AlignMap

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.↩

Re Compliance Vs Adherence Vs Concordance, …

I have another instance to offer that demonstrates the significance of re-naming the same phenomenon.

In the middle of his career, contract disputes led to Prince changing his stage name¹ from “Prince” to the unpronounceable symbol shown under the middle picture in the above graphic. The press circumvented the symbol by referring to “The Artist formerly known as Prince.” The performer has since returned to the hardly prosaic “Prince” appellation although sardonic sorts will still, on occasion, refer to him as “The artist formerly known as ‘the artist formerly known as Prince.’”

Note the transformations wrought by the shifts in names.

1. For the record, Prince’s given, non-stage name is Prince Rogers Nelson↩

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.↩

This One Is About Adherence to COPD Treatment

Source
Patient Adherence In COPD
Bourbeau J, Bartlett SJ.,
Thorax. 2008 Sep;63(9):831-8

The Review

First, I must point out that Patient Adherence In COPD is a well-researched, well-written, accurate review of – well, patient adherence in COPD. It is, in fact, superior to most reviews, eschewing, for example, oversimplified, easy conclusions and recognizing the limitations of the research.

I chose this specific review, in fact, to serve as context for a discussion of the inherent problems with the current concept of patient compliance because it is competently done. I want to emphasize, as I suggested in Patient Compliance Research – Finding Precisely Accurate Answers To The Wrong Question?, that the issue isn’t the quality of the research or the thoroughness of the review; the issue is whether we’re asking the right questions.

The key  points of the article follows.

The Abstract

Section Headings

• Adherence: an overview (compliance, adherence and concordance)
• Medication and regimen factors
• Patient factors
• Healthcare provider and caregiver factors
• Patient adherence in the treatment of COPD: non-adherence to medication in COPD, suboptimal adherence to non-drug therapy in COPD, strategies to enhance adherence

Excerpt From Results

Excerpt From The Conclusion

It’s The Same Old Song

I’m the first to declaim that the standard patient compliance review is not a bad song; in fact, it’s a song I like at lot. I’ve participated in the occasional standing ovation. Heck, if I were on American Bandstand, I’d give it a 99. It’s just that we’ve heard it before – 50 or 60 or a few hundred times.

The fundamental sheet music template for a patient compliance review, which correlates highly with  Patient Adherence In COPD – and dozens of others reviews and reports – calls for  the opening bars to offer an Overview Of Compliance, typically comprising a history of organized medicine’s positions on compliance, a discussion of Adherence Vs Compliance Vs Concordance, selected statistics illustrating fiscal costs, morbidity and mortality, and prevalence. Standard elements of the midsection of the piece include the impact of the treatment and the disorder under discussion on compliance, the impact of the patient’s individual psychology, culture, family, and other background on adherence, and the vital role of the healthcare provider. Specific Results often follow, highlighted by the percentage of population of patients being studied who are noncompliant. Then comes the big finish, AKA The Conclusion – familiar lyrics that go a little something like this: patient compliance must be addressed, there are no evidence-proven compliance enhancement strategies, and – here comes the final refrain – further study is needed.

I think that just about covers it. A great performance won’t get the author on the cover of Rolling Stone, but they could well win a place in a few medical journals.

The question for compliance fans is how much value is left to be garnered by more performances of the same power ballad.

Who believes the problem is that the patient compliance reviews and research aren’t exacting enough, aren’t thorough enough, aren’t insightful enough, … ?  Show of hands.  OK, no one believes that. Who believes that the next review of adherence among tuberculosis patients will reveal a clinical truth of significant importance?  No one? OK, how about that same review written about asthma patients, adolescents with acne, lepers over 60 years old, bloggers following a physical therapy regimen after a hip pinning, … ?

Here’s my point:
Even if one loves Motown (and I do), eventually one learns (and I did) that listening to Leonard Cohen, Bruce Springsteen, or Death Cab For Cutie offers qualities that just aren’t available from The Supremes or Gladys Knight and The Pips. Listening exclusively to the same Top 40 on the same Golden Oldies station is unlikely to expand ones musical horizons.

Source: Great(er) Expectations John Lauriello, M.D., Am J Psychiatry, 164:377-379, March 2007

Expectations For This Post

The following excerpts are from an editorial written by John Lauriello, M.D. in the March 2007 American Journal of Psychiatry. While I have selected those portions that are most pertinent to the goals of treatment for schizophrenia and patient compliance, the entire essay is accessible, well written, and insightful – it is, all in all, a worthy read.

I have little to add to Dr Lauriello’s thoughts on these issues. Consequently, I offer these excerpts with no further elaboration.

At least for now.

“Take nothing on its looks; take everything on evidence. There’s no better rule.”

—Charles Dickens, Great Expectations

Although the successful treatment of schizophrenia is most often measured by symptom reduction and relapse prevention, the quality of everyday life and the ability to function independently are equally important to patients and families. To date, antipsychotic medications have not yet been shown to directly impact quality of life, particularly social and vocational functioning, to the degree hoped. Clinicians are challenged to prescribe medications that not only reduce symptoms but somehow also enable patients to become better functioning members of society. Presumably, as positive and negative symptoms of schizophrenia subside, subjective quality of life and objective measures of psychosocial functioning might be expected to improve. In this issue, two interesting and somewhat complementary articles focus on quality of life and competitive work performance of patients with schizophrenia. Both examine the promises and the limits of our current means of improving psychosocial functioning in these patients.

In the first article, Marvin Swartz and colleagues expand on findings of NIMH’s Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, presenting results derived from Quality of Life Scale ratings. The analysis concentrated on those patients who continued their assigned medications for at least 12 months (a third of the overall sample). …

Contrary to predictions, researchers found no evidence to favor any of the second-generation antipsychotic medications with regard to improving Quality of Life Scale scores. As expected, patients’ baseline quality of life ratings showed impairment, especially in the vocational domain. After 12 months, only modest improvements were associated with any of the randomly assigned medications, with no differences found among any of the individual medications. ……

The Swartz et al. study confirms that improving quality of life does not come prepackaged in a medication bottle. As these authors state, “More intensive psychosocial rehabilitative services, including cognitive rehabilitation, may be needed to affect more substantial gains in functioning…. For patients unable to work, with limited access to vocational and rehabilitative services, even optimal medication may not be reasonably expected to improve … community functioning.”

This statement provides a perfect segue to the second paper, in which Susan McGurk and colleagues examine the effect of cognitive training on supported employment services at two community health centers … . In this study a small number of patients with schizophrenia were randomly assigned to receive supported employment alone or supported employment with cognitive training with the goal of increasing competitive work. Competitive work, the gold standard of vocational functioning, means competing in the marketplace for real work and real wages. Rates of competitive employment for patients with schizophrenia range from 10%–20%. The cognitive training administered by trained cognitive specialists, the “Thinking Skills for Work Program,” consisted of an extensive analysis of the cognitive work difficulties, computer-based training, planning sessions, and ongoing on-the-job assistance. Both study sites were also rated on the fidelity of their adherence to the supported employment model utilizing a standardized scale.

… The good news was that those in the combined program (supported employment with cognitive training) were more likely to work, held more jobs, worked for a longer time, and made more money. An additional benefit to those randomly assigned to the combined strategy was an improvement in depressive and autistic preoccupations as measured by the Positive and Negative Syndrome Scale (PANSS) at 3 months. In other words, those who worked more were less depressed and less internally isolated. The not-so-good news was that despite these noteworthy efforts, the mean number of weeks worked over the 2-year follow-up was only 27 weeks, roughly 6 months. Working for a quarter of the evaluation period (significantly better than the 5 weeks worked by those in the supported employment alone group) is laudable but still falls far short of independent self-sufficiency. One further note: although both study sites embraced the concepts of supported employment and cognitive training, one site scored lower on “fidelity” to the supported employment model. In turn, patients at that site performed worse than those at the more adherent site.

So what do these two studies together tell us about the psychosocial functioning of patients with schizophrenia? The Swartz et al. study coupled with the results of other CATIE publications demonstrate that medication adherence is challenging and that no one medication seems to be a clear winner when balancing all factors. But medication adherence is the stable platform that reduces exacerbations and rehospitalization. And this stability is necessary before any sustained psychosocial treatment can be applied. Supported employment with cognitive training appears to be one good next step for stable patients. The McGurk et al. study shows that adding cognitive training significantly improved time at work and reduced depressive preoccupations and isolating thinking. However, as with medication treatment, functional gains were limited and clearly dependent on adherence to the treatment. (emphasis added)

Gorgeous representation of the gorgeous Ptolemaic cosmological model

The Rant Behind The Patient Compliance Rant

A primary precept of AlignMap has been and continues to be my contention that the contemporary concept of patient compliance is fundamentally flawed. I have made that argument numerous times, most recently in the final portion of the preceding post, Emergency Room Study Confirms Confusion About Instructions – And Compliance.¹

The goal of today’s post, however, is not a defense of my position but an explanation of how it might² be possible that the thousands of published works and clinical studies as well as the theoretical work completed in the field of treatment adherence since the popularization of the current notions of compliance and noncompliance by Sackett and Haynes in the 1970s³ could be wrong and the likely consequences if no changes are forthcoming in that model.

So, for now, I ask that the reader grant Coleridge’s “willing suspension of disbelief”⁴ re the validity of my own ideas about adherence in order to focus on understanding how it is possible that so many smart and experienced individuals and so many well-funded, well-staffed, and well-intended institutions could be wrong about the basics of patient compliance.

The Risk Of A Ptolemaic Model Of Treatment Adherence

Whenever I find myself disconcerted about the lack of progress in patient compliance in the past century, a period during which great advances were made in almost every other aspect of healthcare, I seek solace by putting this disappointment in context.

After all, Ptolemy proposed a model of the cosmos⁵ which positioned the Earth at its stationary center with the moon, sun, planets, stars, and such revolving around it.

Ptolemy

This model, called the Ptolemaic System,⁶ held sway for 1,500 years,⁷ yet it turns out to have been wrong.

The Ptolemaic System was not the dominant school of thought for 1500 years because Ptolemy or Aristotle (whose concepts about a geocentric universe were the starting point for Ptolemy) or any of the others who contributed their ideas to the effort were con men running a scan or because the intellectuals, astronomers, clerics, government officials, and scholars who bought into the model were dummies.

The problem, in fact, was that Ptolemy and the others were extraordinarily smart – so smart that they could build, rebuild, revise, jerry-rig, adapt, bend, and reorient a system that could explain away any apparent discrepancies between real world observations and the results that were expected based on the projections of the model irrespective of its correlation – or lack of correlation – with reality.

Not that reconfiguring the model to make it functional didn’t require some fancy footwork.

Making The Current Patient Compliance Model Work

What if we throw in 40 or 50 epicycles and a few deferents? And maybe an equant? ⁸

As discrepancies between model and reality became apparent, Ptolemy et al added loops, revolutions, retrograde motions, and all manner of kinky maneuvers to hypothetical orbits of heavenly bodies to make actual events and theoretically determined calculations congruent.⁹

In order to explain, for example, retrograde motion, astronomers working long before Ptolemy came on the scene, theorized that the orbits of celestial bodies included epicycles, smaller circles looping around the primary pathway centered on the Earth.

Ptolemy added some refinements such as eccentrics and equants, to explain other details of heavenly observations.

Wikipedia’s description of the Ptolemaic Model is instructive:

The video version is even more impressive

Waiting For The Copernicus of Compliance

I am, of course, suggesting that as long as we maintain allegiance to the current models of patient compliance, successes may be limited to explaining away discrepancies between an artificial system and reality.

Consider this simple example. Over the past five years, I come across a plethora of publications arguing, with varying levels of vehemence, that one name or another be used exclusively to designate the phenomenon that most clinicians call “patient compliance.” Without denying the importance of language, patient participation in treatment planning, or any other shibboleth of choice, I find it requires minimal effort to equate the compliance vs adherence vs concordance vs whatever name game with, say, the epicycles in the Ptolemaic System.¹¹

It’s just a thought; I could be wrong.

I guess we can wait another 1400 years or so to find out.

For Animation Addicts

• Way cool Ptolemaic System Simulator
• Scary Epicyle Demo

1. The relevant segment comprises the paragraphs following the heading, “Is The Problem Noncompliance Or Health Illiteracy Or Both?
   And Why Should Anyone Care?”↩
2. I have italicized some of the indicators of the subjunctive mood to emphasize that my immediate goal is not developing a syllogistic proof that the current ideas are wrong but demonstrating how such an inaccuracy could take root and persist.↩
3. See Sackett DL, Haynes RB, eds. Compliance with Therapeutic Regimens. Baltimore, MD: Johns Hopkins Univ Pr; 1976. and Haynes RB, Taylor DW, Sackett DL, eds. Compliance in Health Care. Baltimore, MD: Johns Hopkins Univ Pr; 1979.↩
4. In this case, the more precisely correct phrase would be, I suppose, “willing suspension of belief [in the current model of compliance],” but quibbling with Coleridge is beyond the scope of this post.↩
5. If one is seeking context, the concept of the cosmos is a handy starting place↩
6. Yeah, I know – big surprise, eh?↩
7. Depending on the source, this era during which the Ptolemaic System was dominant is given as 1300-1500 years↩
8. The oversimplified account that follows centers on the adjustments Ptolemy and others made to compensate for errors in the system rather than the Ptolemaic Model itself. In any case, the Ptolemaic Model is an amalgam of Ptolemy’s own ideas, contributions from his contemporaries, and the concepts developed by his predecessors. Starting points for Ptolemy’s system follow: Pythagoras (569-475 B.C.) articulated what became known as the Pythagorean Paradigm which held that the planets, Sun, Moon and stars move in circular orbits at an unvarying speed, and that the Earth is at the center of the motion of all celestial bodies. Aristotle (384–322 B.C.) further developed a model of the cosmos with the Earth at its center because most popular and observational evidence as well as his own theories of physics (most importantly, he hypothesized that objects by their nature move toward the center of the Earth unless acted on by an external force) necessitated a geocentric universe. His notion, adapted from yet another philosopher, was that each planet, the Sun, and the Moon moved on its own crystalline sphere arranged concentrically around the Earth. The largest sphere surrounding all of the other celestial bodies was reserved for the stars.↩
9. Ptolemy’s orbital variations are, I hasten to note, no weirder than other advanced areas of science. In an article on “strange quarks,” for example, Wikipedia observes, without a trace of jest, that “the φ flavorless meson is pure strange-antistrange.” Further, there is evidence that the Ptolemy’s model is not significantly more complex than the Copernican system that replaced it.↩
10. From History and Philosophy of Western Astronomy↩
11. Obviously, the choice of names for compliance and the use of epicycles in the Ptolemaic System are not truly equivalent – applying the right epicycles to the Ptolemaic System actually produces the correct, real world answer. And, I have never seen any nifty animations illustrating the choice of names.↩

Emergency Room Confusion – The Study And The Findings

Today’s New York Times includes E.R. Patients Often Left Confused After Visits, an article by Laurie Tarkan that focuses on a study published in the Annals of Emergency Medicine, Patient Comprehension of Emergency Department Care and Instructions: Are Patients Aware of When They Do Not Understand?.

Excerpts from the abstract of that study follow:

The Times article elaborates:

78% Of ER Patients Misunderstand Or Lack Discharge Instructions

Based purely on subjective recall of my own limited experience working in Emergency Departments and my treatment of patients who had been referred by Emergency Rooms, I would have guessed at least 60-70% of these clients would demonstrate serious misunderstandings of their discharge instructions. I suspect other clinicians would report similar speculations with some variance based on the presence or absence of a patient population whose native language is different than that used by local clinicians.

Consequently, the finding that 78% of patients in the study left the ER with at least one significant misunderstanding re their discharge instructions falls into that category, familiar to ongoing readers of these posts, of Old News, relegating the chief value of the study to confirmation rather than revelation, the enthusiasm of the New York Times notwithstanding.

On the other hand, this article does raise an important question pertinent to patient compliance:

Is The Problem Noncompliance Or Health Illiteracy Or Both?
And Why Should Anyone Care?

Dr. Eric Coleman, Director of the Care Transitions Program at the University of Colorado (not involved in the study), contributes this observation to the Times article:

In fact, the classic definition of medication noncompliance by Sackett and Haynes is “failure or refusal to comply with treatment recommendations.”² Extrapolating from medication noncompliance to patient noncompliance in general, it would seem that failure to follow ER discharge instructions, whatever the reason, qualifies as noncompliance.

The following may well be a recycled rant for return readers – steel yourselves.

The concept of patient compliance, as used today is not clinically relevant as a management tool because the multitude of factors that have an impact on adherence transcends complexity, commingling disparate categories, primary causes and collateral effects, and generally making a hash of it.

At best, noncompliance is a statistical phenomenon, a nonspecific symptom. If a patient’s body temperature exceeds a given point, that patient has a fever. If another patient demonstrates less behavioral inhibition than a certain percentile of the population, that patient is clinically impulsive. A patient does not take a specified amount (often a seemingly arbitrary percentage) of the total medications prescribed; that patient is noncompliant. Now, symptoms are obviously useful in some ways. They may warn the physician, for example, of an impending catastrophe. Patients spiking a fever of 108, patients so impulsive that they attack bystanders for trivial slights, and patients who take far too many or far too few pills are potential disasters. Bu the fundamental benefit of symptoms is their role in the service of diagnosis and determining etiology of health problems. In this aspect, noncompliance is a no-show. The difference between fever and impulsiveness on one hand and noncompliance on the other as symptoms is that few clinicians would be content to end a workup of a patient once “fever” or “impulsiveness” are identified.

At worst, noncompliance is a truism: patients are noncompliant because they don’t adhere to treatment recommendations; those patients don’t adhere to treatment recommendations because they are noncompliant.

The real clinker, of course, is that exploring a clinically irrelevant concept by pursuing ever more well-designed, ever larger studies and expending more intellectual effort developing models of that concept’s operations will result – if all goes well – in more elaborate and precise explanations that are also clinically irrelevant.

Who knows? Maybe that is part of the reason there have been no significant strides forward in the field of compliance in the past 100 years despite the thousands of articles, books, and reports dedicated to the theme.

Footnotes

1. Oversimplification in the service of stukffing material into the column inches allotted it has resulted, I believe, in a false dichotomy, i.e., that patients suffer from either noncompliance or health illiteracy. Aside from health illiteracy being commonly considered a cause of noncompliance, I would wager that even if all of these patients had been educated to the point of expertise, a large percentage would nonetheless succumb to one or another of the other 42,823 varieties of noncompliance.↩
2. Haynes RB, Taylor DW, Sackett DL: Compliance in health care. Baltimore: Johns Hopkins University Press; 1979↩

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

The Trek Continues

Our family’s move has been more complicated and arduous than anticipated. One consequence has been a prolongation of the posting hiatus here at AlignMap.

I am hopeful posting will begin again next week and apologize for the delay.

Credit Due Department
The photo is from The University of North Carolina at Pembroke

On The Road Again

Barring (more) unforeseen events, da boyz and I should be moving to a new domicile in early September.

That means the next 2-3 weeks will be filled with the joys of packing, moving, discontinuing utilities at one site and starting them at another, sending change of address cards, …

Which means, in turn, that posting may be rare for a while.

But I will be thinking of you.

Credit Due Department
Photo: Moving The Cottage RaeA at Flickr

Zuri – Medication Reminder and Compliance Recorder

An article in today’s (August 19, 2008) Wall Street Journal, Tools Help Patients Interface With Doctors By Victoria E. Knight, opens with this excerpt, a success story about the Zuri, an electronic medication reminder and compliance recorder still in beta:

The article goes on to extol the virtues and promise of

In oversimplified terms, both Intel’s Health Guide and Microsoft’s HealthVault store, organize, analyze, and distribute a variety of healthcare data gathered from a wide array of sources.

The Evolution Of The User Interface In Healthcare Technology

On reading the WSJ article, my first response was – well, OK, my first response was “Where do you sign up to have the WSJ open an article with five paragraphs of a success story featuring your business’s product?”

My very next thought, however, was that the user interface of these gizmos is likely to evolve as have other technological marvels, such as the automobile and the computer. The extent to which new tools are put into use by the population, however obvious their value, is limited by the difficulty, expense, and unfamiliarity of that tool.

In other words, what are the chances my Aunt Hazel from Broken Arrow, Oklahoma will find the Zumi a must-have healthcare device as long as it is a $200 pseudo-iPod with a $40 per month fee that technicians have to set up?

Of course, Aunt Hazel wasn’t interested in driving a car until automatic transmissions became widely available and her best friend began driving her own Ford.

I suspect the the responses by patients to the instruments like the Zuri fall into one of three broad classes:

1. Patients like Ms Shah who have the right problem, the right circumstance, and the right perspective to embrace and use the tool as is, right off the shelf.²
2. Patients who mistrust and are adamantly resistant to (choose one or more) electronics, doctors, healthcare recommendations, sharing personal information, …
3. Patients, like Aunt Hazel, who won’t use a medical tool like the Zuri until it is easier, cheaper, more well known, …

Group #1 is on board already. Group #2 is unlikely to buy into the process regardless of logic, persuasion, or receiving lottery tickets as incentives. But Aunt Hazel’s group? That’s where the action is. Make those electronic whizbangs less intimidating, less difficult, and less expensive.

Then, ask Aunt Hazel to try it out.

Footnotes

1. The quotation marks enclosing self-care are the work of the WSJ folks, and, no, I don’t know the rationale for this punctuation practice.↩
2. It isn’t clear that if Ms Shah was charged for the Zuri’s use or if it is offered free while still in beta. An out of pocket cost of $240 to enhance compliance of a 3 week course of treatment might have rendered the Zuri less attractive to Ms Shah↩