Abstract
Rational creatures and fine words
The other day, I was over at a friend's house (another doctor) and she mentioned that she had otitis media. As a concerned friend, I offered her some paracetamol I had on me and a private prescription for some antibiotics. She thanked me but said she was going to use up some ‘old amox’ and, if she was still feeling unwell, would finish off with some ‘out of date fluclox’ of her mother. We both tittered and carried on sipping tea and picking food up off the floor after a toddler feast.
I started thinking about the way doctors and people in general behave around medicines; I once worked with a respiratory registrar who smoked like the proverbial chimney despite having asthma. He refused to take inhalers on a regular basis but used oral steroids for a couple of months each year. Patients are equally erratic. At a lecture the other day, we were urged to check inhaler technique by a consultant who had done so and discovered one of his patients was spraying it onto her chest ‘like perfume’.
Now, I am not hoping to use my column to laugh at the hypocrisy of doctors or the idiosyncrasies of some patients but to try to consider ‘why’ people behave as they do and how this should influence our day-to-day practice. In the examples above, a few things become clear. Firstly, we often place the significance of our own experience over what we know to be true from studies (me offering, and my friend taking, antibiotics for otitis media because it had worked in the past). Secondly, we do not like taking medicines unless we feel ill (the respiratory registrar who would not take his inhalers) and finally, we act within the framework of our own understanding of the disease (the patient who put the inhaler where she thought the asthma was). This being so, it is clear that rational people may come to totally erroneous conclusions about how to take their medicines.
The point I wish to make here is not that we need to communicate better with patients (although, as demonstrated above, clearly we do) but that their behaviour has a reasoned basis and should be respected. The woman who used the inhalers on her chest could have been applying her knowledge of hormone patches or deep heat spray to her asthma. Prescribing effectively should not be about educating people to come round to an established way of thinking so that they take the pills we want them to but rather about both doctor and patient trying to understand the other's view point. This may require a degree of flexibility on our part but it is surely the only honest way to begin a therapeutic relationship.
Previously, the term ‘compliance’ was used to describe a patient's use of their drugs. In recent years, the word ‘concordance’ has been suggested as the preferred term. The implication being that we should be searching for a way to arrive at a mutually satisfactory outcome. This new terminology is not without fault but it does at least suggest that the search for understanding works in both directions. As doctors, we should be seeking to understand the patient's model of disease so that we can consolidate it and work within it as much as possible.
The term concordance and its compatriots ‘compliance’ and ‘adherence’ all suggest that the doctor makes the decision and the patient ‘concords’, ‘complies’ or ‘adheres’. However, I would suggest that it is the patient who makes the final decision and I would question how important it is for the doctor to feel comfortable with the decision that is made. As long as the doctor is sure that the patient is competent, has assimilated the information and been able to discuss it fully, then the decision to take the proffered drug, and how it is taken, is the patient's and the patient's alone.
After all, doctors are not always right—both as individuals and as a profession. Momentary lapses of concentration and blips in knowledge aside, even if we were all able to keep up to date with all guidelines and have the ‘correct’ options at our fingertips all the time, guidelines change and we may find ourselves eating our own words at any stage. Patients are often fully aware of how the established view can fluctuate.
So we can now use as many big words as we like: adherence, compliance, concordance, beneficence, non-maleficence, autonomy, justice, non-paternalism … In truth, the jargon is irrelevant. Ultimately, we should be doing our best while recognizing our own limitations and always giving patients the respect they deserve.