September/October 2006

the Zen of Science

Doctors' orders are often ignored

BY MARC RINGEL, MD

So much of the success of what I do as a doctor depends on words: how I elicit and understand descriptions of symptoms; how I explain problems; and how I give instructions. I won’t, for example, tell a patient that he’s got “congestive heart failure” because the word “failure” implies that he has somehow failed, that the condition stems from a personal flaw. “Failure” is also a synonym of death, as in “He finally failed on Tuesday and was laid to rest on Wednesday.” Even the word “congestive” sounds downright uncomfortable, creating the expectation of unpleasantness.

Instead, I refer to the decreased function of the heart pump, which is, after all, what congestive heart failure is all about. You can lubricate a pump, replace gaskets, clean out the plumbing. Just sticking with the pump metaphor, wouldn't you rather hear that your pump isn't working as well as it ought to rather than that it's failing? Who would you rather call, the plumber or the coroner?

I choose my words especially carefully every time I hand a patient a prescription, never saying, “This probably won't do any good, but try it anyway.” Instead, when groping for the right therapy in the face of uncertainty (and there’s way more uncertainty attached to the medical decisions than laypeople care to hear about), I’m likely to say something like this: “This is my best estimate of what would help you most. If this medication or dosage isn’t just right, we’ll keep trying. I won’t give up until you’re feeling better. And if I cannot help you, I’ll find someone who can.” There’s a great deal of healing that goes on because the patient believes that I’ve prescribed the best for him and because he understands the strength of the alliance we’ve formed to get him better.

Any patient is much more likely to take the medication I’ve prescribed if he believes it will really help. “Compliant” is the word medical people have long used to mean that a patient follows our directions, and “non-compliant” that he doesn’t. The concept of compliance has lately fallen out of favor. Today, we health professionals are supposed to use the word “adherence” because adherence implies that the patient has actively decided to follow what’s prescribed, as opposed to just passively complying.
There’s a large chunk of medical literature on the subject of patient compliance/adherence. The rules derived from that research are mostly common sense.

Keeping it simple is one factor. One study, based on pill counts and frequency of refills, found that 94 percent of patients complied with a once-a-day pill regimen whereas only 57 percent took all their medication if they had to do so two or three times a day.

If they feel okay, getting someone to take pills for a lifetime may be a tough sell. For example, mild elevations of blood pressure or of cholesterol, both diseases that insidiously put wear-and-tear on arteries, may be wholly asymptomatic until disaster strikes in the form of a stroke or of a heart attack. It’s much easier to keep a severe asthmatic using her inhaler for that disease because, if she forgets, her breathing may be significantly worse in less than a day.

Money can pose a major obstacle to compliance. Annals of Internal Medicine published a fascinating article this year which found, on reviewing a large health plan’s detailed records of frequency of refills for chronic medicines, that patients tended to comply better with low-copay, tier 1, generic drugs than they did with tier 2, preferred name brands with higher copays. Patients were least likely to take as directed the most expensive tier 3, non-preferred brand name drugs. The researchers chose to study classes of drugs in which the clinical performance of the products was not significantly different from tier to tier.

My dilemma, as a busy practicing doctor, is to know which formulary my patient’s insurance plan adheres to and to do my best to comply with it. The little Palm Pilot computer that I carry in my pocket, loaded with ePocrates drug information software, sometimes clues me in to which drug will be cheapest based on a patient’s particular health plan. More often than not, either we get a call from the pharmacist with a request to change to a lower tier drug or I find out at the next visit that the patient simply didn’t take what I’d prescribed because it cost too much.

Compliance may even be a good thing in itself, not just because the patient takes the prescribed medication. A fascinating study published last year in Lancet looked at the effect of a drug called candesartan in treating pump trouble (congestive heart failure). This was a placebo-controlled study, in which half of the subjects received the actual drug and the other half an inactive dummy pill. When the statisticians analyzed the data, they found that patients who received candesartan were 10 percent less likely to die than those who got the placebo. That's pretty significant, though not exactly earthshaking, because candesartan belongs to a class of similar drugs that we already know are good for pump trouble.

The truly astounding conclusion that fell out of this study had to do with compliance. Based on pill counts, they divided the treatment group and the control group into who had taken 80 percent or more of their prescribed pills, versus those who’d taken less than 80 percent. The scientists found that taking all of your medicine, even when your medicine was the equivalent of a sugar pill, had a 3.5 times larger effect on survival than did which pill you actually got.

It’s not at all certain that faithfully taking the placebo is what saved the lives of a number of compliers. It may be that being a complier is an important category in itself, that people who took all of the pills handed them by the researchers also took all of their other medicines, plus maybe they even followed their doctors’ instructions about exercise and diet.

The other interpretation is that having enough faith in a prescription (and in the doctor who prescribes it) is a big piece of what makes that prescription work. I believe there is truth in both interpretations: that overall it’s a pretty good idea to try to do what your doctor says; and that faith in your doctor makes the treatments she prescribes work better.

Where does this leave you, then? Try never to exit your doctor’s office until you understand (or at least trust) what you and she have decided to do for you. If you don’t have that kind of relationship with your physician, find one with whom you really do feel such a partnership. The exactly right drug is not likely to do you any good if it’s left sitting in the medicine chest.

Marc Ringel, MD, is a family practitioner and writer based in Greeley, Colorado.