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

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