Improving Medication Adherence

How to Talk with Patients About Their Medications

Improving Medication Adherence: How to talk with Patients About Their Medications

“As an internist who has specialized in pulmonary medicine, and who also enjoys teaching medical and nursing students, I have fallen in love with this timely and intriguing book. When a reviewer tells you a book is unique, it’s usually not true. When they tell you it is remarkably practical, it’s often an exaggeration. When they say it is beautifully written and fun to read and a “must buy,” you know it’s hype. Except with this book. “Improving Medication Adherence: How to Talk with Patients About Their Medications” by Shawn Christopher Shea is unique, remarkably practical, beautifully written, fun to read, and I honestly believe that every medical and nursing student in the world should read it.”

An Amazon.com Reader

Any type of clinician that treats patients with medications or any other type of treatment, needs to read this book. I am a psychiatrist out of residency for 5 yrs. It is so good that med schools should require it. Students and residents should read it early on. Every person who reads this will find many ways to connect w/ clients and improve outcomes.

An Amazon.com Reader

Critical Acclaim

“First book ever written focused upon how to talk with patients about medications. The interviewing techniques are applicable for improving medication adherence across all types of medications from the treatment of diabetes, asthma, and hypertension to depression.”

Critical Acclaim from the Experts and Reviewers for Shawn Christopher Shea’s Book, Improving Medication Adherence: How to Talk with Patients About Their Medications . . . .
“In the following pages, you are in for a treat. You are about to enter the very soul of what we do, and you could not find a better guide . . . . this little book, in my opinion, is destined to fill a giant void in the training of all medical and nursing students, as well as becoming a classic read for experienced clinicians in search of the art of medicine. My advice is simple – read it.”

Former Surgeon General of the United States (1981-1989)
C. Everett Koop, MD, ScD
Senior Scholar, C. Everett Koop Institute at Dartmouth

“I believe that every practicing clinician, even the most experienced, will find it useful and handy. I also believe that residents in every clinical discipline should read and use the tips daily.”

Annals of Clinical Psychiatry
June 2008

“Introduces a caring approach to developing an alliance with patients around medications that will benefit experienced clinicians and nursing students alike . . . definitely a book that you will reach for again and again.”

Bulletin of the American Psychiatric Nursing Association
June 2008

“As an endocrinologist I can safely say that the secret to treating diabetes lies within the pages of this book, for the secret of successfully treating diabetes – as well as all other serious diseases – lies in improving medication adherence. No book provides better answers to this vexing problem. Laced with humor and compassion it is a fun book, a rare clinical gem, highly recommended for all generalists, specialists, nurses, case managers, and medical, nursing, and clinical pharmacy students. I read it carefully – twice.”

George F. Cahill, Jr. M.D.
Professor of Medicine, Emeritus, Harvard Medical School
Past President, American Diabetes Association

“Should be read by every medical student at the end of his or her first year of medical school and again at the end of his or her fourth year . . . . It should then go on their bookshelf to be drawn upon throughout the rest of their career.”

Psychiatric Services
August 2008

“A bright and refreshing writing style, packed with unusually insightful interviewing tips. Dr. Shea’s book is simply the best resource available on communicating with people about their medications.”

Robert E. Drake, MD, PhD
Andrew Thomson Professor of Psychiatry
Dartmouth Medical School

“A valuable book for even the most experienced clinician from primary care to endocrinology. Dr. Shea brings rich insights to a topic (what words we choose as we introduce medications and address their side-effects), that is seldom discussed in training. He reminds us that our words are as important a part of the pharmacopoeia as the medications themselves.”

John F. Steiner, MD, MPH
Director of the Colorado Health Outcomes Program
Professor of Medicine, Preventive Medicine and Biometrics
University of Colorado

“This is a “must” book for every clinician who wants to partner with patients regarding medications. It is a timely, useful, easy to read book that is well written and thoughtfully prepared. Congratulations!”

Michelle Riba, MD
Professor of Psychiatry, University of Michigan
Past President, American Psychiatric Association

“I want to emphasize how remarkably powerful Shea’s techniques are in working with psychiatric patients – coping with diseases such as depression, bipolar disorder, and schizophrenia – with whom negotiations about medications can be particularly challenging. I can’t recommend this book enough to psychiatric residents and, in fact, to all practitioners of psychiatry.”

Ronald Green, M.D.
Director of Residency Training in Psychiatry
Professor of Psychiatry
Dartmouth Medical School

“An outstanding contribution to our clinical literature – immensely practical – filled with interviewing tips for improving medication adherence for every clinician . . . . . Students and well-seasoned clinicians alike will benefit from the perceptive observations and wise advice that fills this book.”

James Ellison, MD, MPH
Associate Professor of Psychiatry, Harvard Medical School
Clinical Director, Geriatric Program, McLean Hospital

“Blissfully short, blessedly succinct – written with gimlet-eyed clarity and eloquence – this book is a boon for every clinician.”

Mack Lipkin, MD
Founding President
American Academy on Physician and Patient
Professor of Medicine
NYU Medical Center

Written for physicians, nurses, physician assistants, case managers, and clinical pharmacists, this pioneering book is the first of its kind devoted to the delicate interface between clinical interviewing and medication adherence. Shawn Christopher Shea, MD takes the reader on a compelling and eminently practical exploration of how our words powerfully impact on whether or not patients are interested in taking medications and staying on them.

Dr. Shea shares over forty specific interviewing techniques that are equally useful for medications for all disease states from hypertension, diabetes, and CHF to bipolar disorder and schizophrenia. The interviewing tips—brilliantly illustrated with their exact phrasings and all of their clinical nuances—were culled by Dr. Shea from the input of the thousands of front-line clinicians who have attended his popular workshops on “improving medication interest” given throughout the United States and Canada at over 200 locations.

Improving Medication Adherence: How to Talk with Patients About Their Medications is a standout favorite with medical and nursing students in their “Introduction to Clinical Skills” courses because of its immediate practicality, eloquent yet disarmingly witty writing style, and remarkable brevity. It is equally appreciated by seasoned clinicians with years of experience who, as Dr. Shea writes, are keenly aware that “our science is always at its best, when it is held in the hands of compassion and enhanced by clinical skill.”

Foreword by former Surgeon General C. Everett Koop, MD

(This Foreword was written for the book “Improving Medication Adherence: How to Talk with Patients About Their Medications” by Shawn Christopher Shea, MD)

Let me begin with a bias – a strong one. After four decades of clinical practice and 25 years of monitoring it from the sidelines (eight of them from the best seat in the house as Surgeon General), I have become convinced that the cornerstone of all healing in medicine lies within the mysterious bond that grows between the physician and the patient. Call it what you will – bond, alliance, relationship – it is the heart and soul of medicine.

It is one of the reasons that I was so pleased to be the Senior Scholar of the C. Everett Koop Institute created at Dartmouth Medical School dedicated to understanding these mysteries. It has been my goal to explore these mysteries, to honor those protocols that by their nature must remain mysterious and to delineate and teach those processes which can be discerned, made operational, and taught.

I have arrived at a second conclusion – as has the author of this book – a conclusion that is so obvious that it is often not recognized as critical to discuss or even to mention. No medication works inside a bottle. Period. Now let me bridge the relationship between my two conclusions.

Our patients reach for their pill bottles, unscrew their caps, and reap the benefits of our medications almost purely because of the power of their bond with us. They either trust us, or they don’t. They either feel they have been well informed or they don’t. They either feel we care or we don’t. And all of these patient opinions are the reflection of the ongoing nuances of the physician-patient relationship as it defines itself.

Unfortunately far too little time is spent in our medical school education, our residency training, and in our ongoing continuing medical education on this most practical of all interviewing skills – talking with patients about their medications. And when time is spent on these topics it is often, in my opinion, wasted with cliches and admonitions to “be empathic” and to build “collaborative relationships”. Such goals are laudable, but what is needed is a probing, tenacious attempt to uncover the specific interviewing techniques, choices of words, strategies, nuances and experiences that talented clinicians use to convey empathy and to build these relationships, not just talk about the need to do so.

I know of no book that has ever addressed this critical set of interviewing skills regarding the specific task of how we talk with our patients about their medications. By necessity, I leaned heavily on my own experience when I led a program “Take Time To Talk” giving tips to patient and physician alike about talking to each other; I let each group see and hear what I said to the other.

You are holding in your hands the first book, as far as I know, in the history of medicine that admonishes physicians to take the time to talk with patients about their medications. And it does so with remarkable readability, practicality, and elegance. Reading this book never feels like one is reading a textbook of medicine. Instead one feels that one is talking informally with a trusted mentor while doing bedside rounds – a mentor who believes in the mission, understands the complexities of the work, and genuinely both enjoys and loves his patients.

Hopefully Shea’s philosophy of enhancing “medication interest” as opposed to enforcing “medication compliance” will become second nature to generations of future medical and nursing students, as well as residents from primary care to psychiatry. I believe his book will become standard reading in all medical and nursing classes on “medical interviewing” or “the physician-patient relationship,” for it covers a critical topic in medical interviewing often overlooked – how to talk with patients about their medications.

“How to Talk with Patients about Their Medications” is filled with a
remarkable number – around forty – specific interviewing techniques and strategies for talking to patients about their medications and their side-effects in a collaborative fashion in the primary care setting, psychiatry, and elsewhere. The principles are equally relevant for talking with our patients about antihypertensives, oral hypoglycemic agents, and antidepressants.

Curiously, the book has come not from a family practitioner or internist but from a psychiatrist, who, in my opinion, did two wise things: 1) he brought the keen observations and principles that are of use in discussing psychiatric agents – notoriously difficult to get patients interested in taking – to the discussion table and 2) he has distilled his interaction with thousands of primary care clinicians across the country in over 150 workshops, culling from them their very best interviewing techniques concerning all classes of medications – techniques that have proven themselves in the hectic confines of contemporary primary care clinics. Thus this book is, in essence, written by a psychiatrist, but contains the input of hundreds of primary care clinicians, who know what works and what does not work in actual practice no matter what class of medication is being discussed.

I also like the no-nonsense attitude that Shea takes, when he emphasizes that the techniques he describes are not offered as the right way to interview (as if there was a cookbook manner for talking to patients correctly about medications). Instead Shea describes them as reasonable ways. He hopes that the reader picks and chooses those techniques that appeal to each specific clinician , for we are all different and must develop our own styles.

Shea also achieves what I view as an even more remarkable goal. He not only engenders in the reader a genuine excitement about interviewing, he provides a foundation in the principles that are necessary for creating new and effective interviewing strategies. From these principles the clinician can develop his or her own unique techniques, throughout the ensuing years of his or her career, long after they have put the book down. Shea invites the reader to become an innovator, and he gives the reader the necessary tools to be one.

Long ago I learned the power of interviewing technique to enhance my relationships with my patients. For years I had been taught always to address the parents of my patients (I was a pediatric surgeon) by their last names and to be addressed vice versa. And so I did. Pediatrics, as opposed to pediatric surgery, is much more homey and first names are “in”.

So as the years progressed, I began to realize that when talking with people about life and death decisions about their children or other loved ones, that our relationship was not some pseudo-professional exchange of ideas, but an intimate discussion, the closest bond you can have, between people who were building a unique relationship while collaboratively battling frightening diseases and scary surgical procedures, last names often didn’t cut it.

Consequently, when I first introduced myself to a parent or patient I always addressed them by their last name. But then, I did something special – I gave control of how I should address them to themselves – I simply asked, “Mrs. Jones how would you like me to address you, by your last name, your first name, or whatever you like?” With this simple question the bond between the healer and those seeking his or her help began.

By the way, if the patient’s parents told me they preferred his or her first name, I was not averse to being called by my first name as well – I’ve been called a lot worse! And if the patient insists on being addressed formally by their last name, I simply reciprocate, “It’s probably best to call me Dr. Koop.”

Over the years I have found that patients enjoy this collaborative work on an important relationship issue – how we want to be addressed – that opens the door to the recognition that we are entering a most special alliance, one where we will be discussing the most intimate of details, sometimes talking about frightening news such as the presence of cancer or the approach of death, and brainstorming on options, and realizing, together, that sometimes there are no further options. Such are the moments when it is powerful and reassuring to use first names and to even shed a tear or two. In the last analysis, healing is about being human, learning how to allow our science to be guided by our compassion.

In the following pages you are in for a treat. You are about to enter the very soul of what we do, and you could not find a better guide. With sophistication, wit, astute clinical observation, and a vibrant sense of compassion Shea throws a brilliant new light on one of the most crucial topics in medicine – improving medication adherence. Packed with practical interviewing techniques and no-nonsense strategies, this little book, in my opinion, is destined to fill a giant void in the training of all medical and nursing students, as well as becoming a classic read for experienced clinicians in search of the art of medicine. My advice is simple – read it.

Former Surgeon General
of the United States (1981-1989)
C. Everett Koop, MD, ScD
Senior Scholar,
C. Everett Koop Institute at Dartmouth
Elizabeth DeCamp McInerny Professor of Surgery

Preface

“The purpose of life is to serve and to show compassion and the will to help others. Only then have we ourselves become true human beings.”

Albert Schweitzer, M. D.
This is a small book about a big topic. In fact, an argument could be made, that the problem of medication nonadherence is one of the, if not the, major roadblocks to providing effective care in medical practice today. It clearly should be one of the topics most rigorously addressed by all medical, nursing, physician assistant, and clinical pharmacy students during their training. Having intentionally written the book in an informal and conversational style, I hope that these same students will rapidly feel at home with the pages that follow. It is meant to read with the comfortable familiarity of a bedside consult from a colleague one trusts.

It is also my hope that veteran clinicians will feel equally at home perusing the following pages, for their years of clinical experience will provide an entirely different – more powerful lens – with which to play with the following ideas. If I’ve done my job well, as an experienced clinician reads on, he or she will find interviewing techniques and strategies that validate their current practice, provide a handful of immediately useful ideas for their future practice, and, most importantly, stimulate them to find new answers born from their own clinical wisdom.

The techniques in this book are not provided as the “right way” to increase our patient’s interest in their medications, but merely as suggestions of various ways of tackling these difficult and sometimes vexing problems. The reader is invited to check out the following techniques, adopt the ones they like, discard the ones they don’t, and create ever more powerful solutions that resonate with their own interviewing styles and the unique needs of their patients.

Before I turn the reader loose to follow up on my invitation, I should mention where the interviewing tips, that dot the pages of this book, have originated.

Over the past six years, as the Director of the Training Institute for Suicide Assessment and Clinical Interviewing (TISA) – – suicideassessment.com – – it has been my privilege to present workshops on medication adherence and other aspects of clinical interviewing to psychiatrists, primary care physicians, nurses, clinical pharmacists, and CHF casemanagers from around the country. At each workshop I ask my workshop participants to stop me if any of the ideas that I suggest seem impractical in a primary care clinic or in a community mental health setting. In the following pages, I share only those ideas that have passed the “acid test” of their discerning judgement.

More importantly, I always invite the participants of my workshops to share the tips that they have found to be most useful in their daily practices – their private cache of clinical pearls. This book is a direct result of these workshops. It is a compilation of the practical tips, suggested at my workshops, coupled with the lessons that I’ve learned in my own clinical practice over the years.

Concerning my personal ideas for improving medication interest, I should state that they originated far from the world of the Ivory Tower. For almost five years I directed a front-line “in the trenches” psychiatric team that focused upon the thorny issues surrounding adherence. This team provided outreach to severely impaired psychotic patients at a community mental health center. Our patients were hidden away in the rural back roads and small towns of southern New Hampshire. These teams, known as Continuous Treatment Teams (sometimes called ACT teams), were designed to provide care for only the most seriously impaired of mental health patients.

By way of example, to be eligible for care under our team, the patient had to have either out-of-control schizophrenia or bipolar disorder. In addition the patient also had to have either active alcohol or street drug abuse. Furthermore, they had to have one or several of the following: multiple suicide attempts, multiple acts of violence, or multiple hospitalizations. Needless to say, as these patients first joined our team, they were not big medication advocates. Indeed, our clinical challenge was, in essence, to win the Super Bowl of nonadherence.

Our efforts were monitored by a research study run by Robert Drake, M.D., one of the most gifted clinicians with whom I have ever had the pleasure to be associated, and sponsored by the Robert Wood Johnson Foundation. At the end of four years their monitoring efforts revealed that we were able to decrease the number of hospital days per year of these patients, when compared to other more traditional case-management teams, by twenty days per year. In addition, during this time, there were no suicides with this highly vulnerable group of patients.

Much of our success seemed to be secondary to the strikingly high medication adherence that we were able to achieve with many of our patients. And, I am convinced, that it was these same patients that taught us how to do it. We asked and subsequently explored with each of our patients, how we could increase their interest in taking psychotropic agents such as antipsychotics – meds that, I might add, can have some nasty side-effects. The answers that they gave, one way or the other, always seemed to return to the complexities and elusive exchanges of the physician/patient relationship. The answers had to do with how we saw them, how they saw us, and how we, together, saw our alliance against their disease. It is their answers – equally true for a person suffering from diabetes as for a person suffering from schizophrenia – that provide much of the practical wisdom that follows in this book.

Finally, I should add that for over twenty years, it has been my great pleasure to study and write about the art of interviewing. I have specialized in developing methods for training both inexperienced and experienced clinicians.

Over these years I have become convinced of the necessity of providing the clinician, not only with sound principles, but with direct examples of how to implement these principles. The clinician needs to see the exact phrases and questions that can transform a sound principle into a sound practice. In the last analysis, mastering interviewing is probably not as dependent upon knowing what to say than upon knowing how, and when, to say it. Thus, as was the case with my previous books, I have tried to pack this primer with sample questions and concrete interviewing strategies.

In closing, I hope the reader enjoys the following pages. I certainly enjoyed writing them. I truly believe that, in the last analysis, it is a privilege to be a physician, a nurse, a physician assistant, a clinical pharmacist, or a case manager.

Our journey, as physicians and healers, is a rich one. In our efforts to provide help to our patients we sometimes succeed and we sometimes fail, but we always learn. As we move more deeply into their pains and their fears, we encounter the reflections of those pains and fears – their hopes and expectations. Our medications become their hope for relief and their expectations are that our medications will provide it. Sometimes they do, sometimes they don’t.

It is here – within the chaotic world where suffering and compassion meet and sometimes collide – that we move ever more deeply into the souls of our patients. Once there we have the great privilege, as Albert Schweitzer observed, to suddenly know what it is “to become true human beings.” These moments are the moments that define our livelihoods as physicians, nurses, physician assistants, clinical pharmacists, and case managers. This book is about such moments.

Shawn Christopher Shea, M. D.
January 7, 2006

Table of Contents

PrefaceForeword by C. Everett Koop, MD, ScD

PART I
When Patients Choose to Stop Medications: Core Principles

Chapter 1
Nonadherence: The Extent of the Problem

Chapter 2
The Crux of the Problem: The Nature of Medication Nonadherence

Chapter 3
How Do Patients Choose to Take a Medication?

Chapter 4
Is It Really “Noncompliance?”

PART II
Why Do Patients Choose to Stop Medications: Three Key Questions

Chapter 5
Outside the Office: The Weighing of the Pros and Cons

Chapter 6
A Question of Efficacy

Chapter 7
A Question of Cost

Chapter 8
A Question of Meaning

PART III
Helping Patients Make the Right Choice: Finding Solutions

Chapter 9
Medication Interest Redux – Caring for the Patient

Appendix: Tip Archive – A Quick Reference and Summary of All 43 Tips

Index

Chapter 3: How Do Patients Choose To Take a Medication?

(An excerpt from “Improving Medication Adherence: How to Talk with Patients About Their Medications” by Shawn Christopher Shea, MD published by Lippincott, Williams & Wilkins)

“To desire to take medicine is perhaps the greatest feature which distinguishes man from animals.”1

Sir William Osler, M.D.
Renowned Physician (1849 – 1919)

“I firmly believe that if the whole materia medica as now used could be sunk to the bottom of the sea, it would be all the better for mankind – and all the worse for the fishes.”2

Oliver Wendell Holmes, Sr.
Renowned Physician (1809 – 1894)

The “Great Debate” in Theory

Inside each patient contemplating taking a medication or deciding to stay on it, a debate is waged. For patients who feel most comfortable passively accepting the recommendations of their doctor, it is a relatively quiet matter, without much ado. For patients, who feel more comfortable aggressively evaluating their physician’s recommendations, it can be a rather raucous affair, sometimes with much ado about everything. Most patients have a healthy admixture of both perspectives, which enhances their likelihood of being well informed consumers. But the process of choosing to put a foreign substance into one’s body is always a complex one.

It is as if there were dueling lawyers inside the courtroom of each patient’s mind. One lawyer sees only the very real benefits of medications and taps into the deep leanings of the human spirit for almost magical relief, as Sir William Osler describes above. The other sees only the very real dangers of medications and taps into the equally deep doubtings of the human psyche, as Oliver Wendell Holmes so acerbically attests. Across this wide spectrum the bottom line remains the same for all patients – ultimately they have to make a choice.

It is not an easy choice. The data are sometimes conflicting. Determining if the advice of the physician is biased or unbiased can be difficult. To return to our courtroom analogy, is this expert witness a “hired gun” or a “stalwart advocate” for truth. How is a patient to know for sure? Understanding how patients make this decision is at the very core of helping them to wisely decide whether or not to start a medicine. Obviously it is to our benefit to spend considerable time addressing the process that lies at the very center of this decision: “How do patients choose to take a medication?”

Curiously, one of the very best ways to most directly answer this question is to ask the question of the patients who we, as physicians, know best – ourselves. Each of us has been a patient, who, at one time or another, had to decide whether or not to start on a medication. In addition, most of us have been asked by friends or relatives what we think of certain medications. And many of us have had to decide whether one of our children should take a medication. Thus we have a vast reservoir of direct personal knowledge about how humans of sound mind and reasonable intellect choose whether to take any given medication. Our question is thus perhaps best re-worded as, “How do we, personally, decide to take a medication?”

The “Choice Triad”

In my workshops for primary care physicians, specialists, and mental health professionals, I have had the rare opportunity to ask the members of my audience this exact same question. The results have been remarkably similar. Physicians and nurses, from all around the country, tell me that they take medications for themselves if the following three criteria are met:

1) They feel there is something wrong with them.

2) They feel motivated to try to get help with what is wrong (or to prevent future problems from arising) through the use of a medication.

3) They believe that the pros of taking the medication will, in the long run, outweigh the cons.

Nothing startling here. In all of the workshops I’ve given, I have never met a physician, nurse, clinical pharmacist, physician’s assistant, or case manager who would ever take a medication (outside of “meds” such as vitamins or vaccines) unless they thought that there was something wrong with them and felt motivated to get help with the problem via the use of a medication. Nor have I ever met a clinician in all of my workshops, who would ever take a medicine in which he or she thought the cons outweighed the pros. Why would any intelligent person do so? And so it is with our patients.

For ease of discussion we will refer to these three steps, that a patient must navigate before trying a new medication (as well as staying on an old one), as the “Choice Triad”. Over and over again in the rest of this book, we will find ourselves returning to this Choice Triad, for an understanding of its nuances will provide a rich soil from which to transform our patients’ hesitancies and fears about medications.

The “Great Debate” in Actual Practice

Now let’s take a look at a very real patient in a very real setting with a very real disease. How many patients, in the middle of their first break of schizophrenia, think that there is anything wrong with them? Having done this work for some twenty-five years, I can tell you – not many. So when a patient, perhaps a terrified adolescent male of nineteen, tells me – “I am not going to take that medicine, Dr. Shea. No way. I don’t need it. Get it out of here. No way. I’m not taking it.” – is he being resistant or oppositional in the sense of purposefully trying to antagonize me?

As we hinted at in our last chapter, I don’t see why one would make that supposition. Such a patient is seldom being oppositional. Instead, he believes, deep in his gut, without any hesitancy, that there is absolutely nothing wrong with him. He simply disagrees with me. Under these circumstances – a patient strongly disagrees with the first step in the Choice Triad – it would be quite foolish for the patient to take the medicine. It would not be a logical decision. Exactly like ourselves, if we did not feel that there was anything wrong, none of us would take a medication, especially an antipsychotic that could cause tardive dyskinesia and make our tongue dart in and out of our mouths like a lizard for the rest of our lives – so why should a patient do so?

I, personally would never take a medication unless I felt there was something clearly wrong with me. In this instance, refusing the antipsychotic is not so much evidence of a person being illogical or oppositional, as it is evidence of a person being prudent, if, indeed, he or she thinks that there is nothing wrong. The patient is making the exact same choice that I would make if I shared the same belief. It just so happens that in this case, I don’t.

Once this insight is understood by prescribing clinicians, it follows suit that they develop a new-found respect for the patient’s decision making process – it’s the same as their own – while not necessarily agreeing with the patient’s database from which the decision was made or the decision itself for that matter. Our role becomes not one of making a so-called “resistant” or “oppositional” patient become compliant, but of helping a patient with poor information become better informed and motivated for change. We become teachers, and all good teachers are great motivators. Our goal is to increase our patients’ genuine interest in trying a medication or staying on it after it has been started.

Over the years, I have found that once medical students, residents, and nurses truly understand this simple fact – that patients refusing meds are often making the same decision we would make if we shared their belief set – it is rather remarkable how deeply it changes their attitudes towards “resistant” patients. More importantly, it changes how they come across to those patients who don’t want to take medications. The oppositional feelings that we said could trigger medication nonadherence described in the last chapter, seem to melt away because the clinician realizes that the patient is making the wisest decision possible given the belief set that the patient has at the time.

I am reminded of a quote by Armond Nicholi, Jr. a well known psychiatrist that, “whether the patient is young or old, neatly groomed or disheveled, outgoing or withdrawn, articulate, highly integrated or totally disintegrated, of high or low socioeconomic status, the skilled clinician realizes that the patient, as a fellow human being, is considerably more like himself than he is different.”3

Let us now take this reasoning much closer to home for the typical primary care physician functioning in a hectic clinic setting. Let us look, not at a patient with schizophrenia – patients well known for refusing meds – but to a patient with diabetes.

We will look at a middle-aged woman, who is fairly symptom free, except for unusually frequent daytime urination, nighttime awakening with trips to the bathroom, and the recent onset of a sensation of feeling weary. Moderately overweight, and out of condition, the level of her blood sugar suggests the need not only of behavioral interventions such as diet and exercise, but also the use of an oral hypoglycemic agent.

How many of these early diabetic patients starting on a long term med ripe with potential side-effects, truly believe, in their guts, that they have a serious disease on board, one that can have crippling consequences and even have death as an endpoint? Once again, I’ve had the luxury of asking many hundreds of primary care physicians this exact question during my workshops. Even as I’m phrasing the question, I frequently see many physicians nodding their heads in agreement with the point, for they quickly recognize that the answer is the same one we saw in our patient suffering from schizophrenia – not many.

Indeed, patients whose diseases show minimal symptoms at first, such as early diabetes or hyperlipidemia, are notorious for “noncompliance.” Early hypertension, where there is only an abnormal number magically culled from a blood pressure cuff as evidence of disease, may be the king of nonadherence problems for just such a reason.

Sometimes, in my workshops, after the above point has been made by a member of the audience there follows a silence, and then a physician will animatedly raise a hand commenting, “I have a caveat to that, though. The one set of patients with diabetes who do stay on their meds are those patients who have a parent with severe diabetes or a friend with it. You know, if their mom doesn’t have a leg from the knee down or their uncle has a pipe in his arm from dialysis, those patients get it. They take the meds, and they often stay on them almost religiously.”

And so our point is made.

Exactly as our principles, outlined above suggest, these patients will choose to start the med because they believe there really is something wrong with them. They have a vivid picture of what could happen to them that motivates them to try the med. And they project that whatever the cons of this med may be, it probably isn’t as bad as the potential dangers of their disease – renal dialysis, stroke, blindness.

It is not that these patients are smarter or less oppositional than our more typical “resistant” patients with early diabetes, who refuse meds or who, more commonly, are poorly compliant with them. It simply is that these patients truly believe there is something wrong. If they didn’t, they wouldn’t be agreeing to the med.

More importantly, if our “resistant” patients could be led to understand that there is something seriously wrong (i.e. they come to believe in the first step of the Choice Triad) there is a very good chance that a large chunk of them will take us up on our recommendation for an oral hypoglycemic agent. They will have developed a sincere interest in the medication because of their personal belief (as opposed to our professional belief) that it could stave off serious problems. Patients take medications because of their beliefs, not ours.

From Theory to Practice

Now that we have a better understanding, not only of the nature of medication nonadherence, but of the internal thinking that leads to it, we have developed a reasonably sound theory of nonadherence and how to transform it. We now need to put our theory to the test. Specifically, as we stated earlier, a good theory will generate specific interviewing techniques and strategies that will help us to increase our patients’ interest in both trying specific medications and staying on them. Will our theory do this?

To find out, let us return for a moment to the second step in the Choice Triad – the patient feels motivated to try to get help with what is wrong through the use of a medication. While discussing this second step in one of my workshops, a pediatrician who specialized in treating kids with asthma proffered the following tip, which I have found to be very useful.

Interviewing Tip #1: Inquiry Into Lost Dreams

He commented that one of the most powerful motivators for these kids, was the obvious one: they wanted relief from their acute asthmatic attacks – symptom relief. But he also had found that there existed another very powerful motivator, that he could tap when his patients were having tough side-effects or fears, that could help them to give their medications a little more time. He felt, and I have found with my own practice, that this same motivator was equally powerful for adults with many different diseases from rheumatoid arthritis to obsessive-compulsive disorder. What is this other powerful motivator that can help to transform nonadherence?

It is the simple fact that for many patients their illnesses have not only given them something – painful symptoms – they have taken something away – their dreams, their livelihoods, their peace of mind. The desire to recover these lost dreams often provides an intense motivation to tolerate difficult side-effects or to overcome the inconvenience or stigmata of taking medications.

He described his interviewing tip as follows:

“I find it useful with my kids with asthma to ask them this question or a variation on it, ‘Is there anything that your asthma is keeping you from doing that you really wish you could do again?’ What I find with this age group is that there is often a quick answer to this question, and the answer is often related to a sport – say football or soccer.

“What I find to be so useful about this question is that it opens the door for adolescents, who by definition are prone to form oppositional relationships with adults, to tell me what they want me to do for them. They are calling the shots, not me. The oppositional field seems to dissolve away. Meanwhile I gain a deeper insight into their motivation for seeking help from their asthma that goes beyond their desire for symptom relief. I might never have know this powerful motivator had I not asked. I can use this knowledge to enhance the adolescent patient’s desire both to start a medication and to stay on it.

“First, although I never provide false hope, if I feel it is within reason, I can use this newly uncovered information immediately to help shape a shared agenda with a comment like, ‘Now I can’t promise this, but I have had some very good luck with helping other students, with asthma like yours, to get back into sports. We have some great meds that can help with that goal. Once again, no promises, but I would like to work with you to see if we might be able to get you back out on that soccer field. How does that sound to you?’

“Secondly, in the future, if there are tough side-effects or the stigma concerns so often seen with kids having to take meds at school become problematic, I can say something like, ‘I know you are getting some tough side-effects – and they are tough – fortunately I have some ideas on how we might be able to make them much better, and I don’t’ think we have seen the full power of these meds to help you to feel better yet. We are still trying to get you back on that soccer field that we talked about in our first meeting. If you can give me another two weeks to see if I can lower the side-effects and get you some better relief from these attacks, I think I might be able to do that. Is it a deal?'”

Very nice. Very nice indeed. Now there is a useful interviewing question – “Is there anything that your asthma (or whatever disorder is present) is keeping you from doing that you really wish you could do again?” – that can be used – and I have often used it within my own practice – to transform medication nonadherence in the real world of a busy clinic.

The “inquiry into lost dreams” technique was developed directly from asking ourselves about ways of achieving the second step of the Choice Triad. Our model is beginning to show its power. Let us see what happens if we continue to explore the concept of improving motivation which is, essentially the heart of the second step of the Choice Triad. We have already seen that two powerful motivators exist: 1) relief from symptoms and 2) gaining back lost activities and dreams. Our next question is simple, yet potentially filled with great promise, “Are there other motivators we can tap for our patients?”

Interviewing Tip #2: Tapping Family Motivators

A primary care physician, during one of my workshops, shared a tip that I have found to be useful with many patients. His insight also touches upon the usefulness of understanding cross-cultural sensitivities when discussing medication interest. Much of his work was with the Latino population. He found that Latino males often don’t want to take care of their disorders, for “taking care of oneself” is viewed as being self-centered. On the other hand, the Latino culture places a profound emphasis upon family ties and responsibilities, which displays itself as an intense belief in taking care of ones family no matter what the cost. Family needs first. Individual needs second.

Whether discussing diabetes, hypertension, or depression, he would try to become familiar with the patient’s unique family history, family network, and sense of familial responsibilities. He would then tap this information to design an individualized strategy for motivating his patient.

For instance, let us say the patient lost his own father, who had diabetes, to a myocardial infarction at the age of 51, and that the patient had found this experience to be devastating to him as a child. The physician might proceed as follows:

“Mr. Perez, I know you don’t feel much like taking these medications for your diabetes, and I understand that. There might be another reason, in addition to taking care of yourself, why it may be very important for you to try to take them. I think they can help you to take care of your family. You see, your Dad’s diabetes is what led to his dying from a heart attack at such a young age. These medications can help to make sure that you don’t get a heart attack, something that you know from your own experience would be horrible for your wife and kids. We need to keep you healthy, for them. I know it’s a nuisance to have to take medications, I really do, I sure don’t enjoy taking medications myself, but if it can save your family from that kind of pain, I think it is worth it. What do you think?”

A lovely tip. In answer to our question, I believe that we have found a third powerful motivator for many patients – their families – that taps a deep rooted sense of love and responsibility. This technique can also be expanded beyond family members. For some patients it is their commitment to their communities and to helping others that stands as a powerful motivator for them to stay healthy and capable of helping. As one would expect this tip is also of great use, not only among the Latino population, but across all cultures when we find individuals with a high sense of responsibility to family or mission.

Ed Hamaty, a pulmonologist from Philadelphia, who specializes in AIDS, added that such family or community motivators can be enhanced significantly by helping patients to create individualized affirmations such as, “This one is for my grandchild.” A simple repeating of this affirmation every time the patient reaches for his or her medication bottle can go a long way towards inspiring motivation.

Interviewing Tip #3: Providing a Visual Reminder for Family Motivation

A primary care nurse from Kansas, Janet Brack, suggested a wonderfully effective extension of the above interviewing technique. Her tip moves us into the realm of nonverbal enforcers of medication motivation. She noted that in smoking sensation programs it is not uncommon to ask participants to place a picture of a loved one on the cigarette pack, itself, to remind them of one of the reasons they are trying to kick the habit – to make sure they are still around to laugh, love , and help their families.

She asked herself, “Why not transfer this technique to the task of improving medication adherence?” She did, and she was impressed with the results:

“Mr. James, we’ve already decided that one of your reasons – besides taking care of yourself – that you want to stay on your medications for your high blood pressure is to keep healthy for your wife. That’s a great goal, and I think you can do it. Some of my patients with a similar goal have found a neat trick to remind them why they are taking their medications. You simply set your pill bottle on a large picture of your family, so that every time you reach for it, you are reminded what the losses may be to your family if you got a heart attack because of your high blood pressure. Many of my patients say it really helps them to stay motivated. How does that idea sound to you?”

The Missing Piece of the Puzzle

As we have moved from theory into practice, the power of our model is beginning to emerge. All three of the interviewing techniques we have just developed – from our understanding of the second step of our Choice Triad – are simple, take little time, can be readily named, and easily taught to medical students, nurses, residents, and case managers. We are developing a model that provides concrete interviewing techniques and strategies, that can be of practical use to clinicians as opposed to vague principles such as “empower your patient” that offer little guidance as to the actual method of achieving in practice what is, in theory, undoubtedly an important goal.

One piece to the puzzle missing: We need a word to talk about patient nonadherence, that follows our model and does not set-up, by its very connotation, an oppositional feeling towards the patient , an oppositional feeling that the word noncompliance and to a lesser degree nonadherence seem to generate. In short, we need a name for our model.

References

1. Cushing, H.: Life of Sir William Osler. Oxford Press; Clarendon Press, 1925.

2. Holmes Sr., O.W. : From address to the Massachusetts Medical Society, 1860.

3. Nicholi, A. M., Jr.: The therapist-patient relationship. From The Harvard Guide to Modern Psychiatry. Cambridge, California, Belknap Press of Harvard University Press; 1978:28.

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