Adherence: The Silent CV Risk Factor,1 presented by Dr. Keith C. Ferdinand, Dr. Lars G. Osterberg, and Dr. Roger S. Blumenthal, is a solid review of the basics of adherence (although special attention is directed, as the title indicates, to cardiovascular disease, almost all of the principles are transparently applicable to compliance in general) but also offers insights in areas not typically covered by analogous reviews.
Rather than attempt to characterize these usually neglected points that are discussed in this piece, I will provide a few examples.
For instance, while the presenters trot out the familiar stats to indicate the extent of the problem,
… greater than $100 billion are wasted annually due to nonadherence; 125,000 unnecessary deaths are due to nonadherence; and of all medication related hospital admissions, 33% to 69% are due to poor medication adherence.
… they also include the much less commonly addressed point that practitioners rarely have an organized approach to compliance:
We did a pre-survey and results demonstrated that nurse practitioners and physicians’ assistants are more likely than physicians to change treatment strategies to improve adherence. However, 74% of health care providers do not have an active adherence program.
Similarly, they do a nice job explalining the adherence versus compliance issue, defining concordance, and distringuishing betweeen adherence, compliance, and pesistence.
… researchers have recently defined adherence and compliance a bit differently, compliance meaning the day-to-day way patients take their medications from drug prescription as prescribed by the physician; persistence meaning the time they are on their medications, and it actually may discontinue before the actual prescription is ended. Adherence has been used to include the overarching term of compliance and persistence in medication-taking behavior. The British terminology actually uses a term called concordance, which implies more of a patient-centered approach in that the prescription is really a contract between the patient and the physician and that both are really responsible for the medication-taking. The National Council on Patient Information and Education has really now adopted the term adherence as the proper term because it really implies a more patient-centered approach.
They also make a interesting point about the specialist (cardiology is discussed but many other specialists would face the same conundrum) who has to be concerned about compliance in a patient who might only be seen by that practitioner once each year.
One of the challenges that we have in cardiology is that in the past, we used to be able to see certain patients more frequently, but now, almost always, Keith, patients need to get referrals from their primary care provider to see us. It is harder as a cardiologist to provide some of that reinforcement that I think the patient needs. And with the proliferation of managed care and everybody trying to cut costs, we have a struggle of trying to make sure we have gotten all the information we can from the visit to the referring physician and the patient. It is a lot harder for chronic diseases for the primary care physician to pay as much attention sometimes about lipid lowering medicine, blood pressure lowering medicine when the patient has come in for acute issue.
That is interesting: preauthorization may help keep costs down but it may actually lead to greater nonadherence.
I have always felt that when we see a specialist, it is always helpful to have some goals set not just from the medication point of view in terms of what the blood pressure and lipids would be, but also what they are doing from a lifestyle point of view. With the system we have now with the preauthorization, it is often a lot harder for us to see a nonacute patient back within a period of a few months. Many times, the best we can do is maybe see him back in a year.
And consider this economic insight:
One of the biggest issues that we are all struggling with and now, of course, we are dealing with the bailout of financial firms here, is the issue of money. Many of the medications that we prescribe to patients that are still on patent may be $2.00 or $3.00 a day, so the issue of needing to save money, and many times, physicians do not think of perhaps a less potent generic alternative. It would be nice to have a 50% LDL reduction in everybody, but if we can give a generic statin that may give us a 35% or 40% reduction and have people work on their lifestyle habits, that may work out just as well if they take the medicine and may work out better.
Over-reliance On Patient Education
The presentation does fall short in a few areas. The discussion of a chart showing “Reasons For Not Taking Medication,” for example, should have included mention of how this data was collected (patient self-report I surmise) and, if it was by self-report, the possibility that the patient might not have provided accurate information.
My major concern, however, is the overwhelming faith demonstrated in patient education as a compliance enhancer.
… one of the things that I guess we are all trying to do is figure out ways for people to better understand why certain medications are prescribed and try to make these clinical trials that are the basis for the guidelines be more understandable. I have often thought that it would be helpful if the patient got a copy of the notes that we send to the referring physicians, but many times, that is not as easy for our office staff to do. But I think it just points to the fact that to improve adherence and compliance, we need to do a better job of making sure the patient understands why the medicine is prescribed and can relate to the clinical trial data, if there is any, related to blood pressure or cholesterol about why this is important.
While this may be a matter of emphasis, I believe that a teaching presentation such as this should acknowledge that some patients who fully understand the illness, the treatment, and the implications of compliance to their cases will nonetheless fail to adhere to the prescribed regimen unless other steps are taken.
Summary: Worthwhile Review Of Basics Plus Bonuses
That said, I return to my contention that this review is head and shoulders above the usual run of competent offerings and well worth reading, if only for the succinct, helpful summary of the Federal Study of Adherence to Medication in the Elderly (FAME).
In addition, one can earn CME credits2 for completing Adherence: The Silent CV Risk Factor.
Source: Cohort study examining tamoxifen adherence and its relationship to mortality in women with breast cancer. C McCowan, J Shearer, P T Donnan, J A Dewar, M Crilly, A M Thompson and T P Fahey. Br J Cancer advance online publication, November 4, 2008; doi:10.1038. Link To Abstract
Abstract
Increasing duration of tamoxifen therapy improves survival in women with breast cancer but the impact of adherence to tamoxifen on mortality is unclear. This study investigated whether women prescribed tamoxifen after surgery for breast cancer adhered to their prescription and whether adherence influenced survival. A retrospective cohort study of all women with incident breast cancer in the Tayside region of Scotland between 1993 and 2002 was linked to encashed prescription records to calculate adherence to tamoxifen. Survival analysis was used to determine the effect of adherence on all-cause mortality. In all 2080 patients formed the study cohort with 1633 (79%) prescribed tamoxifen. The median duration of use was 2.42 years (IQR=1.04–4.89 years). Longer duration was associated with better survival but this varied over time. The hazard ratio for mortality in relation to duration at 2.4 years was 0.85, 95% CI=0.83–0.87. Median adherence to tamoxifen was 93% (interquartile range=84–100%). Adherence <80% was associated with poorer survival, hazard ratio 1.10, 95% CI=1.001–1.21. Persistence with tamoxifen was modest with only 49% continuing therapy for 5 years of those followed up for 5 years or more. Increased duration of tamoxifen reduces the risk of death, although one in two women do not complete the recommended 5-year course of treatment. A significant proportion of women have low adherence to tamoxifen and are at increased risk of death.
Commentary
Other than the specifics - i.e., which medication, which diagnosis, which patient cohort, etc - there is little new information offered here. The primary messages are clear:
Decreased adherence (to tamoxifen in this case) is associated with decreased survival.
Ongoing use of tamoxifen reduces the risk of death, yet only 49% of patients continue therapy for 5 years.
I had not planned to post this week, but this reiteration of the all too familar patient noncompliance motif is just too damn sad to ignore.
Both posts are thoughtful, insightful, and provocative and I can wholeheartedly recommend both as worthwhile reading.
And yet, those entries inexplicably lack two vital components, which I feel obligated to proffer as a supplement of sorts to the efforts of my brother blogger. This response, by the way, has nothing to do with the failure of Alex Sicre, the author at Medication Non-Adherence, to acknowledgment my own posts on the topic of Compliance-enhancing Robots, including Cute, Cuddly Robot Pets Remind Elderly To Take Pills, …
No, if I were going to have hurt feelings - not that I do, mind you - it would be over the diss implicit in the failure to mention my development and promotion of The RoboCop Compliance Program. Based on the percepts electronically implanted into the hemi-mechanical hero who was the prototype for the law enforcement robots featured in the RoboCop movies, the Program is simplicity itself:
RoboCop (Dr. RoboCop to you) presents the healthcare recommendations.
RoboCop enhances compliance with his trademark line, which also serves as the Program’s slogan (Click to hear RoboCop Treatment Adherence Slogan)
1. A Misanthropic, Wildly Speculative, Tangential Soliloquy
In the literature I’ve found, as well as the sources quoted in the two posts at Medication Non-Adherence, the focus (and often the exclusive focus) is on caring for the elderly. I assume that choice is predicated on two of the fundamental driving forces in contemporary society:
Greed: The elderly are a large and rapidly growing portion of the population, and there is an often referenced, albeit rarely articulated, generic commitment from the government to fund their care.
Responsibility abrogation: My own cohort is facing the increasing likelihood that our parents, if not already in need of assistance, will require extra help in the near future, and I certainly intend to do everything I can to assure that the next generation, including my two sons, shoulder their obligation to care for their elders. It is clear, however, that few of us face this task with enthusiasm. Dispatching a robot to care for Grampa James may be a tad less empathic than Jimmy, Jr helping out, but, hey, it’s better than being pushed onto an ice floe.
I would, nonetheless, suggest that other population segments might provide good candidates for such services. The example that comes to mind is my son who suffered a head trauma followed by a coma and a recovery period of 1-2 years. Especially during the rehabilitation period just after his return home from the hospital, he required constant monitoring. Although 90%+ of his behaviors were appropriate, he would unpredictably have cognitive lapses, one consequence of which was that his adherence to medication doses and schedules was erratic. A robotic companion would have eased the burden on me as his sole caregiver and would, I suspect, have been easily accepted by him. A number of other diagnostic and age groups might benefit as well.
Specialized robots for specialized populations.
Just a thought.
2. Photos You can’t tell your robots without a program.
These carebots from GeckoSystems Inc. cost: $19,950 each, including delivery and two-day training.
This video is from the same company, GeckoSystems Intl. Corp, showing CareBots providing healthcare support of elderly, in this case, it presents “One family’s reaction to a CareBot™ for their mother.”
The graphic below is found at Carebots & the good life, a site produced by the Philosophy Department of the University of Twente, which is one of the three participants in the 3TU.Centre for Ethics and Technology. They are “looking for a PhD student to work on the project “Carebots and the good life: An anticipatory ethical analysis of human-robot interaction in (health) care”.
Infanoid (pictured below) is from CareBots Project (Robotic Platforms). Many other photos and movies of human-emulating robots can be found at this site
Graphics Note: The image atop this post is my adaptation of a scene from Lost In Space. The role of the patient is played by the nefarious Dr Smith. The caregiver robot is, of course, Robot from the show. As everyone knows, Robot is a Model B-9, Class M-3 General Utility Non-Theorizing Environmental Control Robot.
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.
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.
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.
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.
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
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Re the more optimistic tone of today’s post, not to worry; this blog’s normal apocalyptic programming will resume forthwith↩
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.↩
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.↩
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.
Footnotes
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For the record, Prince’s given, non-stage name is Prince Rogers Nelson↩
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:
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
Footnotes
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Does the image of Lincoln atop this post remind anyone else of Lyle Lovett?
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
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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.↩
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.↩
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
Patient adherence to treatment in chronic obstructive pulmonary disease (COPD) is essential to optimise disease management. As with other chronic diseases, poor adherence is common and results in increased rates of morbidity, healthcare expenditures, hospitalisations and possibly mortality, as well as unnecessary escalation of therapy and reduced quality of life. Examples include overuse, underuse, and alteration of schedule and doses of medication, continued smoking and lack of exercise. Adherence is affected by patients’ perception of their disease, type of treatment or medication, the quality of patient provider communication and the social environment. Patients are more likely to adhere to treatment when they believe it will improve disease management or control, or anticipate serious consequences related to non-adherence. Providers play a critical role in helping patients understand the nature of the disease, potential benefits of treatment, addressing concerns regarding potential adverse effects and events, and encouraging patients to develop self-management skills. For clinicians, it is important to explore patients’ beliefs and concerns about the safety and benefits of the treatment, as many patients harbour unspoken fears. Complex regimens and polytherapy also contribute to suboptimal adherence. This review addresses adherence related issues in COPD, assesses current efforts to improve adherence and highlights opportunities to improve adherence for both providers and patients.
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
Medication adherence by patients with COPD is generally poor, with reports citing adherence rates to various treatment regimens of approximately 50%. In a study of adherence in patients with COPD, 31% of patients consciously decided to forego administration of their medication if they were ‘‘feeling good.’’ In this study, forgetting or deciding not to take a dose was reported as the most frequent cause of non-adherence. Conversely, these patients reported overusing medication during periods of respiratory distress. Additional factors contributing to non-adherence included interruptions or changes in normal routines, adverse side effects, running out of medication and polypharmacy with complex dosing regimens.
Excerpt From The Conclusion
Further research is needed to gain insight into health behaviour change interventions in COPD in order to design and implement more effective self-management programmes. Such programmes offer the potential to confer clinically and cost effective strategies for long term maintenance of pharmacological and non-pharmacological treatment. Long term studies are needed to assess how successfully patients can sustain behaviour changes over time. Thus the identification and management of adherence related factors in COPD will improve not only patient health outcomes but also help improve the health status of patients and reduce the economic and societal burden associated with COPD. Trials are needed to document effects on clinically important patient outcomes, feasibility in usual practice settings and durability.
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.
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 1970s3could 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?
Note: The oversimplified account that follows centers the adjustments Ptolemy and others made to compensate for errors in the system rather than the Ptolemaic Model itself.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.
In the Ptolemaic system of astronomy, the epicycle (literally: on the circle in Greek) was a geometric model to explain the variations in speed and direction of the apparent motion of the Moon, Sun, and planets. It was designed by Apollonius of Perga at the end of the 3rd century BC. In particular it explained the retrograde motion of the five planets known at the time. Secondarily, it also explained changes in the apparent distances of the planets from Earth.
In the Ptolemaic system, the planets are assumed to move in a small circle, called an epicycle, which in turn moves along a larger circle called a deferent. Both circles rotate counterclockwise and are roughly parallel to the Earth’s plane of orbit (ecliptic). The orbits of planets in this system are epitrochoids.
The deferent was a circle centered around a point halfway between the equant and the earth. The epicycle rotated on the deferent with uniform motion, not with respect to the center, but with respect to the off-center point called the equant. The rate at which the planet moved on the epicycle was fixed such that the angle between the center of the epicycle and the planet was the same as the angle between the earth and the sun.
Epicycle illustration10 (Click on image for animation)
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.
The relevant segment comprises the paragraphs following the heading, “Is The Problem Noncompliance Or Health Illiteracy Or Both?
And Why Should Anyone Care?”↩
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.↩
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.↩
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.↩
If one is seeking context, the concept of the cosmos is a handy starting place↩
Depending on the source, this era during which the Ptolemaic System was dominant is given as 1300-1500 years↩
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.↩
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.↩
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.↩
As some readers know, in my pre-AlignMap life, three colleagues and I formed EnrichMap to develop a system for grouping patients according to their behavioral patterns pertinent to compliance. That information would allow customized, group-specific strategies to minimize unnecessary treatment failures caused by noncompliance. That decrease in treatment failures would, in turn, reduce the consequent morbidity and mortality, research confoundments, delays, and financial waste.
Our efforts resulted in the Emap Profile, a model that, based on an individual’s responses to a brief (20-25 items) questionnaire, divides the adult, cognitively-intact population into six segments, each with different implications for patient compliance:
Sage and Satisfied
Security Seeking
Self Starting
Uncertain and Concerned
Spontaneous and Impulsive
Vigilant and Suspicious
The problem was that we were unable to find a practical means of testing the tool.1 Consequently, we set the project aside. I began the AlignMap web site and blog, in fact, to provide an outlet for my continuing interest in treatment adherence.2
It now appears likely that my partners and I will be able to work with one of the companies involved in clinical trials to determine, in exchange for future considerations for their use of the this technology, if the Emap Profile does what we think it does.
And thus is reincarnation accomplished in the business world.
One manifestation of this corporate revitalization is the EnrichMap.com web site, which just came online. EnrichMap.com offers, naturally, more information about the Emap Profile, including the opportunity for a visitor to determine which of the six groups best describes his or her pattern of responses to healthcare instructions.
I’m posting about EnrichMap not only because I’m proud of that work but also because visitors to this site should know that I have a personal and financial interest in that service.
Information about EnrichMap and the Emap Profile is available at ~ EnrichMap ~
Footnotes
__________
”Practical means of testing the tool” translates into “a clinically and statistically valid method for testing our hypothesis that we could afford out of pocket.”↩
Yes, if I had known we would be resuscitating EnrichMap, I might have chosen a name for this site other than “AlignMap,” which will inevitably be confused with “EnrichMap.”↩
Gorgeous representation of the gorgeous Ptolemaic cosmological model
