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.

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• Learning From Patient Noncompliance
• Communication & Transparency

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

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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 [back]
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 [back]
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. [back]

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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 ~

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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.

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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

• The Scrubs Patient Compliance Subplot - Part I
• NY Times Coverage Of Patient Compliance
• Dangers Of Making Noncompliance A Medical Condition
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• Web Policies

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. [back]
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 [back]

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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

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• Dangers Of Making Noncompliance A Medical Condition
• 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

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Interest In Health Literacy Grows

Two major newspaper stories in the past month addressed health literacy, one of the major causes of patient-clinician miscommunication, which in turn often leads to inadequate treatment plan execution, a phenomenon typically included under the aegis of patient compliance.

Sources:

‘Doctor-ese’ often stumps patients Jane E. Brody New York Times 4 Feb 2007

A Silent Epidemic Sandra G. Boodman Washington Post 20 Feb 2007

The Points Made In These Articles Are Straightforward

1. Impaired Health literacy is a national healthcare problem of huge proportions. According to the Institute of Medicine, more than 90 million Americans of all ages, races, and income and education levels, are unable to adequately understand basic health information.¹

2. Poor health literacy results in poor adherence to prescription instructions, infrequent use of preventive medical services, increased hospitalizations and visits to the emergency room, and worse control of chronic diseases. The consequences are poorer health and greater medical costs.

3. Doctors fail to speak to patients in plain English (or Spanish or Chinese or any other language) and fail to make sure that patients understand what they are told and what they are supposed to do and why.

The disconnect between the offerings from healthcare and the capacity of patients is noted in a 1999 report by the American Medical Association which found that consent forms and medical information are typically written at the graduate school level while the average American adult reads at the eighth-grade level. Worse, a 2003 survey completed by the U.S. Department of Education found that over 40% percent of adults read at a fifth-grade level or lower, and 5 percent are not literate in English (in some cases because it is not their first language). Math skills are similarly lacking.

The Impact Of Low Health Literacy Is Equally Clear-Cut

These excerpts are characteristic:

Primary Problems

Fixes

These newspaper reports included several specific recommendations for clinicians as well as patients to improve communications, many of which come with the imprimatur of the Joint Commission which recently presented 35 recommendations to address this problem, along with the implication that such suggestions might become future Joint Commission requirements for healthcare facility accreditation. Examples follow:

The advice for the patients is clear – be proactive or risk poor healthcare.

Also mentioned is a Pfizer-sponsored program called Ask Me 3 that was designed by the Partnership for Clear Health Communication, a coalition of national health and literacy groups. The program encourages patients to ask three simple questions and to be sure they understand the answers: What is my main problem? What do I need to do? Why is that important?

Commentary

I’ve summarized and excerpted material from these articles at length to point out (1) the importance of the problem, (2) the growing urgency demonstrated in the press, professional organizations, and regulatory agencies for a solution, and (3) the solution being promoted.

While the severity of the problem and the mounting pressure for a solution are, it seems to me, clear cut, the only solutions offered are incomplete.

Doctors, for example, are unlikely to find that “none of this [i.e., the suggested improvements in communication techniques] should take more than a few minutes,” as the experts quoted approvingly in the New York Times article declare, to be reassuring. By simple arithmetic, “a few minutes” added onto each appointment in a busy day, assuming the estimate is accurate, accumulates into “a few hours” added every week.

Even more problematic is the contention that every patient has, within himself or herself, the capacities to be a “patient expert” on his or her disorders and a self- advocate with the interpersonal skills to assure that the right information (whatever that might be) is provided and understood without being so confrontational that the relationship with the clinician is jeopardized. Neither clinical experience or personality studies would seem to support this hypothesis.

What is to be done for those individuals who cannot, especially in the sick role, assume this proactive stance?

The current Patient Literacy campaigns do not seem to take this issue into consideration, let alone provide pragmatic answers. I believe, however, that there are potentially useful responses, some of which I will be addressing in forthcoming posts.

Footnotes

1. The Journal of General Internal Medicine August 2006 [back]

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Many of the ‘ADD generation’ say no to meds; Newly minted grown-ups are carrying out a massive natural experiment by choosing to do without the drugs that profoundly affected their experience of childhood. By Melissa Healy, Las Angeles Times December 18, 2006¹

This article focuses primarily on a number of young adults who, diagnosed with and treated with medication for Attention Deficit Disorder in childhood, have chosen to discontinue those stimulants.

Commentary

This article exemplifies one of the most problematic aspects of the lay press reporting on healthcare issues by promoting a point of view that could influence readers.

There is no indication that any aspect of the story is inaccurate or intentionally misleading. On the other hand, each of the individuals who decided to stop taking their ADD medications is reported to have done well. Further, support for the discontinuation of medication is presented uncritically while doubt is cast upon theories and studies favoring the ongoing use of these medications.

And, consider the tone of these excerpts:

The penultimate portion of the article is devoted to Dr. Lawrence Diller, the author of “The Last Normal Child,” in which he “raises concerns about the effect on society and children when parents, schools and the medical establishment reach too easily for such medication [for ADD].”

The issues raised, whether ADHD medications should be taken indefinitely and, if not, how the decision to continue or discontinue the medication is determined, is both legitimate and important. A reporter’s responsibilities in presenting the story are less clear. In this case, a newspaper story that features reports of interesting individuals who seem to have made the right decision going off a medication, breezy summaries of research and ideas about the disease, and a clear air of approbation for independence-minded young adults who defy their parents and doctors by discontinuing their medications is, it would seem, more likely to influence those facing this decision than pages of grey print reporting findings of scientific studies.


Footnotes

1. Also see Related Stories “in their own words” [back]

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