the patient.

To dismantle the patient compliance apparatus that has hindered improvements in treatment outcomes, a systemic shift in perspective is necessary.

As an integral element of that shift, the doctor must convincingly transmit to the patient that valid and reliable communication between them supersedes a compliance scorecard.

Or, I suppose we can invest in electronic compliance monitoring devices, lie detectors, and a spy network.

One option for managing patients who may be lying

By the way, we might want to consider changing the name from “lie detector” to something like “trust enhancement processor.”

1. I know – I’m tired of seeing this quotation too. It just fit so well, I felt compelled to use it.↩
2. This scene is extended beyond this point in the original example at Noncompliance Costs, . I recommend reading it in its entirety to gain a perspective on how  impressively simple it is to conjure up plausible scenarios in which initial noncompliance which is compounded by lying  about it leads to severe incapacity or death and, by extrapolation, how likely it is that this sort of thing happens with some frequency.↩
3. E.g., cases involving children or adult patients incompetent to handle their own healthcare and cases in which forced compliance with treatment is legally sanctioned and is pragmatically feasible↩

If the same principles currently prevalent in the field of patient compliance were applied to the study and management of side-effects, …

Intercosmic Journal Of Treatment Side-Effectology

Searching for the cause  of treatment side-effects & its cure

Articles

Patients  equipped with new  side-effect reduction device report  disappearance of  rashes caused by medication

Patient shown operating  Visual
Side-effect Detection Modulator

An AlignMap.com Publication – Allan Showalter, MD, Editor

I’ve published a second post, Patient Compliance – So Wrong For So Long, at the eyeforpharma.com site.

For ongoing AlignMap readers, this will be a new perspective on an old theme – the failure of the concept of patient compliance to provide reliable or valid information about a patient’s response to treatment recommendations.

Specifically, I compare the meager accomplishments in treatment adherence to the civilization-changing benefits produced in the field of epidemiology.

I also offer examples in which minor situational variations may – or may not – change ones assessment whether a given patient is compliant or noncompliant. The implicit question, of course, is how useful can the concept of compliance itself be if the significance of a patient being identified as compliant or noncompliant is nebulous.

About That Fish, The Barrel, And The Smoking Guns

Yeah, I know it seems like overkill, and it is, I admit,  a tad too easy to be enjoyable as a sport, but, after all, the current ideas about patient compliance have so far  been able to dodge bullets for decades and still survive.

More to the point,  this elaboration of the problems with patient compliance is necessary as explanation of and motivation for the changes essential for creating a functional alternative to the current thinking.

In the meantime, take a look at Patient Compliance – So Wrong For So Long if for no other reason than garnering inspiration from epidemiology’s successes and imagine what could be accomplished if we could make similar advances in patient compliance.

I’ve been invited to post on the eyeforpharma.com site. In hopes of extending my audience, I’m giving it a shot.

This is a trial and error process. We’ll see how it works out.

The initial post can be viewed at The Tragedy Of Patient Compliance.¹

1. Because of the differences in formatting and use of graphics at eyeforpharma.com and AlignMap, I’m also considering reposting similar material to that I enter at eyeforpharma.com at AlignMap at the same time or a short time later.↩

The Emperor Views His New Clothes

Unicorns, Atlantis, Easter Bunny, Hooker With Heart Of Gold, World Champion Chicago Cubs In Runners-Up Spots

To illuminate the flaws  inherent in  the  contemporary notion of patient compliance, I have, in previous posts, invoked such cultural references as the Ptolemaic cosmological model,  Rumpelstiltskin, Johnny Cash’s classic  “A Boy Named Sue,” The War of the Worlds, Lincoln’s riddle about how many legs a dog would have if one called the dog’s tail a leg,¹ and the artist formerly known as “the artist formerly known as Prince.”

But, it is the Hans Christian Andersen fairy tale, The Emperor’s New Clothes,² that provides  the most rewarding comparison to  and the clearest understanding of the problems with the concept of adherence to treatment and the need for a comprehensive reorientation of our perspective on this issue rather than a refinement of nuances.

The Emperor’s New Clothes And Patient Compliance

The  congruity between the Emperor’s New Clothes fairy tale and the Myth of Patient Compliance ain’t subtle – or pretty:³

The Emperor’s New Clothes: No one can see the non-existent apparel ostensibly worn by the King, yet the King and everyone else, except one child, behave as though they not only see but admire  those clothes.

The Myth Of Patient Compliance: No one can see non-existent evidence that the current ideas about treatment adherence are conceptually or pragmatically valid, yet the healthcare community behaves  as though these theories are not only well supported but have also proved to be useful means of  improving the proportion of treatments effectively completed as prescribed.⁴

In the fairy tale, the King parades in his “new clothes” that exist  only in the fantasy woven by the corrupt tailors because he has too much invested in his self-image to admit he sees nothing (which would also be confessing, as explained by those same crooked clothiers, that he is too stupid to see the outfit). The crowd of  subjects cheering their Monarch only ostensibly dressed in his finest attire may have shared the Emperor’s narcissism, been intimidated by the Royal Guard, been influenced by the others in the crowd claiming to see the wonderful clothes, or simply succumbed to  the lure of the path of least resistance.

Similarly, few authoritative individuals, healthcare organizations, professional societies, institutions, commercial firms, pharmaceutical companies, or third party payers  identify themselves as passionate disciples of the dominant point of view re treatment adherence.  In fact, the clinician  willing to  unequivocally endorse the utility of the current notion of adherence to treatment may be no more common than the afore mentioned unicorn. Yet, the topic continues to generate ever increasing numbers  workshops, conferences, electronic gizmos, web sites, advertising programs, claims of effectiveness, declarations, sub-theories, and, especially, research papers. The capacity of those in the field to run the same compliance studies and enhancement programs to obtain the same unsubstantial results for the past 30+ years in the face of minuscule, if any, progress is, as the kids used to say, awesome, dude.

At this point a hypothetical reader⁵ may be (conveniently) asking, “Why haven’t we tried other approaches?” Well, as far as I can determine, the healthcare industry persists in treating patient compliance as though it is a pragmatically effective idea (or, at worst, a concept that requires only that one final study to provide definitive proof) because of *1) confusion between patient compliance as a statistic (e.g., the percentage of medication doses taken as prescribed) and patient compliance as a conceptual perspective and (2) simple intellectual inertia.

We in the healthcare community are a persistent fort, albeit perhaps not quite as bright as our mothers might have hoped.

A Tentative Response

How about this for a rule of thumb:

If, after 30 years of extensive and intensive effort based on a given theory, the clinical, scientific, and commercial sectors of  healthcare cannot develop effective solutions to a problem that massively reduces the effectiveness of medical treatment, then  (1) trying the same studies for another 30 years or refining the jargon isn’t likely to be  the optimal course of action, (2) maybe – just maybe -  it’s  the theory rather than the research that is faulty, and (3) approaching the issue from a new perspective could be the way to go.

Yeah, it’s a wacky idea, but it’s so crazy so crazy it might just work.

The Role Of AlignMap

As for me, I’m auditioning for the role of the  conveniently non-self-censoring little brat boy who points out the obvious.  It smacks a bit of typecasting, but still, …

Upcoming AlignMap Series:

Transforming Adherence Into A Useful Concept
Things To Do Until The Manifesto Is Finished

1. Solution: The dog still has four legs because – here it comes – calling a dog’s tail a leg doesn’t make it a leg.↩
2. Wikipedia provides a serviceable  synopsis of the story line:

   An emperor of a prosperous city who cares more about clothes than military pursuits or entertainment hires two swindlers who promise him the finest suit of clothes from the most beautiful cloth. This cloth, they tell him, is invisible to anyone who was either stupid or unfit for his position. The Emperor cannot see the (non-existent) cloth, but pretends that he can for fear of appearing stupid; his ministers do the same. When the swindlers report that the suit is finished, they dress him in mime. The Emperor then goes on a procession through the capital showing off his new “clothes”. During the course of the procession, a small child cries out, “But he has nothing on!” The crowd realizes the child is telling the truth. The Emperor, however, holds his head high and continues the procession.

   ↩

3. The fairy tale and the issues involved in adherence to treatment do not fit perfectly in one area.  Unlike the con men hired as the Emperor’s tailors, the clinician-researchers who formulated our current vocabulary and models of patient compliance were attempting to discover underlying truths rather than pull off a scam  for their personal gain.  On the other hand, it does appear  likely  that some  self-serving claims about certain compliance enhancing technologies have employed especially  creative interpretations of  already ambiguous  terminology.↩
4. Evidence for and an elaboration of these contentions can be found at The State of the Art.↩
5. Or, alternatively, a unicorn↩

I came across the Rumpelstiltskin Phenomenon, a concept that is pertinent to my contention that the focus on renaming the phenomenon now most commonly known as patient compliance or treatment adherence is unlikely to prove an advantage, even if the renaming is accomplished.

The Rumpelstiltskin Phenomenon

From: A Dictionary of Psychology  (2001).  Author: Andrew M. Colman.

Rumpelstiltskin Phenomenon The tendency for the naming of something to create the impression of imparting an understanding of it. It applies, for example, to the naming of mental disorders: a person who tells implausible lies may be said to be suffering from pseudologia fantastica, but that term is nothing more than a name for implausible lying, and any impression that it imparts an understanding of the phenomenon is a cognitive illusion. [Named after Rumpelstiltskin in a famous fairly tale, called Rumpelstilzchen in the German version collected by the brothers Grimm, a strange dwarf who exerts a baleful influence over a miller's daughter until she eventually gains power over him by learning his name]

I confess to feeling gratified to discover that someone has articulated the ambiguous  notion I had  developed in thinking about the renaming of patient compliance.  It is, of course, a tad ironic that I’m happy about finding  the phenomenon I grasped instinctively – that naming something doesn’t necessarily improve ones understanding of it -  has a name

Would someone with a thermometer check whether hell has frozen over?

I just finished posting More Patient Compliance Myths Debunked, in which I endorse points made by  the chief scientist of the Aardex Group. Last week, or goodness sake, I published The Post Is Not Brought To You By Pfizer – It Just Seems That Way.  If that title alone isn’t enough data for a diagnosis, consider this excerpt:

Gosh, this is difficult.  Well, I may as well just come out with it – at the risk of appearing to be a shill for Pfizer, I must admit that the points made by European brand manager, Chris Venn, at eyeforpharma’s recent Patient Compliance Europe 2008 conference, as reported in Patient compliance programs: Learnings from the trenches, are valid, insightful, and useful.

That’s right – Mr. Venn is pushing ideas that are congruent with my own.

I know, what are the odds?

Now, I’ve happened  onto Dose Of Digital, a  blog produced Jonathan Richman, who previously “led some of the compliance initiatives for Arimidex, a breast cancer treatment, at AstraZeneca, a card-carrying member of Big Pharma.

The blog is dedicated to “help[ing] figure out how healthcare can leverage some of the digital technologies available today.”

Well, that’s nice.  What impresses  me, however, is Richman’s willingness to point out the glaringly obvious – such as compliance is a complex and complicated issue.  And Mission Accomplished claims for a single compliance methodology should be held suspect. Does that sound familiar?

Check out the content and, especially, the tone of this excerpt from Glorified Alarm Clocks:

So, if Mr. Rose says it isn’t a “reminder problem” and that most devices are “glorified alarm clocks,” how is his device which includes services such as “reminder calls” and “weekly emails” not a reminder device that’s a “glorified alarm clock?” The answer is that it is. This device is a glorified alarm clock. Just because it doesn’t ring and sends an email instead doesn’t change this fact. Using digital, such as email, doesn’t inherently make your product better or change it’s basic function.

If reminders worked, then simple beeping alarms would have solved the compliance problem long ago. The way I look at this is for a serious disease like breast cancer, isn’t opening your eyes each morning enough of a reminder that you have a disease that could kill you at any point? I’d think that might remind you about your medication. If reminders worked, wouldn’t the fact that you could die be reminder enough?

The reality is that compliance isn’t a reminder issue. It’s a complex psychological issue. People don’t take their medications for a number of reasons many of which include the patient’s decision that the drug isn’t helping them or isn’t necessary. Very few patients are informed enough to truly make this decision (they’re called doctors though) and yet it happens every day. People aren’t convince themselves that the risks outweigh the benefits or that they are feeling fine, so they must be “cured.” Point is, it’s something different for everyone. Very few people actually stop because they simply can’t remember.

Now, zip over to Dose of Digital to read the rest of Glorified Alarm Clocks.  Yes, now. Just hustle back here after you finish.  While I await your return, I’ll be humming the Jeopardy tune that played while each contestant scrawled his or her “Final Jeopardy” answer, in the form of a question.

Da, da, da , da da, da, daaa, da, da, da, da, dah!, da, da da da da, da da, da, da da, da, …

Is that post cool or what?   If I published those paragraphs here under my name, I’m willing to wager it would fit so well that no one would think it anything but one more of my politely phrased rants. As far as I know, Mr Richman and I were not separated at birth, he is not my evil twin (which leaves the possibility that I’m his evil twin), there has been no mind meld. I think  we may be kinda like those identical cousins in the Patty Duke Show.¹

One parallel post can,  of course, be an aberration, but this is a blog that I’m going to watch closely. In any case, I am excited about the notion that a blogger, especially one with a heavy duty corporate background, seems to be pushing a patient compliance agenda that mirrors some of the ideas I promote at AlignMap. Heck, if a few more bloggers and corporate types come into (ahem) alignment, we could have us a movement.

1. Mr. Richman may not, by the way, agree with my assessment of our similarities. And, even if he does see our  points of view as congruent, he may not necessarily view that as a positive.↩

Because so many misunderstandings and misconceptions about patient compliance are considered common sense and consequently go unchallenged, presenting them as “myths” can be an effective, if perhaps hackneyed, means of correcting misperceptions.

At least I hope so. One of the most popular pages on the AlignMap.com site has long been the discussion of my own pet compliance myths.

I recently found another set of myths.  Dispelling The Myths Of Patient Adherence, Lisa Roner’s summary of a presentation made by Bernard Vrijens, chief scientist with Aardex Group, at eyeforpharma’s Patient Compliance Europe 2008 conference is a succinct, clearly explained debunking of  widespread beliefs about compliance that are dangerously wrong.

Dr. Vrijens discusses these myths:

1. Caregivers assure adequate adherence.
2. The circumstances of clinical trials assure satisfactory adherence.
3. Adherence can be expressed as a percentage of prescribed doses or as a dichotomy.
4. Patient adherence improvement programs can rely solely on motivating.
5. Electronic monitoring is expensive.

The entire article is just over 1000 words and easily read, representing one of the best benefit to effort ratios you’re likely to come across today.  It can be found at Dispelling The Myths Of Patient Adherence

Alternative Perspectives On Patient Compliance

We Interrupt This Rant, …
As ongoing readers know, recent AlignMap posts have been a series of jeremiads lamenting both (1) the repetitive nature of patient compliance research, programs, and theoretical thinking and the resultant paucity of advances in the field and (2) the questionable value of  recurrent skirmishes over details such as the most appropriate appellation du jour for the system currently known as patient compliance, a battle which strikes me as the equivalent of a bidding war for naming rights to the Titanic breaking out just after the collision with the iceberg.

Well, to invoke the astoundingly convenient Monty Python pseudo-segue, now for something completely different, i.e., an atypically positive post suggesting a pragmatic means of expanding the conventional knowledge base of patient compliance. While that appropriately modest goal falls short of a universal panacea for treatment failure, the redemption of men’s souls, or the establishment of cosmic justice, it’s not a bad way to start the week.¹

Patient Compliance Information Source Alternatives:
We Are Not Alone

The key to unlocking a wealth of information and thoughtful research with direct and inferential links to treatment adherence is the willingness to consider the possibility that the two-part iconoclastic hypothesis presented a few lines below may, however incredible  it may seem, be valid.

Before revealing this fundamental reshaping of the intellectual firmament, authorial responsibility  dictates that I issue certain caveats. Those easily shocked, those with sensitive temperaments, and those diagnosed with high anxiety, severe cardiac conditions, or other disorders known to be  exacerbated by strong  emotional or intellectual challenges may wish to confer with their personal physicians before continuing. Medications, if appropriate to the situation, should be at hand. Ladies and older gentlemen, even those in superb health, should be seated or recumbent upon reading the remainder of this post. Those who feel they cannot tolerate further chaos in their lives at this point should cease reading no later than the end of this paragraph.  Knowing ones own limitations is a strength, not a weakness. The  official AlignMap Blog position holds that  there is no shame in dropping out now rather than risk ones wellbeing.

Those intrepid souls determined to pursue this idea should now prepare themselves.

Precursor Principles For Expanding The Patient Compliance Model

Principle 1. Patients are not exclusively patients. Reliable evidence has begun to accumulate, for example, that some individuals, despite meeting rigid criteria identifying them as “patient,”  also hold  jobs, sometimes devoting 40 hours or more a week to their occupational roles. Others are now known to operate as parents, grandparents, brothers, sisters, friends, partners, and a myriad of other roles. Rumors have even arisen that many patients have strong positive and negative feelings toward others that seem to have nothing to do with health or healthcare. There have been confirmed sightings of patients functioning simultaneously in several social, cultural, and spiritual spheres independent of their medical treatment status. Further, many patient brazenly and casually admit to these non-clinical identities and invest considerable psychological resources in them. At a minimum, these observations cast doubt on prevailing Patient Theory which holds that patients, when not in the presence of a clinician or in the act of executing a prescribed treatment, are maintained in a state of suspended animation until awakened for their next clinic appointment or medication dose.

Principle 2. The processes that culminate in Patient Compliance or Noncompliance do not operate exclusively in matters of health and healthcare. In fact, the manner in which a patient responds to treatment recommendations from a clinician and the extent to which that patient follows those treatment recommendations may be similar to the manner in which that person responds to and follows recommendations from a lawyer, a broker, a business consultant,  a teacher, a military superior, a friend, a mechanically derived algorithm, …  – even if those  recommendations have no direct implications for healthcare.

Heady stuff, eh?

It’s a lot to digest, but there is a payoff. Because of the extensive data, research, and literature available about how people respond to and follow those non-healthcare recommendations (often called “advice” in the non-medical world), these metaphysical musings transform into something real – and something immediately useful. In the fields of psychology (in this case, that portion of psychology not directly linked to medicine), sociology, economics, political science, education, business, and market research, among others, a plethora of data, interpretations, studies, and reports exist under topical headings such as decision-making, the spread of ideas, purchase resistance, learning processes, behavioral influences, … .

And, even better, most of that material is not a rehashing of the medical literature on patient compliance, but, in fact, may offer  perspectives that are unique from yet could be applicable to clinical adherence.

Serendipitously, an example is at hand.

The Impact Of Emotion On Patient Compliance

Source: Feeling the Love (or Anger): How Emotions Can Distort the Way We Respond to Advice Knowledge@Wharton, October 1, 2008

Knowledge@Wharton is the online newsletter of the Wharton School of the University of Pennsylvania. Wharton is, of course, an eminent business school and the newsletter is congruently oriented.

I’m not covering the article in depth. Instead, I will present excerpts to give a flavor of the entire piece, point out some specific elements I think are significant to those of us invested in understanding patient compliance, and, finally, invite the reader to review the original essay itself along with the relevant research on which the article is based. Both the article and the essay are available on the same Knowledge@Wharton web page.

Here’s a piece of advice: Don’t read this story if you have just had a fight with your spouse or a co-worker. You will probably ignore it, despite its grounding in solid academic research. At least that’s what Maurice Schweitzer, a Wharton professor of operations and information management, would most likely suggest. In a recent paper written with Francesca Gino of Carnegie Mellon University, he shows that emotions not only influence people’s receptiveness to advice but they do so even when the emotions have no link to the advice or the adviser.

“We focus on incidental emotions, emotions triggered by a prior experience that is irrelevant to the current situation,” the two scholars note in their paper, titled “Blinded by Anger or Feeling the Love: How Emotions Influence Advice Taking.” “We find that people who feel incidental gratitude are more trusting and more receptive to advice than are people in a neutral emotional state, and that people in a neutral state are more trusting and more receptive to advice than are people who feel incidental anger.”

… until recently, economic analysis has taken as its premise the idea that, when it comes to dollars and cents, people can wall off their emotions. “Classical economics is predicated on this rational-man idea and also on the idea that mistakes will get extinguished by the market,” Schweitzer says.

But Schweitzer and Gino’s research suggests that emotions can systematically distort people’s receptiveness to advice and thus their rationality. And if everyone errs in similar ways, that could skew the classicists’ perfect calculus. “My intuition was that we often base complicated decisions on how we feel,” Schweitzer says. “If I ask you something complicated like, ‘Should we hire this person or should we buy this house?’ you have to consider a lot of attributes and compare a lot of complex things. So we often use a simple summary statistic, which is how we feel about the job candidate or the house. When we do that, we open ourselves up to the possibility of making a mistake based on emotion.”

That makes sense, but how do you prove it? Schweitzer and Gino designed experiments in which they — as difficult as it sounds — manipulated their subjects’ emotions, gave them advice and measured the effects. In their first experiment, they recruited college students and asked them to make a judgment about something they were sure they could not know for certain. In this case, they showed each subject a photograph of another person and asked them to estimate the body weight of the person in the photo. They then induced an emotion by having each subject watch a short movie clip. Some subjects saw an anger-inducing bit from The Bodyguard in which a man gets treated unfairly. Others viewed a gratitude-inducing clip from Awakenings in which another man receives an unexpected favor from his co-workers. And the rest saw a neutral outtake from a National Geographic documentary about Australia’s Great Barrier Reef.

In a separate study, the two scholars assessed how the videos induced different emotions. Because the students had no real connection to the scenes, the researchers could classify their reactions as incidental as opposed to integral. If you watch The Sopranos and then get angry with your spouse, that’s incidental emotion. If your spouse slaps you and you get angry with your spouse, that’s integral.

After watching the clips, the students reflected in writing on what they had seen and how it had made them feel, and then had a chance to re-estimate the weights of the people in the pictures. This time, they also received estimates that the researchers told them had been done by another participant. Though the subjects didn’t know it, everyone received the same set of second estimates. These estimates — the advice — were helpful, not misleading. “The emotion manipulations significantly influenced the accuracy of participants’ final estimates,” the two scholars state.

Participants “who experienced incidental gratitude weighed advice more heavily than did participants in a neutral state,” they write. “Participants who experienced incidental anger weighed advice less heavily than did participants in a neutral state. Even though the emotions induced in this study were unrelated to the judgment task, we find that these emotions significantly changed the extent to which participants relied upon advice.”

In the real world, as opposed to a behavioral lab, these findings play out in all sorts of ways. Co-workers, for example, often annoy each other, sometimes for legitimate reasons, like missed deadlines, and sometimes for silly ones, like how stupid someone’s laugh sounds. And sometimes, a person will get ticked off and fail to heed another’s good counsel just because of a bad mood.

“If I’m angry at my wife and therefore trust you less and am less receptive to your advice, then that’s clearly irrational,” Schweitzer says. “The fact that my wife crashed my car has nothing to do with you. But maybe I’m angry because you cancelled our last meeting and now we’re interacting again. Maybe there’s some real information about your reliability in the fact that you cancelled our meeting. It takes a controlled, clean experiment to disentangle rational reasons from biased ones. What we haven’t shown [with this study] but I’m confident would work is that, if you do something that makes me angry, then I trust your advice differently.”

Schweitzer says that people with what he calls “high emotional intelligence” are probably already putting his and Gino’s insights into action without even knowing it. “Emotional intelligence is the ability to recognize emotions and understand how they operate and also the ability to manipulate or change them. If I have emotional intelligence, I know what the right time to talk to my boss is. I know that my new partners had a terrible flight and lost their luggage and aren’t going to be receptive to what I’m saying, so I shouldn’t make my pitch right now. Or I know that, if I take them to this particular restaurant or I buy tickets to this Indy car race, I can shift their emotional state to feeling more gratitude toward me and listening to me.”

Skilled negotiators tend to have high levels of this kind of aptitude, and they apply it in small, subtle ways when they are doing their work. They might, for example, apologize for a perceived wrong, even when no apology was expected or required. Or they might, during a particularly tense time, call for a break, go get a soda and also bring something back for the people on the other side of the table.

Schweitzer sees what he and Gino observed operating in all sorts of business interactions. When a sales person takes a client to a ball game, for example, he’s not just cozying up in the obvious way. He’s also creating a sense of gratitude. When a drug rep brings lunch to a doctor’s office, she’s doing the same thing. “Can this backfire?” he asks. “Yes. If it doesn’t seem genuine, people aren’t going to believe it. Suppose that I try to induce gratitude and I go over the top. That’s the sales rep who’s giving too many gifts.” Push it too far, in other words, and you could end up making someone angry.

Observations On Patient Compliance Articles Not Presented As Patient Compliance Articles

Those accustomed to reading about patient compliance in publications such as The New England Journal Of Medicine, The American Journal of Psychiatry, The American Journal of Managed Care, white papers put out by pharmaceutical manufacturers and benefits management companies, and, of course, AlignMap.com, may find my free form observations helpful in orienting themselves in this brave new world.

1. The referenced article does not mention healthcare but does list an extensive set of business scenarios in which emotional content could affect ones decisions. The application of the content to compliance seems, as I read it, strikingly apparent. This is not, in my experience, unusual. Literature with a business, sociology, or economics orientation, for example, seem less concerned about how decision-making (in this case) works in specific, well defined situations than finding general principles that are valid in many settings. When healthcare is mentioned, it is often as one of many examples.
2. The article’s primary finding, that emotions experienced by the individual affect how that person responds to advice, even if the origin of those emotions have nothing to do with the immediate decision to be made – or, to extrapolate, the patient’s disorder or the healthcare situation, has not been emphasized in the medical literature.² Although in this example the findings are only moderately different from the conclusions of analogous articles with medical orientations, other instances will demonstrate entirely different, but not necessarily contradictory, approaches.
3. The experiments designed to test the hypothesis in this article lie closer to the basic research pole of the pure science-applied science spectrum than do the typical patient compliance studies and, not incidentally, are more akin to the animal behavior labs than naturalistic clinical trials favored in healthcare journals. Experimental approaches to similar questions vary dramatically from field to field.

My contention is not that the compliance-pertinent material available from non-medical fields is of higher (or lower) quality, that its experimental style is more (or less) valid, or that its findings are more (or less) useful. My contention is that the work done in non-medical fields often asks different questions, approaches solutions differently, presents findings in different contexts, … .³

Given the lack of progress in comprehending the workings of, let alone improving, compliance after many years of effort by the mainstream healthcare fields, the exploration of the potential contributions from these legitimate, well credentialed alternatives would seem a wise investment, if not an obligation, for anyone invested in understanding the phenomenon that most of us know by its healthcare-names, patient compliance or treatment adherence.


Footnotes

1. Re the more optimistic tone of today’s post, not to worry; this blog’s normal apocalyptic programming will resume forthwith↩
2. There has been significant material published in the medical compliance literature on stress caused by the medical problem being treated, the coping styles of the patients, and co-existing psychiatric diagnoses, especially depression.↩
3. Research and theoretical work in each of these non-healthcare fields may be as restrictive and narrowly focused as that done in healthcare. I am only pointing out that these fields view and treat issues that are part and parcel of patient compliance differently than do those of us in medicine.↩

Abe Lincoln¹

What Does Abraham Lincoln Have To Say About The Uncivil War Between Compliance and Adherence Proponents?

Another quotation pertinent to the contentiousness over the appropriate name for the phenomenon most clinicians call patient compliance has occurred to me. This one is attributed to  Abraham Lincoln. More about the provenance later.

In most of the myriad versions used today in sermons, debates, business presentations, and political speeches, Lincoln is confronted with a difficult situation in which the decision seemingly rests on the interpretation of a linguistic nuance. Lincoln ponders, then asks the individual pressing him for a response how many legs a dog would have if one called the dog’s tail a leg.

The questioner, apparently the only individual in western civilization who hasn’t heard this before, does the mental arithmetic and answers “5.” Lincoln then sagely observes that no, the dog still has four legs because – here it comes – calling a dog’s tail a leg doesn’t make it a leg.

The application to the compliance Vs adherence Vs concordance Vs a rose by any other name competition is, I trust, obvious.² Incidentally, in pithy anecdote land, such a comment squelches its target, instantly and irrevocably wins the debate, and redirects the course of world events. Of course, in the real world, the opponent says something like, “What are you talking about? What do dog’s legs and tails have to do with adherence to treatment?” Sometimes, I wish I lived in pithy anecdote land.

The Tangential But Arguably Interesting Issue Of Provenance

The good news is there is an interesting story about the 5-legged dog story. It has nothing to do with patient compliance – which may be off-putting or a blessing.  In either case, read on at your own risk.

In an attempt to track down the provenance of the quote attributed to Lincoln, I found Millard Fillmore’s Bathtub, a site “striving for accuracy in history, economics, geography, education, and a little science” which houses a post about this quotation. An excerpt follows:

I have a source for the quote: Reminiscences of Abraham Lincoln by distinguished men of his time / collected and edited by Allen Thorndike Rice (1853-1889). New York: Harper & Brothers Publishers, 1909. This story is found on page 242. Remarkably, the book is still available in an edition from the University of Michigan Press. More convenient for us, the University of Michigan has the entire text on-line, in the Collected Works of Abraham Lincoln, an on-line source whose whole text is searchable.

Rice’s book is a collection of reminiscences of others, exactly as the title suggests. Among those doing the reminiscing are ex-president and Gen. U. S. Grant, Massachusetts Gov. Benjamin Butler (also a former Member of Congress), Charles A. Dana the editor and former Assistant Secretary of War, and several others. In describing Lincoln and the Emancipation Proclamation, George W. Julian relates the story. Julian was a Free-Soil Party leader and a Member of Congress during Lincoln’s administration. Julian’s story begins on page 241:

Few subjects have been more debated and less understood than the Proclamation of Emancipation. Mr. Lincoln was himself opposed to the measure, and when he very reluctantly issued the preliminary proclamation in September, 1862, he wished it distinctly understood that the deportation of the slaves was, in his mind, inseparably connected with the policy. Like Mr. Clay and other prominent leaders of the old Whig party, he believed in colonization, and that the separation of the two races was necessary to the welfare of both. He was at that time pressing upon the attention of Congress a scheme of colonization in Chiriqui, in Central America, which Senator Pomeroy espoused with great zeal, and in which he had the favor of a majority of the Cabinet, including Secretary Smith, who warmly indorsed the project. Subsequent developments, however, proved that it was simply an organization for land-stealing and plunder, and it was abandoned; but it is by no means certain that if the President had foreseen this fact his preliminary notice to the rebels would have been given. There are strong reasons for saying that he doubted his right to emancipate under the war power, and he doubtless meant what he said when he compared an Executive order to that effect to “the Pope’s Bull against the comet.” In discussing the question, he used to liken the case to that of the boy who, when asked how many legs his calf would have if he called its tail a leg, replied, ” Five,” to which the prompt response was made that calling the tail a leg would not make it a leg.

Update: October 5, 2008
Those taken by the Lincoln-Lyle Lovett link referenced in Footnote #1 may wish to check out an expanded discussion with better graphics (including the new Lovett Penny) at today’s post on my personal Heck Of A Guy blog, Lookalikes: Lincoln and Lyle Lovett

1. Does the image of Lincoln atop this post remind anyone else of Lyle Lovett?
   

   ↩

2. If not, a PDF of the complete answer is available for a nominal fee of $63,200. See, that was a joke about assigning an arbitrary meaning to the name, “nominal fee.”↩

I’ve run across another batch of articles in which the authors have flashed onto the epiphany that “adherence” is an altogether morally, ethically, and spiritually superior term to the malignant, inhumane, and generally repugnant “compliance” for designating the degree of a patient’s cooperation with a given treatment recommendation.¹

Given that I’ve been on a rant roll of late, it probably won’t be a surprise that I’m preparing a post on the Adherence Vs Compliance Vs Concordance Vs Whatever issue and how it at best misses and may well distract from the point. Heck, I may as well show the entire spoiler – I contend that the discussion itself implicitly sustains a fundamentally flawed concept of compliance.²

It will be some time before my full diatribe is completed and posted. I’m publishing this prelude now because of a quote from  a news story I recently read. The story is about the economic crisis rather than the patient noncompliance catastrophe, but I think the words are precisely applicable.

John McCain has a piece of advice for the House of Representatives when it reconvenes later this week for a second go around at a $700 billion financial package, call the bill a “rescue” rather than a “bailout.”

“The first thing I’d do is say, let’s not call it a bailout, let’s call it a rescue because it is a rescue. It’s a rescue of Main Street America,” McCain said in an interview on CNN’s “American Morning.

Well, thank goodness we now have the names straight. I’m sure that soon, this repair by renaming tactic that transformed an evil “bailout” to an all-American, virtuous “rescue” will somehow result in an improvement in my fiscal well being and an increased confidence about the future.

Any time now …

Footnotes

1. Has anyone else noticed these name game pieces seem to be published in packs? I am, in fact, now suggesting that a group of articles focused on competing names of phenomena is herewith to be called an appellation of names.↩
2. I hereby confess that 15-20 years ago I had the same revelation about the names and, had I been blogging at that time, would no doubt have self-righteously led the inquisition to re-educate those medical miscreants who dared use “compliance.” It is, trust me, a blessing to us all that I recovered before blogs evolved onto the scene.↩