From Wired’s list of 10 Top Technology Breakthroughs of 2008
9. Edible Chips
Grandma’s pillbox with the days of the week neatly marked is set to go high tech. Tiny edible chips will replace the organizer, tracking when patients take their pills (or don’t) and monitoring the effects of the drugs they’re taking. Proteus, a Redwood City, California, company, has created tiny chips out of silicon grains that, once swallowed, activate in the stomach. The chips send a signal to an external patch that monitors vital parameters such as heart rate, temperature, state of wakefulness or body angle.
The data is then sent to an online repository or a cellphone for the physician and the patient to track. Proteus says its chips can keep score of how patients are responding to the medication. That may be just the beginning, as the chips could improve drug delivery and even insert other kinds of health monitors inside the body. Now doctors may have a better answer to a common patient complaint — they will know exactly how it feels.
Outlook: If proven in clinical trials, edible chips could let physicians look into a patient’s system in a way that could change how medicine is prescribed and how we take the drugs.
Commentary
While I am less confident than the denizens of Wired that the edible chips will automatically mark a revolution in health care, I do believe they could be a key tool in researching and confirming patient compliance.
At the least, they should be the new gold standard for tracking medication adherence.
Credit Due Department: Image from Businessweek
Nocebo-Effect Noncompliance: When Telling The Patient Enough May Be Too Much
Power of Suggestion: When Drug Labels Make You Sick is an article on placebo and nocebo effects, the sort of piece that appears regularly in the popular press,with little to surprise anyone familiar with clinical practice. It is, however, a useful stepping-off point for a consideration of the impact a clinician’s manner of imparting information about treatment to a patient has on that patient’s response to the treatment and, inevitably, that patient’s adherence to the prescribed treatment regimen.
The following excerpts contain the core issues:
Research has shown that expecting to feel ill can bring illness on in some instances, particularly when stress is involved. The technical term is the “nocebo effect,” and it’s placebo’s evil twin. “It’s not a psychiatric disorder — it’s the way the mind works,” says Arthur Barsky, director of Psychiatric Research at Brigham and Women’s Hospital in Boston.
… in one 1960s test, when hospital patients were given sugar water and told it would make them vomit, 80% of them did. Studies have also shown that patients forewarned about possible side effects are more likely to encounter them. In a study last year at the University of Turin, Italy, men taking finesteride for enlarged prostates who were informed that it could cause erectile dysfunction and decreased libido were three times as likely to experience such side effects as men who weren’t told.
… Doctors may unwittingly foster placebo or nocebo effects by how enthusiastically or warily they discuss medication. “Physician communication with patients is the closest thing to magic. It gets communicated in incredibly subtle ways—a flash in the eye, a smile, a spring in the step,” says Daniel Moerman, an emeritus professor of anthropology at the University of Michigan-Dearborn. Doctors may also subconsciously transmit an expectation of pain. In a double-blind study of 60 patients who had wisdom teeth extracted, when clinicians thought they might be administering a medication that could heighten the pain instead of lessen it, the patients reported much more pain—even though they were really receiving placebos.
Should doctors discuss all those risks with patients, or can they be a self-fulfilling prophecy? It depends on the patient and the drug. “Patients should be made aware of anything that could be dangerous, so they don’t keel over on the street,” says Flavia Golden, an internist in New York City. “But if it’s minor like a headache, I don’t mention it. It’s better to keep the channels of communication open and say, ‘Call me if you have any problems.’ “
Patient-Clinician Interaction, Treatment Recommendations, Nocebo Effect, and Adherence
For the purposes of this exercise, I ask readers to stipulate that (1) the placebo and nocebo effects operate as described in the excerpts and can cause some patients to suffer significantly negative symptoms and (2) a significant number of patients will not follow a recommended treatment regimen if they suffer those significantly negative symptoms.
Now, you’re the physician recommending medication XYZ to your patient (as long as we’re stipulating, let’s also stipulate that this is the optimal medication for this patient, who will be 5 times more likely to recover from the affliction being treated than would be the case if a placebo were taken). Like most medications, there is a reasonable chance XYZ will cause some minor side-effects in a large fraction of patients and a relatively small chance it will cause a severe side-effects in a few patients.
The question is what you tell the patient and how you tell the patient about about (1) the likelihood of a favorable outcome and (2) the side-effects, including which side-effects (all, none, some) and the likelihood of those side-effects.
Keep in mind that, because of the placebo and nocebo effects, an optimistic appraisal of the outcome delivered enthusiastically is likely to cause some patients to achieve that outcome and encourage the patient to pursue the recommended treatment. Similarly, every side-effect you list for some patients will increase the likelihood they will suffer that side-effect and, as a result, increase the risk they will terminate the treatment. Of course, you can modulate that effect by how you describe the chances the side-effect will occur or how severe it may be.
It’s important to understand that the information you offer is not benign. The choice you make to tell your 100 patients taking drug XYZ that it can cause debilitating fatigue means, taking the nocebo effect into account, that some of those patients who would not have suffered debilitating fatigue will do so only because you chose to tell them about this potential side-effect. Further, some of those affected by this side-effect may well refuse to continue drug XYZ because they may think debilitating fatigue is worse than their original ailment, i.e. some patients will drop out of their optimal treatment plan only because you chose to tell them about this potential side-effect.
Are you proud of yourself?
Of course, you could decide not to tell any of them about the risk of debilitating fatigue. That’s fine – if you don’t mind hiding potentially important information from your patients and, in the process, perhaps violating ethical canons. Heck, if there is a hot shot plaintiff’s lawyer involved, you may find a jury of 12 of your peers have decided you’ve committed malpractice by not providing informed consent.
Naturally, you believe the patient must always be a partner on the clinical team so you can’t revert to the paternalistic Dr. Welby methodology of telling each patient only what you think that particular patient needs to know. And, to be fair, even if you were into retro-medical practice, unless you’re a TV doctor with good scriptwriters you won’t have more than a hunch which patients you should tell what.
Incidentally, that bit in the excerpt, “But if it’s minor like a headache, I don’t mention it. It’s better to keep the channels of communication open and say, ‘Call me if you have any problems,’ ” works better as a sound bite than as a general practice. It turns out that lots of patients are seriously miffed when they discover from the doctor taking call for you over the weekend that the headache that kept them from going to Thanksgiving dinner was a side-effect you knew could happen but chose not to tell them.
Notice that the decision about how to inform a patient about the side-effects of a prescribed medication resolves rather straightforwardly into a forced choice about how you will manipulate the patient. Because of the placebo-nocebo effects, the reaction of some patients (and, no, you can’t tell which ones) to data, even when its transmission is seemingly neutral, is dramatically distorted. Consequently, what the clinician chooses to tell – or chooses not to tell – a patient about the side-effects of a single medication has a necessarily exaggerated impact (at least for a large number of patients), making that task, that may take place a dozen times in a morning clinic, incredibly challenging. Discussing a complex, comprehensive treatment plan for a disorder like diabetes is exponentially more difficult.
The Answer
Hey, don’t look at me – I’ve been trying to figure this out for 25 years.
The only answer I’ve come up with so far is the same declaration that opens this post:
Clinicians can choose how, not if,
they influence patient compliance
__________
Alignmap In Cites Goes Video
A plethora of compliance-pertinent videos are now available online. I’ve begun posting some of these flicks on this blog’s tumblelog counterpart, AlignMap In Cites.
Videos selected for the AlignMap In Cites Patient Compliance Theater meet one or more of the following inclusion criteria:
- Presentations of patient compliance research that briefly and clearly present highlights of findings
- Tips targeted to patients or clinicians that may improve adherence
- Demonstrations of and infomercials about devices that ostensibly enhance adherence – or at least amuse me.
- Testimonials from patients and pontifications from clinicians that provide useful information, reveal pertinent attitudes that could have a positive or negative impact on patient compliance, or surpass a difficult to articulate but easy to recognize threshold of – oh, let’s call it eccentricity.
- Anything else that strikes my fancy.
The following videos in the list that follows have been posted to AlignMap In Cites in the past 24 hours. The links below go directly and only to the post indicated. These posts can also be accessed en masse by going to the AlignMap In Cites home page and scrolling back through the chronologically listed posts.
Now Showing
The AlignMap In Cites Patient Compliance Theater
Infomercial about the e-Pill Cube Pill Timer and Pillbox My first impression, based on the rather complex explanation of its operation, is that the device might be better positioned as a test of cognition rather than a convenient medication dose reminder.
Tips to enhance adherence to medication regimen Nothing unusual but potentially helpful ideas about remembering to take ones medications. Targeted to patients.
Medication compliance survey: Moderately self-serving presentation and recommendations from The National Community Pharmacists Association.
Infomercial about the e-Pill MD2 dispenser
Psych Medication Non-compliance: A patient’s own story of medication noncompliance.
Adherence to ARVs — Part 1 and Adherence to ARVs — Part 2: Poignant patient educational video from Baragwanath Hospital, Soweto, South Africa promoting adherence to anti-HIV ARV drugs.
How to Improve Patient Compliance in Dyslipidemia Diagnosis: Medscape produced video report on study affirming value of electronic patient reminders.
Importance of Patient Compliance in Healing: Presented by a clinician and targeted to patients. Excerpt: So, do what the doctor tells you. Try to be compliant. Try to get better. And if you need our help, we’re Baker Chiropractic. We put patients first.
