AlignMap

The So Re-name It Already Persistence Campaign

This post is part of my ongoing strategy to persist in writing about the re-naming of patient compliance until it annoys folks enough that a consensus on one name or another is reached, if for no other reason than to stop me blogging about it.

Today’s question: What are the likely consequences of a suboptimal or a distinctly inappropriate name?¹

When Good Children Have Bad Names

Who worries more about the catastrophes of a bad name more than parents? Well, the kids with those weird names, of course, but my point is people take the naming of their progeny seriously.  That the results are sometimes peculiar should perhaps be the first lesson in this parable. Taking naming too seriously means somebody gets named “Ima Hogg.”

Anyway, based on the premise that bad names are even more worrisome when applied to people than to phenomenon such as patient compliance, I thought a look at what happens when children are saddled with goofy  names might be enlightening.

Today’s source of sane thinking is A Boy Named Sue, and a Theory of Names by J. Marion Tierney from the  March 11, 2008 New York Times.  I’ve excerpted the pertinent portions but the entire piece is short, accessible, and a worthwhile read.

During his 1969 concert at San Quentin prison, Johnny Cash proposed a paradigm shift in the field of developmental psychology. He used “A Boy Named Sue” to present two hypotheses:

1. A child with an awful name might grow up to be a relatively normal adult.

2. The parent who inflicted the name does not deserve to be executed.

… Studies showed that children with odd names got worse grades and were less popular than other classmates in elementary school. In college they were more likely to flunk out or become “psychoneurotic.” Prospective bosses spurned their résumés. They were overrepresented among emotionally disturbed children and psychiatric patients.

… Today, though, the case for Mr. Cash’s theory looks much stronger, and I say this even after learning about Emma Royd and Post Office in a new book, “Bad Baby Names,” by Michael Sherrod and Matthew Rayback.

By scouring census records from 1790 to 1930, Mr. Sherrod and Mr. Rayback discovered Garage Empty, Hysteria Johnson, King Arthur, Infinity Hubbard, Please Cope, Major Slaughter, Helen Troy, several Satans and a host of colleagues to the famed Ima Hogg (including Ima Pigg, Ima Muskrat, Ima Nut and Ima Hooker).

The authors also interviewed adults today who had survived names like Candy Stohr, Cash Guy, Mary Christmas, River Jordan and Rasp Berry. All of them, even Happy Day, seemed untraumatized.

“They were very proud of their names, almost overly proud,” Mr. Sherrod said. “We asked if that was a reaction to getting pummeled when they were little, but they said they didn’t get that much ribbing. They did get a little tired of hearing the same jokes, but they liked having an unusual name because it made them stand out.”

…  But after I looked at experiments in the post-Sue era by revisionists like Kenneth Steele and Wayne Hensley, it seemed names weren’t so important after all.

When people were asked to rate the physical attractiveness and character of someone in a photograph, it didn’t matter much if that someone was assigned an “undesirable” name. Once people could see a face, they rated an Oswald, Myron, Harriet or Hazel about the same as a face with a “desirable” name like David, Gregory, Jennifer or Christine.

Other researchers found that children with unusual names were more likely to have poorer and less educated parents, handicaps that explained their problems in school. Martin Ford and other psychologists reported, after controlling for race and ethnicity, that children with unusual names did as well as others in school. The economists Roland Fryer and Steven Levitt reached a similar conclusion after controlling for socioeconomic variables in a study of black children with distinctive names.

“Names only have a significant influence when that is the only thing you know about the person,” said Dr. Ford, a developmental psychologist at George Mason University. “Add a picture, and the impact of the name recedes. Add information about personality, motivation and ability, and the impact of the name shrinks to minimal significance.”

… I sought an answer from Cleveland Kent Evans — not because he might have gotten into fights defending Cleveland, but because he’s a psychologist and past president of the American Names Society. Dr. Evans, a professor at Bellevue University in Nebraska, said there is evidence for the character-building theory from psychologists like Richard Zweigenhaft, but it doesn’t work exactly as Sue’s father imagined it.

“Researchers have studied men with cross-gender names like Leslie,” Dr. Evans explained. “They haven’t found anything negative — no psychological or social problems — or any correlations with either masculinity or effeminacy. But they have found one major positive factor: a better sense of self-control. It’s not that you fight more, but that you learn how to let stuff roll off your back.”  …

Commentary

OK, I’m willing to stipulate that human beings and other phenomena are different and therefore the whatever principles govern the impact of a bad name for humans may not be applicable to names of other phenomenon.

On the other hand, there is little evidence that the field of patient compliance would look differently today if it had been called “adherence,” “concordance,” or “Jimmy Bob.”

And, certain principles, such as Dr. Ford’s notion that

names only have a significant influence when that is the only thing you know about the person. Add a picture, and the impact of the name recedes. Add information about personality, motivation and ability, and the impact of the name shrinks to minimal significance,

ring true and seem as though they might fit the naming of ideas as well as they do the naming of children.

In any case, there are enough similarities and parallels that it would seem that we should at least consider the possibility that even being stuck with a name with some possible negative aspects may not make all that much difference and get on with improving compliance (or whatever) already.

1. For the purposes of this exercise, we’ll assume that “compliance” is a bad name, or that “compliance” has been replaced by “adherence” which is later discovered to be a bad name, or whatever term selected to designate the new compliance is revealed as bad.↩

Again With The Names?

Yep, and here’s why – I read a lot of the contemporary lay and professional literature dealing with what is commonly known as   patient compliance or treatment adherence or something similar – i.e., the variation between a prescribed treatment regimen and a patient’s implementation of that treatment regimen.

Based on that reading, my unproven but sincerely and confidently held contention¹ is that the most frequently and most vehemently addressed issue in that corpus of material is the re-naming of the phenomenon (i.e., compliance, adherence, concordance, … ) itself.

There’s more. I suspect that much of the sturm und drang associated with this effort has less to do with advancing adherence to treatment than with labeling who is right and who is wrong.

A significant number of folks consider the name, compliance, to be not only a suboptimal term but an abomination² in general and a roadblock specifically to progress in the field to be formerly known – if the re-namers are indeed successful – as compliance.³

Further, they are also certain that the correct, not-a-roadblock label is adherence

… except in the U.K., where the preferred appellation appears to be concordance

… except for those who lump adherence and concordance together with compliance as equally nefarious elements of the same Satanic vocabulary used to sustain the pjower of the healthcare  establishment and suppress the rights and independence of patients.⁴

There’s Still More – Naming Becomes Name Calling

Some re-naming diatribes clearly posit compliance Vs adherence⁵ as a litmus test. As far as I can determine, compliance is associated with a paternalistic, condescending, and uncaring style of medicine while adherence is an indicator of medicine practiced such that the patient is co-equal with clinicians, the inevitable consequences of which include mutual respect and caring between the patient and clinicians, enhanced treatment outcomes, and quite possibly humankind’s last best chance for peace on Earth, good will to men.⁶

The compliance Vs adherence battle has another unusual quality; adherence adherents and other anti-compliance groups are vocal and thus easily identified, but I have yet to track down the leaders of the compliance crusade. These days, the most adamant pro-compliance stance may, in fact, be something along the lines of my own laissez-faire recommendation found elsewhere on this web site:

Lacking compelling advantages favoring the use of any of the suggested terms and given the institutionalized encoding of “patient compliance” and “patient noncompliance” into the National Library of Medicine database’s official Medical Subject Headings, it makes sense — until something better comes along — to continue using this familiar phrase to designate the extent to which individuals follow an agreed upon treatment plan, and, unless specified otherwise, assume that adherence, compliance, and concordance refer to the same phenomenon.

It’s not going to replace The Ride of the Valkyries in those battle scenes, is it?

An (Apparently) Little-known Fact

Reading this re-naming material gives one the idea that, sometime in the 1970s, the Grand Vizier of Medical Literature decided it was time to name this process by which patients follow, don’t follow, or partially follow treatment recommended to them. He (in the 1970s all Grand Viziers of Medical Literature were white men; at least 67%, in fact, were dead white men) looked about and malignantly/inexplicably (choose one) selected, from the hundreds of thousands of words in the English language,⁷ the despicable compliance even though the far better adherence was right there, probably giving off a wholesome inner glow, available under “A,” near the front of the dictionary. Thus was healthcare progress stymied  for half a century.

What was he thinking?

As it turns out, reality is less dramatic but far more significant than my How The Grand Vizier of Medical Literature Named Compliance tale.

Compliance and noncompliance were first used in the healthcare literature in the 1950s but were popularized in the 1970s when Sackett and Haynes wrote and edited books, symposia, and articles about these phenomena.

The term compliance was, in fact, consciously chosen as a nonjudgmental alternative to earlier descriptions, such as “untrustworthy,” “uncooperative,” “unreliable,” or, my personal favorite, “faithless.” Compliance and noncompliance were specified as declarations of fact rather than indications of blame.⁸

Put another way, compliance was the 1970s version of adherence.

Well, I bet we get it right this time, by golly.

My Dirty Little Secret

I don’t much care which term – compliance, adherence, concordance, persistence, or any combination or permutation of these words or any other existent or yet to be coined word – is used to indicate the variation between a prescribed treatment regimen and a patient’s implementation of that treatment regimen. As long as everyone knows what that term is and what it means, and I can use it as an effective search term in the medical databases and Google, it’s OK with me.

The New Compliance

So, here’s my offer. You guys for whom this re-naming is a big deal – and you know who you are – get together and decide on a name for the new compliance. Heck, new compliance has a nice ring to it. Use it if you like  – gratis. Anyway, debate, vote, fight a duel, use a Ouija Board, draw straws, whatever. Once you have reached a decision, convinced the administrators of databases and search engines to enter a few fudge factors into their codes to make the new term work for old data, and spread the word among clinicians, researchers, patients, and, of course, all other stakeholders (don’t forget to translate the new term into every language used by organized healthcare), just e-mail me and I’ll adapt.

And yet, some folks think I’m argumentative.

1. If “unproven … contention” causes you to effect that  well-practiced sneer of contempt that you tragically believe passes for a bemused, classy, sardonic viewpoint and automatically dismiss whatever notion follows, just pony up the bucks and a couple of grad students to process the literature and I’ll produce the statistical proof. Otherwise, you’ll have to take my word for it.↩
2. I kid you not. “Abomination” is by no means the worst accusation hurled at compliance. One comment on a post, for example, condemned both adherence and compliance as “some of the worst terms in the health care industry!”↩
3. My apologies to the artist previously – and now once again – known as Prince↩
4. To complicate matters, certain subgroups, prominently but not exclusively in the pharmaceutical industry, have begun to stridently insist on the distinction between compliance, adherence, and persistence. Roughly, compliance is the extent to which a recommended treatment is followed within a designated timeframe while persistence addresses how long a patient follows the treatment plan. In oversimplified form, compliance + persistence = adherence. The good news is that I haven’t found any complaints that persistence furthers the Dr. Darth Vader agenda – yet. ↩
5. There are also cases in which compliance, adherence, and even concordance are all targeted as the vocabulary of a conspiracy against the rights and dignity of individual patients. For now, I will focus on the compliance Vs adherence model for the sake of simplicity.↩
6. For the record, I experienced the same kind of  pseudo-epiphany when I first became interested in patient compliance. It went a little something like this

   Doctors are just too paternalistic, too narcissistic, and too out of touch with their patients. As a result, they just tell patients to take X pills Y times a day, without explaining why the medicine is necessary, what the side-effects are, etc. If only all doctors were empathic, perceptive, and sensitive  – well, like me, for example – we could whip this noncompliance thing in a couple of weeks. Why hasn’t anyone else figured this out? It’s so simple. …

   It seems  I fancied myself the Luke Skywalker of adherence in this particular battle of the forces of good against the evil empire.

   Then I saw the sequel to the first epiphany. It turns out that the arrogant doctor thesis may explain some cases of noncompliance but by no means does it account for even a majority of patients who who don’t adequately follow their treatment plans to an adequate degree. So much for the Force being with me.↩

7. The second edition of the Oxford English Dictionary, for example, includes over 600,000 definitions according to Wikipedia.↩
8. See, among others, Haynes RB, Taylor DW, Sackett DL, eds. Compliance in Health Care. Baltimore, MD: The Johns Hopkins University Press; 1979 and Sackett DL, Haynes RB, eds. Compliance With Therapeutic Regimens. Baltimore, MD: The Johns Hopkins University Press; 1976.↩

Source: Psychotropic Medications for Patients With Bipolar Disorder in the United States: Polytherapy and Adherence Ross Baldessarini, Henry Henk, Ami Sklar, Jane Chang, and Leslie Leahy, Psychiatr Serv 2008 59: 1175-1183

Medication Regimen Adherence And The Bipolar Disorder Polytherapy Trend

In the 1970s when I began my residency in psychiatry, a movement denouncing the scourge of polypharmacy in the treatment of psychiatric disorders was being mounted in the literature. Not long afterward, those physicians who tended to use only one medication for the treatment of these same disorders were similarly criticized.  This is not necessarily a matter of clinicians succumbing to fads (although medical professionals are as susceptible as others to unscientific influences, including peer pressure); advances in research, changes in the concepts of a given pathology or the criteria of successful treatment, and the development of new biological agents may cause shifts in the recommended course of treatment.

In any case, the use of a combination of medications in the treatment of bipolar disorder is currently in favor.

In addition, the popularity of the diagnosis of bipolar disorder has steadily increased. Over the past 10 years, according to Moreno and colleagues,((Moreno C, Laje G, Blanco C, Jiang H, Schmidt AB, Olfson M. National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry. 2007 Sep;64(9).)) clinic visits by adults that resulted in a diagnosis of bipolar disorder doubled and visits by children and adolescents that resulted in that diagnosis increased by a factor of 40.

Consequently, the widespread – but not universally held – contention that adherence to medication regimens decreases  as the complexity of a dosage schedule increases makes the examination of compliance by this group of patients especially important.

The Study

Baldessarini and colleagues studied national health plan claims data (2000–2004) of 7,406 patients with bipolar disorder (bipolar I: 55%, bipolar II: 15%, bipolar disorder not otherwise specified: 30%).

I have excerpted some of the findings pertinent to compliance:

Treatment adherence
Additional new findings included identification of factors independently and significantly associated with long-term adherence to an initial mood-stabilizing treatment. Perhaps not surprisingly, only a minority (30%) of U.S. patients diagnosed as having bipolar disorder were nominally continued for a year on an initial mood stabilizer, and only 28% of this subsample were considered to be treatment adherent, on the basis of an MPR =80% averaged over 12 months.¹  Factors associated with greater treatment adherence included being older, use of lamotrigine or lithium, lack of substance abuse, and treatment by a psychiatrist rather than a primary care physician. Inferior adherence was associated with use of valproate (the most commonly prescribed anticonvulsant mood stabilizer), use of carbamazepine or oxcarbazepine, use of supplemental anticonvulsants that lack FDA-approval for use in bipolar disorder, alcohol or drug abuse, and greater illness complexity.

… However, no significant association were found between MPR and co treatment with antidepressants or antipsychotics, nor with sex, diagnostic subtype, comorbidity index, or geographical region.

… Finally, we found complex associations between treatment adherence and utilization of health services. Office, and especially emergency service, visits for bipolar disorder–related care were more frequent in association with greater treatment adherence, whereas emergency service utilization for other indications and days per year of hospitalization for any reason were lower with greater adherence to mood stabilizer treatment). The lesser utilization of emergency and inpatient services suggests potential cost savings with greater adherence to mood-stabilizing treatments. On the other hand, greater use of ambulatory and emergency services for bipolar disorder–related indications suggests that greater treatment adherence may reflect relatively close monitoring, with more frequent clinician contacts. However, the available data do not permit clarification of cause-effect relationships between treatment adherence and utilization of clinical services.

Conclusions
… Adherence to long- term mood stabilizer treatment, although uncommon, was associated with several plausible clinical factors. Our findings of heavy reliance on antidepressants and polytherapy, low mood stabilizer utilization and adherence rates, and high rates of dropout from long-term mood-stabilizing treatment strongly suggest that more effective and better-tolerated mood – stabilizing treatments are required for patients with bipolar disorders, along with redoubled educational efforts to underscore the importance of sustained, longterm prophylactic treatment of such patients, even through periods of relative euthymia.

Commentary: Sadly, No Surprises

It is important to keep in mind that, as indicated in the article, the study used claims data as the information source and, congruently, defined adequate adherence as a medication possession ratio (MPR = the percentage of the past 365 days with apparent access to the medication) of at least 80%. This methodology is a rational research approach but is subject to limitations, one of which is that access to medication tends to define the maximum number of patients who may actually take sufficient amounts of their medication (i.e., patients cannot take their medications if they don’t have access to them, but  having access to medication does not necessarily mean those medications were administered appropriately).

The most significant finding is also the least surprising: Of the 30% of patients diagnosed as having bipolar disorder that were, on paper at least, continued for a year on an initial mood stabilizer, only 28% were found to be adherent.

The associations between treatment adherence and utilization of health services is, as the authors note, “complex.” The connection between better adherence and decreased use of emergency service utilization for indications other than those related to bipolar disorder  and days per year of hospitalization are heartening.  But, as the article points out, one cannot establish a cause-effect relationship. It may be, for example, that, as other studies have suggested, patients who tend to be adherent to treatment are also healthier, independently of the effects of their treatment.

I am also hesitant to subscribe to the authors’ positive spin on the data reflected in their speculation that “…  greater use of ambulatory and emergency services for bipolar disorder–related indications suggests that greater treatment adherence may reflect relatively close monitoring, with more frequent clinician contacts.”

Other explanations are possible. One alternative hypothesis, for example, is that a subgroup of noncompliant patients whose family or friends assure that doctors’ appointments are kept and that the patients are taken to the ER during exacerbations of their disorders might also be more likely to have prescriptions filled, again because of the insistence and assistance  of  friends and family. Those patients, who might rarely take the medications, would be accounted adherent because the medications are  accessible to them.

Of course, the difference in those interpretations may have less to do with a cognitive assessment of the data than with the difference between the research team’s world view  and my own perspective.

Those differences could also explain my lack of enthusiasm for the paper’s recommendations that “more effective and better-tolerated mood – stabilizing treatments are required for patients with bipolar disorders, along with redoubled educational efforts to underscore the importance of sustained, longterm prophylactic treatment of such patients, even through periods of relative euthymia.”

Before I start getting nasty emails, I will point out that I’m not against “more effective and better-tolerated mood – stabilizing treatment” or “redoubled educational efforts.”

I am, in fact, 110% in favor of producing treatments that are more effective for every disease, that are better tolerated by patients, that taste like cherry pie, and that render those patients more attractive, all of which could enhance compliance.  I am also in favor of clean streets, lower taxes, an end to world hunger, and a World Series championship for the Cubs.

And, I’ll call your  “redoubled educational efforts” and raise you a  retripled educational  effort. Heck, I’m willing to go as high as an exponentially increased educational effort.  I just don’t find much evidence that quantum leaps in educational effort beyond a competent communication of information have a significant positive effect on compliance.

As explained in my introduction, adherence to polytherapy of bipolar disorder is an especially significant area and Dr. Baldessarini et al have provided an important confirmation of the catastrophically low proportion of bipolar patients who are receiving an adequate course of treatment.

I suggest, however, that the appropriate primary response to these findings is not better drugs and more patient education but further research that would explain  why these results, that less than 30% of bipolar patients even have access to sufficient medication during the 12 months studied, isn’t on the front page of today’s New York Times and Chicago Tribune and broadcast as the lead story on CNN and the ABC Evening News.

Footnotes

1. The research group measured adherence to mood stabilizers by using a medication possession ratio (MPR).  MPR is the percentage of the past 365 days with apparent access to an initial mood stabilizer.↩

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.↩

I take a green pill and an orange pill every day, …

While it may seem a bit of a stretch to consider this entry about color and medication pertinent to patient compliance, color plays a major role in our perceptions and, as experience and research have shown, a patient’s perceptions about illness, clinicians, the manufacturer of medication, family and cultural attitudes, and a seemingly endless list of other factors influence medication adherence. In that context, that the look and feel of a pill could have an impact on compliance does not seem so unlikely.

Rachel Perls has posted The right color pill helps the medicine go down, which addresses the effect of pill and capsule colors.

Ms Perls publishes Hue, a blog dedicated to color:

In addition to the highlighted entry, I read several random posts, all of which were interesting and some of which portrayed colors and combinations of colors that can only be described as gorgeous.

These are not academic discourses on color theory but are instead brief expositions of a topic with the goal of providing an impression of the impact color can have. Most striking are the examples, such as the blister-pack of pills shown atop this entry.

Of the non-medical posts, I especially recommend Watching the progress of an artist, an entry from February 17, 2007 which links to a video of Picasso painting on a transparent canvas while time lapse photography captures his strokes. Ms Perls elaborates in this excerpt:

The right color pill helps the medicine go down is a worthwhile reminder of the nuances that affect healthcare compliance, and Hue strikes me as an enriching, stimulating blog to brighten ones Monday.

Source: Teaching doctors to teach patients about lifestyle Kate Murphy International Herald Tribune April 17, 2007

The American College of Lifestyle Medicine

The American College of Lifestyle Medicine is a new national medical specialty society formed within the past two to three years to make lifestyle medicine a credentialed clinical specialty and a part of basic medical training.

Their philosophy is characterized by a quote from the organization’s president, John H. Kelly Jr., who holds that symptomatically treating disease without assessing patients’ lifestyles or offering them guidance on how to change is “irresponsible and bordering on neglect.”

Excerpts from the article:

The Centers for Disease Control and Prevention reports that 1.7 million Americans die and 25 million are disabled each year by chronic diseases caused or made worse by unhealthy lifestyles. And a 2005 study in The New England Journal of Medicine predicted that average life expectancy in the United States would decline in the next 20 years as a result of unhealthy lifestyles, reversing a trend dating to the 1850s. The American College of Lifestyle Medicine has 150 members in a wide array of specialties – nutritionists, ophthalmologists, gastroenterologists and oncologists, among others. Helping their cause is a new publication, The American Journal of Lifestyle Medicine, which appears every other month with peer-reviewed research on the way daily habits affect health.

Lifestyle medicine proponents include researchers and clinicians from the fields of medicine and public health. While they agree on the importance of questioning patients about their lifestyles and giving tailored advice on how to make improvements, there remains disagreement about who should provide such counseling and with what sort of training. Nor is there a widely accepted prescriptive approach for encouraging patient compliance.

Proponents of lifestyle medicine are quick to distinguish it from alternative medicine. “This is mainstream medicine supported by mainstream medical research,” said James M. Rippe, associate professor of cardiology at Tufts University School of Medicine and the editor of The American Journal of Lifestyle Medicine. “The lifestyle medicine movement is not an anti-procedure, anti-medication movement.” Rather, he said, it advocates that lifestyle interventions become part of the doctor’s arsenal in fighting disease: “For too long we’ve ignored our most powerful weapon when it should be our first line of defense.”

Commentary

While there is much potential from systematically integrating lifestyle medicine into clinical practice, I am most taken with the notion that patient compliance is an element of the same basic category as diet and exercise. That seems to me a more appropriate and useful conceptualization of adherence than as a pathology.

The American College of Lifestyle Medicine can be found online at LifeStyle Medicine

‘Cognitive Dissonance’ Became a Milestone In 1950s Psychology By Cynthia Crossen Wall Street Journal December 4, 2006

As the title of this article suggests, it is an historical look at Leon Festinger’s development of the concept of cognitive dissonance. I’ve written about it today because (1) it’s interesting on its own merits and (2) it serves as a reminder that the phenomena underlying patient compliance are not unique to healthcare and that theoretical work in non-healthcare fields, including but not limited to cognitive dissonance, may be directly applicable to the problems of nonadherence to treatment.

This excerpt makes the same point:

Why, for example, do people who know cigarettes are bad for their health continue to smoke? This is classic cognitive dissonance: They know one thing and feel another. Mr. Festinger believed this incongruity is as uncomfortable to the human organism as hunger. One way or another, the anxiety must be assuaged. So the smoker builds a bridge — a rationalization — from feeling to fact: If he stopped smoking, he’d gain weight, which would also be unhealthy; some risks are worth taking to have a full life; the risks of smoking have been exaggerated. Indeed, in a 1954 survey asking people if they felt the link between lung cancer and cigarettes had been proven, 86% of heavy smokers thought it wasn’t proven, while only 55% of nonsmokers doubted the connection.

And, the examples are fascinating. For example,

But where Mr. Festinger found the richest raw material for his theory was in a cult that developed in Chicago in 1954. A woman Mr. Festinger called Marion Keech claimed she was receiving messages from another planet, Clarion. The messages predicted that on a given date, a cataclysmic flood would engulf most of the continent. Those who joined Mrs. Keech’s sect would be picked up by flying saucers and evacuated from the planet. … Before the dates of the expected flood, the cult was mostly averse to publicity and had no interest in attracting other believers. On the day before the flood, the group was told that at midnight a man would appear at Mrs. Keech’s house and take them to a flying saucer. But no knock came at her door, and the group struggled to find an explanation for why there would be no flying saucer or flood. At 4:45 a.m., the group said, a message arrived from God saying He had stayed the flood because of their strength. What interested Mr. Festinger was not so much this face-saving explanation as what the cult members did in the following weeks. Rather than shunning public attention as they had before, they began zealously proselytizing. “There were almost no lengths to which these people would not go now to get publicity and to attract potential believers,” Mr. Festinger wrote. “If more converts could be found, then the dissonance between their belief and the knowledge that the prediction hadn’t been correct could be reduced.”

Commentary: Cognitive Dissonance And Noncompliance

Among other insights it offers, cognitive dissonance goes a long way toward explaining why starkly presenting patients with facts, regardless of how valid the data and how elegant the research, is insufficient to improve compliance. In fact, as the example of the doomsday cult excerpted above points out, those individuals whose beliefs are proven inaccurate in the most definite and most public manner are most likely to react by intensifying their commitment to those erroneous beliefs. It further follows that perhaps aggressive, dramatically confrontational approaches to patient education are not only ineffective but counterproductive.