AlignMap

Lessons About Subsistence Consumers-Patients from The Wall Street Journal

Source: Emerging Lessons By Madhubalan Viswanathan, José Antonio Rosa And Julie A. Ruth. WSJ. Oct 20, 2008.

The subtitle, For multinational companies, understanding the needs of poorer consumers can be profitable and socially responsible, limns the focus of the article. My contention is that the concepts available from this piece, while targeted to multinational companies dealing with “people in developing nations like India who earn just a few dollars a day and lack access to basics such as education, health care and sanitation,”  are also applicable to healthcare provided to low income and low health literacy patients by clinicians in, say, northern Illinois.

To illustrate, I’ve listed a few excerpts from the article. It’s the usual drill – translate the following into healthcare-ese (e.g., change words like “consumers” to  words like “patients”). Even if you haven’t done this before, don’t worry – it’s easy.

Excerpts:

… One of the key observations we made is that low-literacy consumers have difficulty with abstract thinking. These individuals tend to group objects by visualizing concrete and practical situations they have experienced.

… Being anchored in the perceptual “here and now” also interferes with the ability of low-literacy consumers to perform mathematical computations, especially those framed in abstract terms. For example, when we asked low-literacy shoppers in the U.S. to estimate whether they had enough cash to pay for the groceries in their cart, many needed to physically handle cash and envision additional piles of currency or coins to accurately estimate the cost of goods in their cart; when the sensorial experience of counting cash was taken away, they often were at a loss.

… One of the most potentially detrimental results of concrete thinking, however, is the difficulty that low-literacy consumers have with performing price/volume calculations. They tend to choose products based solely on the lowest posted price or smallest package size, even when they have sufficient resources for a larger purchase, because they have difficulty estimating the longevity and savings that come from buying in larger volumes. Some base purchase decisions on physical package size, instead of reported volume content, or on the quantity of a particular ingredient — such as fat, sodium or sugar — but without allowing for the fact that acceptable levels of an ingredient can vary across product categories or package size. They tend to think in pictures, so any change in visual cues such as sign fonts, brand logos or store layouts can leave them struggling to locate a desired product category or brand. Price displays can cause confusion because of the many numbers presented, such as original prices, discounted percentages and discounted prices.

… When shopping in familiar stores, many low-literacy consumers buy only the brands they recognize by appearance or have purchased previously. While this approach reduces the incidence of product purchases for which the consumer has no use, it precludes the adoption of new and improved products as a category evolves and improves over time.

… To win and enhance customer loyalty in developing markets, manufacturers and retailers need to understand the difficulties faced by low-literacy consumers and create shopping environments that make them feel less vulnerable. Here are a few ways that companies can help customers make better purchases and avoid embarrassment:

• Display prices and price reductions graphically — a half-circle to indicate a 50% markdown, for example, or a picture of three one-dollar bills to indicate a purchase price of $3. Price products in whole and half numbers to make it easier for low-literacy consumers to calculate the price of, say, two bags of rice. These pricing practices are critically important in marketplaces where general stores and kiosks are being replaced by self-service stores, where there is less interaction between customer and store owner.
• Clearly post unit prices in common formats across stores, brands and product categories to make it easier for low-literacy consumers to perform price/volume calculations.
• Include illustrations of product categories on store signs to make it easier for low-literacy consumers to navigate new or refurbished stores. Similarly, use graphical representations of sizes, ingredients, instructions and other information to communicate product information more effectively in shelf and other in-store displays.
• Put the ingredients required for the preparation of popular local dishes in the same section of the store. This would be helpful to low-literacy consumers who often envision the sequence of activities involved in fixing specific dishes to identify the ingredients and quantities they need to purchase. The same can be done for other domestic tasks.
• Incorporate familiar visual elements — such as color schemes or font types — into new store concepts or redesigned brand logos to minimize confusion and anxiety among low-literacy shoppers and increase the likelihood that they will try new products and stores.
• Create a friendly store environment by training store personnel to be sensitive to the needs of low-literacy shoppers and by verbally disclosing and consistently applying store policies. In addition, allow employees to form relationships with consumers by learning their names and offering small amounts of individualized assistance. This is particularly important for global brands and companies entering markets where foreigners are mistrusted or have accrued a history of mistreating people.

This is yet another case in which those of us in the healthcare  community can learn (and borrow) from methodologies developed by those in other fields.

Friends Don't Let Friends Go To The Doctor Alone

I hadn’t planned to post today, but after I came across Bring Friend To The Hospital, a 9 Sept 2008 Chicago Tribune article by Susan Kutchin Pallant, I found it so resonant with my own experience that I felt compelled to point others to it. In addition, the linkage to patient compliance is apparent.

The following excerpts indicate the focus of the piece, but the entire article is worth reading:

The complete article is online at Bring Friend To The Hospital

Patient Education Goes Bollyhood

Once again, AlignMap takes patient education from the sad and drab ghetto of mainstream materials to the fab world of entertainment.

Check out Tracey Ullman’s conceptualization of patient counseling performed by the pharmacist.

AlignMap readers will, I suspect, find little new in “Doctors Without Orders,” an article about medication noncompliance by Jessica Wagner at Slate.com.

In fact, the material may seem very familiar to those readers of AlignMap posts because much of the article is indeed based on an interview with me and data drawn from the AlignMap site.

Even the material dredged from these archives, however, seems altogether more impressive when Ms Wagner writes it under the Slate aegis.

Jessica Wagner’s Slate.com essay on medication noncompliance can be found at

Two Wall Street Journal articles that are especially pertinent to patient compliance were published on 20 November 2006 during the AlignMap blog’s holiday hiatus.

Cell Phones Provide Medication Information and Reminders

don’t 4get ur pills: Text Messaging for Health¹ by Rachel Zimmerman explores the use of text messaging on nearly ubiquitous mobile phones as a real time means of conveying information about medical treatment, responding to healthcare queries, and, most significantly for patient compliance, sending reminders about medication doses to patients.

While I have been critical of marketing that promotes reminders of various sorts² to be the complete solution to medication noncompliance or suggests that reminders always result in downright miraculous improvements in adherence rates, I am taken with the notion of cell phone text messaging as a useful tool for patients who have difficulty taking the right medications at the right time (a category in which I frequently find myself when a new medication, such as an antibiotic, is added to my ongoing medication schedule for a one or two week period) and for exchanging information precisely because it requires, for most of us, no new or specialized equipment and fits into our daily routines.

Because I already use an analogous service to text messages to myself about everything from taking out the trash early Monday mornings for the weekly pickup and buying specific items currently on sale at my local grocery to adapting a business presentation in time for a meeting next week, I can see how medication reminders could also integrate into rather than impinge upon ones behavioral patterns. I can also imagine younger individuals, such as my 18 and 21 year old sons who would promptly toss a reminder device that attracted attention to themselves under a passing truck, being comfortable with this type of reminder.

Readers may recognize one service provider mentioned in the article, Intelecare Compliance Solutions, as the group represented by Knight, the author of the Medication Noncompliance Blog:

Patients, Doctors, Dollars, and Communication

Your Doctor’s Business Is Your Business by David Armstrong discusses how patients might best deal with the possibility that their doctor has a potential conflict of interest (e.g., a physician with a financial interest in an orthopedic device he developed might be tempted to prescribe it unnecessarily or a doctor might advise patients to undergo a CT scan at a given facility which he owned). While I certainly see the value of open disclosure on the part of clinicians re special financial considerations they might receive from prescribing a specific treatment, I’m less convinced of the practicality of the course of action promoted by this article. In a framed box entitled “WHAT EXPERTS RECOMMEND,” the recommendations are

Even though I’m a physician myself, I would find it awkward to ask each of my doctors every time they prescribe a medication, operation, physical therapy, etc, if they will personally benefit from that transaction. Using as an example, the treatment I received for my recent hip fracture as an example, I should, according to a straightforward reading of the article, have asked about conflicts of interest when

• My personal physician ordered a diagnostic x-ray from a facility located in a different office of the same medical building as his office
• My personal physician had his nurse obtain blood samples for the hospital admission work-up
• My personal physician referred me to a specific hospital for reparative surgery
• My personal physician referred me to a specific orthopedic group for further diagnosis and treatment
• The orthopedic surgeon recommended a hip pinning rather than other options
• The orthopedic surgeon referred me to a inpatient physical therapist for purchase of an assistive walking device and training in its use as a condition of discharge
• The orthopedic surgeon ordered pain medication for my post-operative use as needed
• The orthopedic surgeon ordered follow-up x-rays of the hip to be done in his office before every follow-up appointment
• The orthopedic surgeon recommended outpatient physical therapy at a specific facility

It seems to me that the real question readers are being prompted to consider is “Is my doctor ripping me off?” And, I think that is a legitimate enough concern; the problem is that if such fiscal treachery is afoot, one would hardly expect the perpetrator to automatically fess up when confronted with a simple question. How useful would it be to ask a car salesman, “By the way, my good man, are you charging me an excessive amount for this automobile and pushing the special undercoating only to build up your own commission?”³

The author of the article, perhaps recognizing this issue, advocates a second opinion if any potential conflict of interest is found. I’ve always pushed my own patients to obtain second opinions to pacify any qualms about my diagnoses or treatment recommendations, but second opinions are themselves often expensive (especially if not covered by insurance) and take time to arrange. Moreover, an expert in the appropriate field whose reputation is blemish-free and who is absolutely independent of potential conflicts may be hard to find on short notice. And, if the course of action recommended in the second opinion differs from the first treatment suggested, does the patient get a third opinion to break the tie? What if it turns out that the doctor providing the second opinion has his or her own financial arrangements that compete with those of the first doctor?

Finally, how significant and how specific to a given treatment does that financial involvement have to be to warrant notifying patients? Should the doctor who sells and dispenses mediations within the office list his profit margins for those medications? Does the prescriber who owns stock in a pharmaceutical company have a different obligation to inform clients than the prescriber who helped developed a medication and receives a royalty for every pill sold? Do doctors working for an HMO who receive an incentive for prescribing generic rather than brand drugs disclose that to every patient? Does a doctor who sends patients to a facility that uses a certain type of CT machine on which holds a patent have a different responsibility to disclose his financial arrangement than a doctor who orders CT scans on his patients done in the office with the CT machine his group practice owns and operates?

If the following statements were true, should I have told patients, “I’m prescribing Prozac for your depression, but you should be aware that Eli Lily, the company that manufactures Prozac, …

… pays me a royalty for every Prozac capsule sold because I helped get FDA approval”
… sells these capsules to our pharmacy wholesale and our pharmacy, which our practice owns, charges you a 200% markup when we sell you your medicine I’m prescribing”
… sends a salesman here every month who takes me to lunch where he tells me why I should prescribe Prozac instead of another medication”
… may be in the portfolio of some of the stock funds in which I’ve invested so their profit would benefit me”
… offered second year medical students at many medical schools in 1973 a free, medium quality stethoscope that I accepted”

I suspect few would think that admitting that I accepted a stethoscope from Lily is either necessary or useful, but defining how much financial involvement by a physician merits or requires disclosure is not a trivial task.

My discomfort with this piece, in fact, is not that the problem of a physician’s conflict of interest doesn’t exist but that the simple fixes the article described belies that complexity of the problem.

Additionally, such questions put to doctors are not always benign and may yield negative results, a concern noted in this excerpt:

Readers may also recognize Trisha Torrey as the author of Every Patient’s Advocate, a blog which occasionally appears here at AlignMap.

Disclosure Statement

Ahem, I have not accepted any financial remuneration from The Wall Street Journal, Every Patient’s Advocate, Medication Noncompliance, their authors, or their associated companies for mentioning them in this post.

One possible reason, in addition to my stalwart Midwestern upbringing, my seven years of perfect attendance at Sunday School, the two semesters I spent at Oklahoma Christian College, and my preternaturally staunch moral fiber, for my incredibly righteous stance in this regard is that none of those entities has (yet) offered me any such remuneration. I mean, if someone were to go to the trouble of, say, placing a manila envelope filled with a significant chunk of cash in small, unmarked bills in a locker at the bus station and sending me the locker key, it would be rude not to at least consider taking the money. Or if Mr Murdoch, who could certainly afford it, saw fit to comp me a daily copy of the WSJ, to which I subscribe at the exorbitant, full-price online subscription rate, I would feel obligated to live up to the standards of politeness instilled in me by my mother and to accept that offer as a no-strings goodwill gesture from a fellow publisher.

I freely admit that both of the individual blog authors mentioned do occasionally email me, typically to tell me or ask me about something going on in the wide world of patient compliance or exchange a tidbit or two about our personal lives. Trisha, for example, moved recently, and we briefly discussed the stresses such endeavors may inflict on households. I am only a teen-tiny bit jealous that their businesses were mentioned in WSJ articles and mine wasn’t. Both bloggers have written positive comments about AlignMap or me in previous posts, which is always nice.

Footnotes

1. If this article falls in the “subscriber-only” section of the WSJ, readers without such a subscription may be able to access this article by first going to the Digg Connection to this piece and then clicking on that link↩
2. “Reminders” include wrist watches that signal the time for medication, dispensers with flashing lights, recorded messages, and overtly noxious sounds, telephone calls, orbs that glow at the appropriate time, and a variety of Rube Goldberg contraptions↩
3. While a villainous doctor might be more forthcoming and the questioning process more amusing and gratifying if one employed more vigorous interrogation methodology such as that used on TV police procedurals or in the Spanish Inquisition, those techniques could prove off-putting to some healthcare professionals and could tend to taint the relationship between physician and patient.↩

Follow-up To AlignMap Post On Study Claiming Switch From Lipitor To Generic Is Dangerous

Rather than sacrifice blogging’s inherent advantage of timeliness, I’m deferring the promised conclusion and summary post on the Personal Medication Record to link to and comment on this 3 November 2007 New York Times article, Maker of Lipitor Digs In to Fight Generic Rival, by Stephanie Saul And Alex Berenson, which addresses the Pfizer-sponsored statin research project study that was the focus of the 8 September 2007 AlignMap post, Lipitor Would Rather Fight Than (Have Patients) Switch

The article from the Times recapitulates much of argument I made in the earlier blog entry sans my lengthy exposition of some of the study’s problematic methodological issues. The crux of the New York Times essay is congruent with the final line of my post:

The most useful lesson from this study may well be the reminder that certain medical research projects may have as much to do with market share as with morbidity and mortality.

I’ve included a short excerpt of the opening of the article but the full piece is available without charge at ~ Maker of Lipitor Digs In to Fight Generic Rival ~

And Bloggers On John Edwards

Were one to draw the Venn diagram of patient compliance and presidential campaigns, one would anticipate the intersecting portion would be minuscule if it existed at all. Further restricting that intersection to an overlap patient compliance, presidential campaigns, and public controversy certainly, one would think, doom that result to the ignominy of the null set.

Well, as of 2 September 2007, one would be wrong.

That day, presidential candidate, John Edwards elaborated on his healthcare plan to the folks in Tipton Iowa in a speech described in Edwards Backs Mandatory Preventive Care, the AP news story by Amy Lorentzen:

From the lighting of that fuse to explosions of outrage in the conservative blogosphere required only a few hours.

Consider, for example, a Newsalert post published at 7:52 PM the same day the speech was given:

And, just in case the reader doesn’t pick up on the subtle political connotations of “Comrade Edwards,” the post is headed by the following emblem:

How about a few other examples, just for grins?

From the post with my favorite title, Healthcare Part VIII – Drop that Twinkie or I’ll Shoot! at Angry Bear,

And from John Edwards: “you can’t choose not to go to the doctor for 20 years” posted at Althouse, come these passages:

Daystar51 goes beyond lambasting Edwards for promoting “mandatory preventive health care” to speculating on the possible origins of this notion buried in the candidate’s psyche:

An blog/article, dated September 5, 2007, in US News & World Report wields the British healthy practices incentives plan as a blunt instrument to batter the obligatory preventive care Edwards espouses:

Weird Is Relative, writing in What’s the punishment for noncompliance? Endless jury duty?, implies that the Tipton Iowa speech may be fatal to the Edwards candidacy:

It would be difficult to misunderstand the perspective of Not Larry Sabato, who exclaims in John Edwards on Health Care,

In fairness, not every blogger or commenter was bashing Edwards, but pro-Edwards postings are difficult to find. Plunderchat is a one of those few who straightforwardly support the mandatory preventive care, declaring in John Edwards Looking Good on Health Care that

Commentary

1. It turns out that the complete healthcare plan Edwards supports apparently allows folks to opt out of the program if they wish to manage their own healthcare without government mandates. This discovery disappoints me; when I read about the Tipton speech, I envisioned a post about Edwards declaring Patient Compliance “Mission Accomplished.” Then, I would go on to sardonically observe that “the answer to noncompliance was right in front of us – just issue a presidential proclamation that compliance was obligatory. And so on. If folks have the alternative of leaving the system, the obligatory preventive care lacks the extremity of arrogance that would otherwise render this notion an appealing target.

2. Few bloggers noted that we already have a batch of healthcare mandates on the books, including reporting and quarantine of various infectious diseases, undergoing certain vaccinations, obligating parents to follow doctor’s orders re their sick children, lest they be made wards of the state, and, more recently, restrictions on smoking and intake of some foods.

3. I have to wonder if Mr. Edwards and his advisers have considered the difficulty of monitoring, let alone enforcing patient compliance. While checking attendance records to determine who kept and didn’t keep a doctor’s appointment seems simple enough (although distinguishing between appointments missed because of traffic, scheduling snafus, and family emergencies from those missed through noncompliance may require compliance interrogations abetted by bright lights, good copy-bad cop tactics, and polygraphs), medication compliance, for example, is notoriously difficult to determine, and adherence to diet, exercise, and similar non-medication prescriptions is rarely even attempted. Enforcement methods, short of the Pill Police, are relatively easy to come by; e.g., dropping healthcare coverage for noncompliant patients or tying official authorizations such as driver’s licenses to certificates of healthcare compliance would be simple enough, but even a compliance-pusher like me recognizes that this would be a major shift in the patient-clinician relationship as well as in the role of government in this country.

Patient Compliance Used To Develop A Character In A Crime Novel

From A Darkness More Than Night by Michael Connelly

Empathic Young Doctor Empowers Patient

Elliot, although less skilled clinically than Dr. Cox, has insight into the patient that he lacks because of her own experiences.

Because of Elliot’s empathy (key point: teenaged girls have no control over their own lives), the patient reveals she is “so tired of people telling [her] what to do, when to be home, what to wear, when to take [her] medicine, …” and declares she can handle her own treatment.

Elliot builds rapport [note her forward leaning to signify interest in the patient] and then empowers patient by putting control of her medication in her hands. (Prescription will go to patient instead of parents; she will be in charge of getting and taking her Dilantin.)

Patient says “Thank you” to Elliot [and, one suspects, becomes 100% compliant and lives happily ever after]. Dr. Cox learns a valuable lesson from Elliot.

Upcoming: Commentary On The Scrubs Patient Compliance Subplot

Taking The Right Pills At The Right Time

In yesterday’s Wall Street Journal Health Journal column, Take Your Medicine: Strategies for Sticking to a Drug Regimen, Tara Parker-Pope takes on the practical problems of medication compliance, focusing on pill organizers, reminders, and a few of the strategies previously discussed in this blog: Picture-cards, Alerting Devices, The Asheville Pharmacist-driven Project, and Pharma-sponsored Compliance Programs.

Commentary

My criticism of this article is – well, that it’s not the article I would have written.¹ The time and space restrictions on a columnist are not issues I face posting here. If I skip a day, someone might complain, but I won’t be fired. And, if I am rant-oriented, I can write as many pages if I wish. Ms Parker-Pope does not enjoy such luxuries.

That said, I still believe the columnist’s criteria for usefulness when it comes to compliance methodologies is a tad lax. As the Dodo declares after a race in Alice’s Adventures in Wonderland, “Everybody has won, and all must have prizes.” While one may be able to find instances in which each of the techniques listed made a difference for a given individual or group of individuals, but convincing evidence of overall efficacy is lacking for most.

Interventions to Enhance Medication Adherence in Chronic Medical Conditions: A Systematic Review by Kripalani and colleagues,² an article referenced in the column, concludes its abstract with a sobering line, “Several types of interventions are effective in improving medication adherence in chronic medical conditions, but few significantly affected clinical outcomes.” I would contend that the column should have emphasized both clauses of that statement rather than focus exclusively on the first.

Footnotes

1. If I were to write a single piece for a periodical like the WSJ, I would want to delve into the research, the conceptual basis of compliance, the political and economic implications, … , creating a tome which would displace all other news, columns, and features for weeks. Consequently, the risk to readers is, I suspect, slight.↩
2. Sunil Kripalani, MD, MSc; Xiaomei Yao, MD; R. Brian Haynes, MD, PhD. Interventions to Enhance Medication Adherence in Chronic Medical Conditions: A Systematic Review. Arch Intern Med. 2007;167:540-549↩

Pompous Doctor Unable to Deal With Noncompliance

Source: Scrubs: My Big Move. Episode 90, Season 4, First Aired: April 12, 2005

The Story

Dr. Cox confronts his 16 year old patient, with whom he mistakenly feels he has good rapport, on her nonadherence to her anti-epileptic medication regimen, informing her that she will die if she doesn’t take the medication appropriately. Elliot [AKA "Blond Haired Doctor"], is appalled.

The patient meekly agrees to take her medication, but [gasp] doesn’t do so.

Guilty to discover that shouting at his patient caused her to cry, Dr. Cox awkwardly tries to establish communication with his patient by talking about issues he, again mistakenly, thinks teenaged girls would find interesting.

Dr. Cox, despite hours of effort, fails to forge a working relationship with his patient.

Updated: The Scrubs Patient Compliance Subplot – Part II

The Scene

During the fourth season of Seinfeld, Dr. Reston, Elaine’s manipulative psychiatrist, has whisked her to Europe. He breaks an embrace with her on a balcony in Paris and assumes a thoughtful, concerned stance. Elaine asks “What is it?”

The psychiatrist replies, “I was just thinking about this patient of mine, … just wondering if he’s taking his medication.”

As it turns out, the patient, “Crazy Joe Davola,” has not taken his medication and becomes psychotic. Wikipedia recounts his course following his unilateral termination of medication.

The Moral

Once you’ve seduced one of your patients and taken her to Paris, it’s too late to worry about another patient’s medication compliance.

Reference
Seinfeld. Season 4; Episode 3. “The Pitch”
First Aired: September 16, 1992