Medical (non)adherence: You really have to ask

By Dennis Rosen, MD


It can sometimes seem as though the easy part of being a doctor is taking a history, making the diagnosis, and prescribing the appropriate treatment. There are occasions when the most challenging—and vexing—part is actually getting the patient to follow through with what you’ve recommended. Medical non-adherence is a huge obstacle to good care: more than one third of patients with type-2 diabetes, for example, don’t take their medications as prescribed.

When patients don’t take their medications correctly, they don’t just not get better, they actually get even sicker because their disease progresses in the absence of effective treatment. It is estimated that 125,000 Americans die annually as the direct result of medical non-adherence.

In addition to being less healthy, medically non-adherent patients are also more costly to care for. They tend to have fewer office-based physician visits and more emergency-room visits and hospitalizations than adherent patients.  In 2010 the direct costs of medical non-adherence for diabetes, hypertension, and dyslipidemia exceeded $105 billion.

It is easy enough to blame the patient for not taking medicines as prescribed. However, that misses the mark completely. The fact that the patient is there in your office—even if he hasn’t carried out what you both agreed upon the last time you met—is a good indication this person wants your help.

A better approach, then, is to try and understand why they aren’t adhering to the prescription.  Here are just some of many possible reasons:

  • Does the patient understand when the medications are supposed to be taken? Is it supposed to be after symptoms occur (e.g. eye drops for allergic conjunctivitis), or to prevent symptoms or organ damage from occurring (e.g. eye drops for glaucoma)?
  • Is the patient unable to pay for the medicine you’ve prescribed, but too embarrassed to bring that up? If so, is there a less-expensive alternative you could prescribe?
  • Does the patient have underlying beliefs that might be interfering with his willingness to proceed with treatment? Might you be able to address and defuse these beliefs (e.g. certain potential side effects he read about on the internet)?
  • Is the patient taking so many different medications that they are having trouble keeping the dosing schedule straight?

Unfortunately, many physicians do not spend enough time discussing medical adherence with their patients. One observational study of primary-care medical visits found that doctors asked their patients basic questions about less than one third of their medications. Unless asked directly about how they are taking their medications, patients tend not to volunteer that information.

Without having a conversation about how her patient takes his medications—or why he doesn’t—there is no way that the doctor will really be able to help her patient, even though both go through the motions of doing what they’re supposed to: coming to appointments and prescribing treatments. The result is suboptimal care, a greater risk of complications and the additional—and avoidable—costs associated with treating them.

Dennis Rosen


Dennis Rosen, MD, is a pediatric pulmonologist practicing in Boston. His book Vital Conversations: Improving Communication Between Doctors and Patients will be published by Columbia University Press in September 2014.  


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