The AlignMap Top Ten1
#1. It’s “I Before E”
And It’s Alignment Before Empowerment
The empowerment of patients has the potential to improve treatment adherence and healthcare in general but only if that empowerment is accomplished in the context of a therapeutic alliance with the goals and values of patients, clinicians, and the system though which care is provided in alignment.
The empowerment of patients without such alignment endangers rather than enhances healthcare on both the individual and systemic level.
For example, members of a jazz band may discover hitherto untapped power and evocativeness from a composition when they are empowered to improvise and take responsibility for their performance rather than play as automatons. On the other hand, fourth graders in a beginners orchestra may have implicitly agreed to play from the same sheet music and follow the lead of the same conductor, but it requires only a few moments of observation to grasp that such nascent musicians, however desirous they may be to please the audience or how enthusiastically they approach the task at hand, lack the maturity of temperament and conceptual capacity necessary to operate independently without an ensuing cacophony.
Senge’s warning, although written about business administration, is equally valid in this situation,
Empowering the individual when there is a relatively lower level of alignment worsens the chaos
#2. Love Is Not Enough: Neither Are Good Intentions
If I Only Had a Brain
~ Wizard of Oz
A desire to cooperate on the part of all those involved in a given case — patients, clinicians, and healthcare administration — is a good starting point, but effective implementation of treatment requires knowledge and skills as well as motivation. Further, healthcare situations are dynamic; all parties involved must continuously update their ability to cooperate. The best healthcare will occur when patients, clinicians, and healthcare administrators learn fast and apply what they learn most expeditiously. Accelerating this process is a key responsibility of healthcare professionals.
#3. A Desire For Health & Motivation To Comply With Treatment
Are Not Identical
Let all men, if they can manage it, contrive to be healthy!
~ Thomas Carlyle
Even patients who desperately want to be healthy can vary remarkably in their willingness and capacity to adhere to the prescribed treatment.
It is a mistake to assume that patients will necessarily follow treatment instructions because they want to get well or because they are fearful of the negative outcome of their disorders, even if those consequences are catastrophic.
The goal is to help the patient connect his or her desire for health, as defined by the patient, with a course of treatment that is most likely to be beneficial, also as defined by the patient.
#4. Oneupsmanship Or Compliance-Enhancement: Choose One
More often than not, the first clinician to see the patient for a given ailment is actually providing a second opinion. It is the rare patient who does not arrive at a doctor’s appointment without forming an idea about what his or her symptoms portend. The source of the patient’s self-diagnosis may have been the New England Journal of Medicine, the Miracle_Snake_Oil.com web site, the 90-second personal health feature (inevitably called “To Your Health”) produced as a school project by the local TV station’s 19 year old intern, the overheard fragment of a conversation between two psychiatrists at a party, or my Aunt Hazel from Broken Arrow, Oklahoma. Even if the ideas are inaccurate — make that especially if the ideas are inaccurate — the failure to ask about and listen to these ideas is dangerous. That the clinician renders the correct diagnosis when he interrupts the patient’s prolonged account of recurrent dizziness, fluctuating appetite, and intermittent left knee pain does not insure the patient’s agreement, respect, gratitude, or compliance.
#5. “Complianceadherenceconcordance” Just Doesn’t Scan;
Let’s Call It Compliance Until Something Better Comes Along
Now look, Colonel Bat Guano – If that is really your name
~ from Dr. Strangelove
They certainly give very strange names to diseases
And to compliance
Even though I’m a doctor, I just can’t go along with “medical compliance” as an ideal term for whatever it is we’re talking about. I’ve also had it with “patient compliance.” “Cooperation” doesn’t quite work with me. And while “adherence” has its adherents, it does not seem something I could stick with. As for “concordance,” which carries the official sanction of the Royal Pharmaceutical Society of Great Britain, it just doesn’t lend itself to puns.
Pragmatically, whatever distinctions once may have existed between the connotations of “compliance” and “adherence” have likely been washed out by the pervasive use of these and their congeners as synonyms in the preponderance of the medical literature. The argument can legitimately be made that such semantic quibbles may now produce more distraction than insight into the clinician-patient relationship. Lacking compelling advantages favoring the use of any of the suggested terms and the institutionalized encoding of “medical compliance,” “patient compliance,” and “medication compliance” into the medical literature and databases, it makes sense — until something better comes along — to continue using this familiar phrase to designate the healthcare behaviors of individuals responding to medical recommendations and, unless specified otherwise, assume that “adherence,” “compliance,” and “concordance” refer to the same phenomenon.
My own hunch is that eventually, the issue of compliance/adherence will be properly subsumed by a focus on treatment implementation and execution.
For what it’s worth, my preference is to get behind “alignment” under the premise is that we are striving not so much to persuade, coerce, or trick patients into doing what their doctors prescribe as to align clinicians, patients, payers, and anyone else involved in healthcare so that everyone is working in concert. An easy example of alignment’s advantages is the case in which a patient does not adhere to the prescribed treatment plan but does communicate that decision and his or her reasons to the clinicians. That is not “compliance” (at least by a strict definition), but it seems different from and exponentially preferable to the case in which the patient not only does not follow the treatment plan but also misleads the clinician into thinking he or she is doing so. Assuming the patient was not just perversely turning down all options, he or she and the clinicians could be in “alignment” although the patient is not in “compliance.” The other important connotation is that “alignment” obviates the assumption, essential to “compliance,” that patients are either obedient or disobedient to the dictates of the clinician; rather, “alignment” allows for a less one-sided involvement of the clinicians and patients. Nonetheless, “alignment,” used in this sense, would not be recognized by the medical community.
For more on the issue of nomenclature, see:
#6. There is no universal antidote for noncompliance
AKA The Universal Truth About Universal Panaceas
It’s the rare coach of a team sport who even claims to treat all his or her players the same; teachers acknowledge the need to individualize education as much as possible; and, perhaps most telling, marketers espouse as their ultimate goal a sales message personalized for a specific potential customer. Yet, the medical literature dealing with patient compliance often expresses perplexity, frustration, and, on occasion, amazement that a given intervention (whether that intervention is patient education, cues & reminders, free medical services, easy access to services… ) improves compliance among some but not all patients.
That different patients react in different ways to healthcare recommendations and compliance-enhancing efforts is a concept that hardly rises to the level of a profundity but must, it seems, be evangelized.
#7. “Better patient education” is the answer — but only if the question is “What is the only response made to correct noncompliance in 90+% of cases?”
This is a specific case of Mencken’s observation,
For Every Complex Problem, There Is A Solution That Is Simple, Neat, — And Wrong
There is no indication that patient education is uniformly the appropriate corrective reaction to noncompliance; there is evidence that patient education, regardless of how well structured the teaching process and how motivated the client, is unsuccessful in achieving compliance in a significant portion of cases.
More information does not necessarily result in more compliance. It is a difficult intuitive leap, for example, to concur with the bureaucratic a priori rationale that providing a patient a three-page listing of a medication’s adverse effects (instead of a one-page list of a subset of those adverse effects) will result in that patient taking the medication more faithfully.
Educating the patient without first determining if education will solve the problem for that patient in that situation is no more rational than automatically prescribing antibiotics to every patient complaining of coughing and a sore throat.
#8. Compliance Enhancement Can Be A Win-Win-Win Game
While there may be, despite the unremitting efforts of pharmaceutical detail reps, no free lunch, compliance enhancement may be the source of that equally elusive goal, the Win-Win outcome. In fact, compliance enhancement may be the sole example, other than casino and lottery ads, of the Win-Win-Win game.
Looking Out For #1, #2, and #3
Improved compliance tends to result in happier
- Clinicians: who can count on treatment plans being implemented as written
- Administrators: who savor the lower costs
- Patients: who avoid unnecessary delays in recovery, relapses & side-effects
#9. Once You’ve Seen One Noncompliant Patient,
You’ve Seen One Noncompliant Patient
The extent to and manner in which Patient X, in a specific set of circumstances,2 adheres to a prescribed treatment can be extrapolated and generalized to accurately characterize — the extent to and manner in which Patient X, in that specific set of circumstances, adheres to that prescribed treatment.
Compliance is the result of a complex collection of cognitive, emotional, physiological, and cultural factors, some of which are obvious, others which are subtle, and many of which may be in conflict. Compliance not only varies from patient to patient but the same patient may respond differently to the demands of different treatment regimens and in response to various disorders. Further, Patient X’s compliance behavior vis-à-vis the same disorder and treatment may vary under different circumstances; patient X’s adherence to the same treatment for the same disorder may, for example, be different at ages 5, 15, 35, 55, and 85.
Past compliance behavior for a specific patient may be somewhat predictive of that patient’s future compliance, but the power and reliability of such predictions are not impressive even if the circumstances are similar. Generalizing beyond a specific patient to a group of patients has proven a sucker’s bet for clinicians.
#10. Complacency about compliance leads to treatment failure
If you know that 75% or more of your patients follow your treatment recommendations, one of the following explanations holds:
- You are charismatic, empathic, and knowledgeable — and incredibly lucky. If enough poker players try drawing to an inside straight enough times, someone — somewhere — sometime — does eventually end up with that hand. So, sure, it’s possible that 75% of your patients are compliant. If you’re this lucky, however, let’s you and me go buy some lottery tickets.
- You are incredibly charismatic, empathic, and knowledgeable but are no luckier than the rest of us schmucks. You also sustain a charmingly naive confidence in human nature despite evidence to the contrary, tend to invest heavily in Franklin Mint commemorative plates depicting the official fungus of each state, continue to expect the check that (you have been assured) is in the mail, and believe for every drop of rain that falls, a flower grows.
A reasonable rule of thumb is to assume, lacking proof that the situation is otherwise, that 50% of patients do not comply with treatment recommendations.
- David Letterman’s blog cameo prompted me to compile AlignMap’s own Top Ten List.Yeah, I know — Dave’s Top Ten Lists are a lot funnier but just see how much they improve adherence to scheduled clinical appointments. And, we acknowledge that the content of the original Top Ten (AKA The Ten Commandments) has not required any patches, let alone major revisions, in the past few thousand years (although we would submit that since the first set of tablets crashed — literally — the current revision is arguably the 1.1 version). Our product is just more — uh — flexible.↩
- E.g., the severity of Patient A’s disorder, the side-effects of any medication, the doctor’s empathy, etc.↩